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HomeMy WebLinkAbout3333 Bristol St - Building Permits (Public)(714) 754-5273 • Fax(714)754-4656 www.cf.costa-mesa.ca.us. 77 FAIR DRIVE, COSTA MESA, CA 92626 BUILDING PERMIT Job Address: 3333 BRISTOL ST Suite: 1638 Vicinity: 1638 Parcel Number: 41250107 Zoning: PDC PDC Plan Check: BARTH, Calc Valuation: $20,000.00 Applicant: $321.25 _ _ __ .. Claim Valuation: $20,000.00 Address: 140 LOMAS SANTA FE - SMIP Com: SUITE 200 Phone: (858) 793-9104 Other: SOLANA BEACH, CA, Zip: 92075 Inspection: $0.00 Owner: SOUTH COAST PLAZA, Address /COSTA PLANNING & ZONING SETBACKS MESA CA Phone: • ' 3315 FAIRVIEW ROAD Zip: 92626 Contractor: DICKINSON CAMERON CONSTRUCTION INC Address: 140 LOMAS SANTA FE Required: 0 Proposed: 0 SUITE 200', Phone: (858) 793-9104 SOLANA BEACH, CA Zip: 92075 License: 690239 Arch Eng: Address: Address: Phone: Status: ISSUED Applied: 05119/2004 A, issued: 05/19/2004 NO q? $rl ISSUED BY: Phone: Zip: License: License: SCOPE OF PERMIT DEMOLISH NON BERAING WALLS FOR UNIT 1638 POLO RALPH LAUREN. REF B04-00790. NOTES: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12.21.92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within-180 hin•180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal,,such,work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and/final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 / tags-ae (a100) FEE SUMMARY Plan Check: $0.00 Calc Valuation: $20,000.00 Permit: $321.25 _ _ __ .. Claim Valuation: $20,000.00 SMIP Res: $0.00 - SMIP Com: $4.20 Other: $0.00 Inspection: $0.00 Total: $325.45 PLANNING & ZONING SETBACKS MAIN STRUCTURE Front" 0-10 Rear 0-0 Leff 0 0 Right 0-0 ACCESSORY Front-, 0-0 Rear 0-0 Left 0-0 Right 0-0 PARKING Existing: 0 Required: 0 Proposed: 0 NOTES: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12.21.92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within-180 hin•180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal,,such,work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and/final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 / tags-ae (a100) FA DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the for which this permit Is Issued. I Have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work tot which this permit Is Issued, w ars' compensation Ins trier and polio number are: Camay: Ali" Poli um section need not Be completed ff the permit is valued at one hundred dollars ($100) or less.) ❑ I certify that in the performa�I�W ofch th permit is issu shall not employ any person In any manner so as to become subject to the workers' compensation laws of CallfOI sh Id become joct o the workers' compensation provisions of Section 700 of a Labor Code, I shall forthwith ase provision�� plicant 51 re: N1NG: FAILURE TO SECURE WORKERS' COMPENSA ON COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($10D,0001, IN ADDITION TO THE T OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I herqby-effirr RPdtf 2Tmiicensed nde provisions of C apter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is In full torce�rr a - tract nature: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lends agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lenders Name: Lenders Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (5500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor($) license pursuant to the Contractors License Laws.). ❑ I am exempt under Sec. Business and Professions Code for this reason: Signature: Date: Owner 10 verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or dead): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title S, California Administrative Code). ❑ As owner -builder, f will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the -applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which hes at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 600 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ..................................................................................................................... I ..................... I— ................... _w.._11..11.. ........ ............................. ..................................................................................... 111.. 1 _1111.......,,................................... 2 Does or will the applicant or present ar future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cuNc feet of compressed gas at standard temperature and pressure). ............................................................................................................................................................................................................................................................................................................................._............................................. 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. _..............................................................................__..................._................_----- ................._.............................,..........................................................�._.....................................,......................................... 4 If en RMPP is presently required, has Section 25534 of the- Cafifomia Health and Safety Code b9e-n fully complied with? ❑ Yes ❑ No ..................................................................................................................................................................._............ --.... ............................ -........ --•............................... 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this a plication aggermil for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Li Yes u No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ......... ....... ............................ ,............................................................ ...........-.,.................................................... ................................................................................ ....... .......................................................................................... 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ........................... ........... ...............................................................................................................�.............................---------.......................................------------.......... .................................................................. ........... ....•--.. 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? C) Yes El No .. ........ _..................... ....... _........._._.......................................... ....................................................... _............... __.......................................... ........_.._......... .............. .........._................. -._................................ , attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. 1 agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. i etu al0 s) A d10p scan BODE I. INSPECTION TYPEjy reM INTITIALS _CODE A INSPECTION TYPE 26M 6 1616 Fixed System Final ire vention 206 Final Mechanical 1266 Pool Spa Final 206 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 467v 222 Final Site 204 Final Demolition ` 250 Final Building/Occupancy (714) 754-5273 • Fax(714)754-4856 • www.cl.costa-mesa.ca.us ELECTRICAL PERMIT Job Address: 3333 BRISTOL ST Suite No 1638 Vicinity: Parcel Nunmber: 41250107 Applicant: EDDY BARTH Temp Dis! System / Lighting Address: 140 LOMAS SANTA FE Temp service test $0.00 SUITE 200 - Phone: (858) 793-9104 ` Res. a/c package SOLANA BEACH, CA "l "- Zip: 92075 Owner: ,SOUTH COAST. PLAZA New Res (1-2 units) $0.00 Address Y $0.00 0 New Res (3+units_ ),- COSTA MESA CA Phone: ; $0.00 3315 FAIRVIEW ROAD Zip: 92626 0 t ...............:up to 10 kva/kw ," $0.00, 0 Contractor: DICKINSON CAMERON CONSTRUCTION INC Address: 140 LOMAS SANTA FE 0 Recept Outlets\ \\ $0.00. SUITE 200 Phone: (858)793-9104 0 SOLANA BEACH,'CA - Zip: 92075 ..................over 100 kvalkw ' License: 690239 - 77 FAIR DRIVE, COSTA MESA, CA 92526 Status: ISSUED Applied: 09/20/2004 Issued: 09/20/2004 ISSUED BY: SCOPE OF PERMIT INTERIOR 5389 SF STORE TI FOR "POLO.RALPH LAUREN" IN SPACE 1638. REF: B04-00790 AND E04-00604 . ELECTRICAL TO INCLUDE: ADD 8 LIGHT FIXTURES AND 2 SWITCHES. - - - FEE SUMMARY Quantity i Quantity ISSUE FEE$23.50 Temp Dis! System / Lighting $0.00 0 Temp service test $0.00 Busway 1100 it : ' $0.00 0 Res. a/c package $0.00 - Standing Section $0.00 0 New Res (1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0 New Res (3+units_ ),- �� �, $0.00 0� Transformers up to 1 kvalkw $0.00 ;' 0 Pool/ Spa,, ;$0.00 0 t ...............:up to 10 kva/kw ," $0.00, 0 Lighting FExts , %,, `$8:80 B -r ...........up to 50 kvalkw - .", $0.00 ' 0 Recept Outlets\ \\ $0.00. '0. .............up to 100 kvalkw $0.00 0 Switches / �, $2.20; ; , ,. ' 2 1,0, ..................over 100 kvalkw 50.00 0 Non Res App, • �, l,/ $0.00 ' . 'Low Voltage Equipment - $0.00 0 Res App, $0.00Q_ ' Low Volt Wiring System/. Ckt- ' $0.00 0 Service to 200a �� - $0.00 ', 0 Misc. Conduit. so.00", 0 • Service to 1000a \ $0.00 0 Misc. Conductor - $0.00, , 0, Service over 1000a $0.00 0 Circus ( gen or ride) -$0.00 0 Motors to 1hp $0.00 4 Circus (mech ride or lights) $0.00 0 Motors to lohp x$0.00 0 Christmas Tree Stand - , $0.00 0 Motors to 50hp $0.00.,--_ 0 ,Fireworks Stand - : $0.00 0 Motors to 100hp $0.00 0 Other Electrical Fee '$0.00 Motors over 100hp $0.00 0 Communication drops $0.00 0 Investigation Fee "" $0.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia statutes and related regulations. (Ord. No. 92.28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work Is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: in order for the work authorized under this permit to be considered legal, such work must comply with all applic as, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the exof this permit. FOR INSPECTIONS CALL: (714) 754-5626 ((((((////// DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the tabor Code, for the performance of the work for which this permit Is Issued. I have and will maintain workers' compensation insurance, as required by section 3700 01 the Labor Code, for the performance of the work for which this permit Is issued. My workers'corn nsatlon Insurance c rrier and policy number are: car�er� / ' i� -(Thls'sectlon need not be complete i1 the permit is,valued at one hundred doffars ($ 100) or less.) ❑ 1 certify that in the performance of ork for which this parmi 's issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Cnlifornl gree t i1 I should b 1 to the workers' compensation provisions of $action 3700 of the Labor Code, I shall forthwith comply with these provisions. !� E Icant Si nature:_ NING: FAILURE TO SECURE WORKERS' ODMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT ANE �I NfEfiTQ CRIMINAL NALTIES D GVIL RNES UP TO ONE HUNDREDUSAND DOLLARE ($100,0001, IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am [Jcensgd 9vpqnjh*ervi 9 (commencing with Section 7000) of Division of the Bwclnsss and Professions Code, and my license t5 in full -force•and'e eci. Oil Lontrectars &Ignature: a - . [Lslgnaluro: ONSTRUCTION LENDING AGENCY: 1 hereby affirm that there is a construction lending agency for the performance o1 the work for which this permit is issued. (Sec, 3097, Civil Code). ender's Name: Lender's Address: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner o1 property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not Intended or offered for sale. If, however, the building or Improvement Is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors license Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws,). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No, Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet In depth Into which a person Is required to descend, will be made In connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (38) feet high. (Chap. 3.2, Grp 2, Art 2, Sac. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 590 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _ ...... — __ _.......................... __ _......................................... .. - - ----- _ ............ �...................... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes 0 No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 Cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program far acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Depanment may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. _ ........................... _ _._. _ ---.—...--- ......... _.......... _..... 4 If an RMPP Is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction ar modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). _ _-.....---............................. _................ _... -- --- -- .--................... ................._.......------ — __.�_..--...........__.............._........... 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outar boundaries of a school? ❑ Yes ❑ No (If yes', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Coda). --...............__......_—....._—....---_....................... _.............. .......... — �_.........----- — . _._ ......—..............._....._ 7 a a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ------.......— ........................__ __.—_..... ......................................... _..... _.. _— ..... _......... .............._............. 6 (If yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I Lenity that under penalty of perjury the information given above is correct, i agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Data: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY. I cerilty under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. 9 Ila fur gal Own (s) Datf 1=Z:._-_2_ � — !!J/F� 7d!�� — lAK4TAA FAnthodzed`Applicant-- - Ff� ate _ CODE 1. INSPEL•T10N TYPE tag 1NTIT161S CODE t INSPECTION TYPE QAIE 1NTITIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical Guall 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition • 250 ' Final Budding/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.cl.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 MECHANICAL PERMIT ,lob Address: 3333 BRISTOL ST Suite No 1638 Vicinity: SPACE 1638 (POLO) Parcel Number: 41250107 Applicant: BARTH, EDDY " Quantity ISSUE FEE Address: 140 LOMAS SANTA FE Inst FAU <100 k BTU $0.00 0 SUITE 200 Phone: (858) 793-9104 Repair / Alt Cooling/Heat SOLANA BEACH, CA Zip: 92075 Owner: SOUTH COAST PLAZA - Refrig Sys <100 k BTU $0.00 Address: Refrig Sys X100 k BTU $0.00 0 Gas Piping COSTA MESA CA " " Phone: Factory Fireplace $0.00 3315 FAIRV15W ROAD Zip: 92626 0 VAV Box $53.25 5 Contractor: DICKINSON CAMERON CONSTRUCTION INC. Address: 140 LOMAS SANTA FE $0.00 0 Fire Dampers SUITE 200 Phone: (858) 793-9104 $0.00 SOLANA BEACH, CA Zip: 92075 0 Air Handlers < 10000cfm License: 690239 ISSUED BY: Status: ISSUED Applied: 05/26/2004 SCOPE OF PERMIT INTERIOR 5389 SF STORE TI FOR "POLO RALPH LAUREN" IN SPACE 1638. 5 VAV BOXES. 5 REPAIR/ALT COOLINGIHEAT, 1.VENT FANISINGLE DUCT REF: B04-00790' FEE SUMMARY Repair 1 Alt Absorbtion Unit Repair,/ Alt Refrigeration Unit Ventilation System Evaporative Cooler Commercial Incinerator Domestic Incinerator Compressors I Absorption Systems Up to 3 hp./ 100 k BTU 3 To 15 hp / 500 k BTU. 15 To 30"hp / 1,000 k BTU 30 To 50 hp / 1,750 k BTU Over 50 hp I Over 1,750 BTU ; Boilers ' Up to 3 hp 3To15hp 15to30hp- 30to50hp, Over 50 hp Other Mechanical Fee Investigation Fee Plan Check Fee _,,Reinspection Fee $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00" $0.00' $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Quantity 0" 0 0 0 0 0 0 0" 0 0 0 0 0 0 0 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92.28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days, or If work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2448.48 (8!40) I Quantity ISSUE FEE $23.50 - Inst FAU <100 k BTU $0.00 0 Inst FAU >100 k BTU $0.00 0 Repair / Alt Cooling/Heat $68.50 5 Inst / Rep. Recess Wall Htr $0.00 0 Refrig Sys <100 k BTU $0.00 0 Refrig Sys X100 k BTU $0.00 0 Gas Piping $0.00 0 Factory Fireplace $0.00 0 Hood w/Mech Exhaust $0.00... 0 VAV Box $53.25 5 Vent Fan / Single.Duct $7.25 1 Appliance $0.00 0 Fire Dampers $0.00 -0 = Smoke Dampers $0.00 0 ` Inst or Relocate Appl Vent - \ $0.00 0 Air Handlers < 10000cfm $0.00 0 Air Handlers > 10000cfm \ $0.00 '0 Floor Furnace ., $0,00 0 Floor or Suspend Heater 50.00 -o FEE SUMMARY Repair 1 Alt Absorbtion Unit Repair,/ Alt Refrigeration Unit Ventilation System Evaporative Cooler Commercial Incinerator Domestic Incinerator Compressors I Absorption Systems Up to 3 hp./ 100 k BTU 3 To 15 hp / 500 k BTU. 15 To 30"hp / 1,000 k BTU 30 To 50 hp / 1,750 k BTU Over 50 hp I Over 1,750 BTU ; Boilers ' Up to 3 hp 3To15hp 15to30hp- 30to50hp, Over 50 hp Other Mechanical Fee Investigation Fee Plan Check Fee _,,Reinspection Fee $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00" $0.00' $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Quantity 0" 0 0 0 0 0 0 0" 0 0 0 0 0 0 0 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92.28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days, or If work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2448.48 (8!40) WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. My workers' compprisaflon, urarice carder and poll number ar : Carrier:-2Policy Number: (This section he& no be completed if the permit Is va usd at one hundred dollars {$100) or less) ❑ I certify that in the performance of thew f hlch t is permit is i ed, I shelf not employ any person In any manner so as to become subject to the workers' compensation laws of Califo ,and gr h If I old t>e Ject to the workers' compensation provisions of Section 3700 of the labor Code, I shalt forthwith comply with these provisi s. Applicant Signature: Date: �(d/ WARNING: FAILURE TO SECURE WORKERS' EN T) ERI IS U W UL AND SHALL SUEUECT AN EMPLOYER TO CRIMINAL ENALTrES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND OOLLARE ($100,000), IN ADDITION TO THEET OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I'am licensed und,visions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business rid Professions Code, and my license Is in full force and effect. tic. # Class # Contractor's Signature: Data: CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lenders Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Profasslons Code: Any city or county which requires a permit to construct. alter. Improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. It, however, the building or Improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.)- ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who buffds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License taws.). ❑ I am exempt under sec. _ Business and Professions Code for this reason: Signature: Date: Owner 10 verified by drivers license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION. ❑ I hereby certify that no excavation five (5) or more feet In depth into which a person is required to descend, will be made In connection with work authorized by this permit, and that no building structure, scaffolding, faisework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, SBC. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I Will the applicant or prose t or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? C-1Yes prose (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of SW pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applloant or present or future building occupant need to the a registration form for acutely hazardous matedals7 ©Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .................. ................ ........................................................ .......................................................... ................................................................................................................................................................................................ _._.................. 3 Does Or will theappplicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. _......................................... - --- ----._....__.................... __..................... _............................................................................ _...... _—....._........ — .._. - 4 It an RMPP Is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? [3 Yes [I No __.----._...._. _...................._........................._....................................................................._— ...._..._...—..__..— 5 Does or will the applicant Or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification from the South Coast Air quality Management District or from any other air pollution control district or agency? UYes No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if'yee. the facility must Meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have allot the disclosures prescribed by Callfomia Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ................._................. c th—........ ri •.......ir poll.................. __................-..................................................................................... ............................. ..__......_.. ................ r............. 8 (It 'yes", attach certificate of compliance from the appropriate air pollution Control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the Informatlon given Is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for Inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. afore egal Owne dfOrr r Dat cf' cgD1 F. INSPECTION TYPE PAIS INTMA CODE ! INSE&CTION TYPE pdjE 1616 Fixed System Final Fire Prevention 206 Final Mechanical - to • OK 1266 Pool Spa Final 208 Ffnal Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final $he T 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us PLUMBING PERMIT .lob Address: 3333 BRISTOL ST Suite No 1638 Vicinity: SPACE 1638 (POLO) Parcel Nunmber: 41250107 Applicant: BARTH, EDDY'-, ` Address: 140 LOMAS SANTA FE SUITE 200, SOLANA BEACH, CA Phone: (858) 793-9104 Owner: "SOUTH COAST PLAZA Address ` COSTA MESA CA , 3315 FAIRVIEW ROAD Phone: (858) 793-9104 Zip: 92075 Phone: Zip: 92626 Contractor: DICKINSON CAMERON CONSTRUCTION INC 77 FAIR DRIVE, COSTA MESA, CA 92626 Status: ISSUED Applied: 05/26/2004 Issued: 05126/2004 ISSUED BY: Address: 140 LOMAS SANTA FE ` SUITE 200 Phone: (858) 793-9104 SOLANA BEACH, CA Zip: 92075 License: 690239 Arch / Eng Address: Phone: _ Zip: , - - - - License: - j, SCOPE OF PERMIT INTERIOR 5389 SF STORE TI FOR 'POLO RALPH LAUREN" IN"SPACE 1638. 2 FLOOR DRAINS, 1 SERVICEIMOP SINK, 1 TRAP PRIMER, 1 WASTE AND VENT SYSTEM, 1 WASH ,- BASIN, WATER CLOSET, 2 WATER HEATERSIVENT - V� REF;,B04-00790 -FEE SUMMARY" AMT QTY ' AMT QTY AMT QTY ISSUE FEE $23.50 .Laundry Tub I Washer $0.00 0 Sump Pump" $0.00 0 Backflow irrigationX `'�. $0.00 `= 0 ; 'Landscape Irrigation`. $0.00 0, _''--" Swimming, Pool, = $0.00 0 Backflow Preventer $0.00 0 ' ' . P -Trap = $0.00 = 0 r Trap Primer $9.80 1 Bathtub ` $0.00 ` - 0 Pressure Regulator $0.00 0 Urinal $0.00 0 Clarifier System $0.00 0 Process Piping (per 10 ft) $0.00 0 , Vacuum Brkf Bkflow(1-4) $0.00 0 Connect (Ice,Soda,etc) $0.00 0 Receptors ` ' $0.00 0 ` ' Vacuum Brkr Bkflow(5+) $0.00 0 Dental Units $0.00 - 0 Septic Tank $0.00 0 Wash Basin $0.00 0 Dishwasher $0.00 0- Sewer Cap for Demo, $0.00 0 Wash Basin Set $0.00 0 Drain, Floor $19.60 2 Sewer Connect $0.00 0 - ' Waste and Vent System $9.80 1 Drain, Rainwater $0.00 0 Sewer Private Line -_, $0.00 0 Water Closet (Toilet) $9.80 1 ' Drain, Roof $0,00 0 Shower $0.00 0 Water Heater I vent $24.60 2 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12.21.92) EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 2446.46 (6M) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. b� I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Cade, for the performance of the work for which this permit is issued. !� My wo compensation I%surer as ernd Iicy num re: Carrier: Y C-t _,_. Policy Number, ©� (This section need not be completed if the permit is valued at one hundred dollars ($100) or less.) ❑ I certify that In the performance o1 the w I r h thi ermlt is iss of employ any person in any manner so as to become subject to the workers' compensation laws of Callforn roe 1 If sh d becom ubje to the rkers' Compensation provisions of Section 00 of the Labor Code, 1 shall forthwith comply with these provisio Applicant Signature: Date: WARNING: FAILURE TO SECUR ERS' COMPENON COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND IL FINES UP To ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE T OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed d ro 's1 s o Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Llo. # Crass # Contractor's Signature: Date; _ CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is Issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Slgnature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to Its Issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (5500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her awn employees, provided that such improvements are not Intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a coniractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Drivers License No, Expires: Verification of Ownership by (typo of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to Tile and comity a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ....................................._.................................._........................................................... ................................................................. _.._ 2 Doas or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ..........._.._............_....................................__.................................._ ............................. ..,.................... —................. __.................. ---............................................... _........ —•-... -.................... .^..................... _� 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes Cl No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, cartification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ...............................................1"y-.................,...............................................................Tio,r'n"I'---........................."af'..............................f'u"............................. iih,...................a ................................... .................................................................................... 4 !f an RMPP is presently required, has Section 25534 o. the California Health and Safety Code been fully complied wilh7 ❑Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication aHrmit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Ll Yes LJ No {Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ......... .... •.......................... __................ _... ...- ......... ­---­­.-....................... ..................................................... .._-................... ............................... _,... _.......................... --.... _.................. ---....................... __................... __... 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the CaliforniaHealth and Safety Code). ......................................................................................................................................................................................................................................................................................................................................... •................ 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ................................................................................................................................................................................................................................................................................................................................................................... 8 pf fires", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Si ai neT( to Arid/Or Authorized Applicant Date CODE A. INSPEC710N TYA QAU IHTMALS CeDEN INSPECTIONTYPE PAM Ifs 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 13- jo -n 200 Final Re-Roof 210 Final Electrical 201 Final BlocktRetalning Wall 212 Final Fire Prevention 202 Finat Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.Ci.costa-n'PjRffLS JPRESSION PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Suite: 1638 Vicinity: Parcel Number: 41250107 Applicant: DUFY, BRIAN Address: 4208 PHELAN RD PHELAN, CA - Owner: SOUTH COAST PLAZA Address ' COSTA MESA CA 3315 FAIRVIEW ROAD Contractor: TRI COUNTY FIRE Address: 4208 PHELAN RD Zoning: PDC PDC Phone: 760-868-6200 Zip: 92371 Phone: Zip: 92626 Status: ISSUED Applied: 06/03/2004 Issued: 06/15/2004 ISSUED BY: Phone: 760-868-6200 PHELAN, CA Zip: 92371 License: 803096 SCOPE OF PERMIT RELOCATE 72 OVERHEAD SPRINKLER HEADS FOR "POLO RALPH LAUREN" SPACE #1638. REF.: B04-00790 FEE SUMMARY Plan Check: $81.41 Permit: $125.25 Other: $0.00 Total: $206.66 Calc Valuation: $6,000.00 Claimed Valuation: $6,000.00 G NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92.28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 446-46 (6=) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the Vh.vo k for which this permit is issued. and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. coo ars wmpen flan Insurencef(�rnor and policy number are: Carrier: err IAJf _]iXiPl l %AIS • Policy Number: (This section need not be complete if the permit is valued at one hundred dollars {$100} or less.} ❑ I certify that In the performance of the work for which this permit Is Issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that If I should become subject to the workers' compensation provisions of Se tion 3700 of the Labor Code, I shall forthwith ^ycompy with these pr ' Ions. -Applicant'Signature: Date: fix WARMING: FAILURE TO SECURE WORKEMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIPA PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOUARE (8100,ODD), IN ADDIT TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensey,dar pr sions of Chapter 9 (commencing with Section 7000) of Division 3 of the Businessland Professions Code, and my license is in full force and effect. Lic. If Class # L IContMg_t,S€gnature: Date:12 CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500),): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for safe. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden o1 proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not appy to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made In connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec, 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ............. ........... ................................ ................................... .........11........................ ............................... ..................................................... ..................................................................................................... _....... ................................. 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 o1 the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight o1 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 does or will the applicant or present or future bu€Iding occupant need Io preparean RMPP (R€sk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ............. ............................._................................................................................................................................................................................................................................ ,....................................................................... 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully compiled with? ❑ Yes ❑ No ................................................................................................................................................................................................................................ oes .........-......... 5 Dor wilt the applicant or present or future building occupant require for the work which is the subject of this a plication a mit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? 5 Yes g No (Section 65850.2 of the California Government Code requires that the requested Information be furnished on applications for non-residential building permits). .,...... 'e..................................n. s. 'r'u....odu,'n"'...........................................-h-i......................-ir-.................u"t'................................................................... .....................,.................................................................... 6 Will any part of the facility to be constructed under this permit be w€thin 10D0 feat from the outer boundaries of a school? ❑Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). .........................................-......---......--................................................................ ... .............. ................................ ......................................................................................................... ...................... ..---.................................................... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district Cr agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ......................................... .................................. .......................................................... ..................................................................................... .............................................................................. _......................................................................... B (If yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-deschbod property for inspection purposes. I agree not to occupy or allow occupancy of any building authorizod by this permit until final inspection. Si fur f Le al Owner(s) ate Or-Authorized_Applicant D e CODE t• INSPECTION TYPE am INTm645 CODE I INSPECTION TYPE 2M INTITIA 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention tl G 4 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 BUILDING PERMIT Job Address: 3333 BRISTOL ST Status: ISSUED Suite: 1638 Applied: 04/23/2004 Vicinity: SPACE 1638 (POLO RALPH LAUREN) Issued: 05/26/2004 Parcel Number: 41250107 zoning: PDC PDC Applicant: SISSUED BY: Address: �67)7QA�s� Phone: 3 Zip: Owner: SOUTH.COAST PLAZA` Address ' � COSTA MESA CA Phone: '3315 FAIRVIEW ROAD�� " " Zip: 92626 Contractor: Aj CfX.58yr C�RiYyleJ� B%� C�rIS%!'.lii G c.L/ �.L /Address: �+ l [ d ;,lrOY)14S �lt� one: rj S� �! 5'zao Zip: ; SO/Q Hat j5( C/4 License: gDZ3 Arch : INTERIOR SPACE INTERNATIONAL' /FRANK LIMAHELUEng: Address: 10960 WILSHIRE BL '_ , Address:; STE 900', . _ Phose: 310-473-5358 Phone: LOS ANGELES, CA' ' Zip: 90024, ' ".,License: C14425 License: SCOPE OF PERMIT h , INTERIOR 5389 SF STORE TI FOR POLO RALPH LAUREN" IN'SPACE•1638:, 1' ♦f.-! , -- FEE SUMMARY J Plan Check: -$632.00 - Calc Valuation: $638,000:00 Permit: $3,889.25 -. - -- - Claim Valuation: $618,000.00 SMIP Res: $0.00 'SMIP Com: .$133.98 Other: $0.00 Inspection: ' ,$0.00 _•�u' _ - - ;7otal: .$4,655:23 ' _ PLANNING &ZONING SETBACKS ; MAIN STRUCTUREFront 0-6 'Rear` 0-'0 Left- 0-0 ''Right_ ,0-0, � i " ACCESSORY Front 0- 0�, Rear 0- 0 � . " L"eft - 0- 0 Right` 0- 0" - r - ed: l o' PARKING Existing Q _. - R/equ 0 Proposed:. NOTES: - NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-26, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446-46 (6100) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 o1 the tabor Cade, for the performance of the work for which this permit is issued. .E� i have and wi l maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. j" Myworkers' compe sation Insurcar er,anY nu +d tic Carrier:_� ranc ��CJft L��/ / Policy Number: (This section need not be completed if the permit is valued at one hundred dollars ($100) or less.) ❑ 1 certify that in the performance of the w ich is permit is i ued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws ro inion mi gre hat f I ould be ubl to the workers' compensation provisions of recti bar Code, I shall forthwith comply with these provisions.. Applicant Signature: Date: WARNING: FAILURE TO SECURE WORKERS' COMPEN ATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE ff OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed un rovis' ns of Chapter 9 (commencing with Section 7000) of Division 3 of the Busin ss and Professions Cade, and my license Is in full force and effect. Lid. # Class # r Contractors Signature: Date: _ _ _ . _ CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued.'(Sec. 3097, Civil Cade). Lenders Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Cade) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WELL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSEE) CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .. ........ ......... .......... ................................... ............................................................................................................................................................................................................................................................................................................ 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ........... ............... ........----..................................................................-•--------........................................................................................................................................................................................................... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and tiling with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ............................................_....................................................................................---............................................................................................................................................................................................1111................ 4 if an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? [I Yes El No ............ ............... ........................................I ................... ......•.............................................. ........................................................................................................................................................................ ............11..11. ...................... .. 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this plication a ermit for such construction or modification farom the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes No (Section 55850.2 of the California Government Code requires that the requested information be furnished on app$ications for non-residential building permits). ......................... ............................_.....................................................................................................................................................................................................................................................--------------............................... 6 will any part of the facility to be constructed under this permit be within 1000 feet from the Outer boundaries of a school? El Yes ❑ No (If "yes% the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Cade). ................................... .............. ......................................................... .................................................. .... .......­--------......................................................................................................................................................................................................... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have, all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No •................................................................................................................................................................................................................................................................................................................................ ........................ B (It "yes", attach certificate of compliance from the appropriate air pollution control Officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: 1 certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. tur O e i wner(s D r uthori a pp (cant t Date CODE L I"PECTIONTYPE QBIE INTRIALS CODE + INSPECTION TYPE DATE INTITIALs 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 206 Final Plumbing 200 Final Re -Roof 210 final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy 'zt( -0y (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 BUILDING PERMIT Job Address: 3333 BRISTOL ST Suite: 1638 Vicinity: SPACE 1638 POLO (RALPH LAUREN) Parcel Number: 41250107 Applicant: SNIDER, MARK Zoning: PDC PDC ISSUED BY: Status: ISSUED Applied: 08/26/2004 Issued: 09/08/2004 Address: _ - -"- Phone: 949-251-1692' , Zip: Owner: SOUTH COAST PLAZA Address COSTA MESA`CA !� - Phone: ; 3315 FAIRVIEW'ROAD Zip: 92626 - Contractor: INDOFF INCORPORATED Address: ;. 29351 ELBA DR Phone: 949-251-1692 LAGUNA NIGUEL, CA r" Zip:' 92677. License:.• 732090 Arch : Eng: SAL E FAT,EEN 1 SEIZMIC'INC Address: J- Address: 161 ATLANTIC ST Phone: ' - Phone: 909-869-0989' POMONA, CA- Zip: j License: 91768 `;' 259691 `License: SCOPE OF PERMIT \ �` INSTALLATION OF 10' SHELVING IN CONJUNCTION WITH THE INTERIOR 5389 SF STORE_ TI FOR "POLO RALPH LAUREN" IN SPACE 1638. REF:' B04-40790 FEE SUMMARY Plan Check: $24.90 �_�' �`� , -" _Calc Valuation: $8,000.00, Permit: $153.25 - - — -Claim Valuation: $8,000.00' SMIP Res:' $0.00- SMIP-Com: $1.68 Other:, $0.00 Inspection_ t. x$0.00 / Jotai: $17983 `"' PLANNING & ZONING SETBACKS,' MAIN STRUCTURE` Front 0-'O-_:) Rear','„.0-_0 ti' Left 0- 0 ; ,Right.- o- 0 _. _ ~Front '0-0 ACCESSORY ` 0- 0' /Rear. 0- 0 Left 0-0 Right .. PARKING Existing:, ``0. , '-Required:.'-,; /0 Proposed: 0 J J NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work Is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. f=ailure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446.46 (6100) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the fallowing declarations: ❑ I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. My workers' ccompeinsation Insura/n�cce crier d ollcy number are: p Garvie' !/`'�G/�TSUlLQ_ r /w/� SCS '�[aP ~ Pt NirmtierF- �� 3 Z Z / 7Q"" o 7 is section need not be completed if the permit is valued at one hundrW dollars ($100) or less.) , ❑ I certify that in the performance of the work for which th' ermit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Callipm1a, an agroe If 7sd become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provi Appl' Signature: '' �Date; p_ _ VYARNiNG. FAILURE T ECURE ORKERS' 10 V GEIS UNLAWFUL AND SHALL SUBJECT AN EMPLOVLTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,DDD), IN ADDITION 70 THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under rovisions of Chapter 9 (commencing with Section 7000) of Division 3 Business and Professions Code, and my license is in full fo effect. L'IC. # a lass Contractor's Signature: 14Date: CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). - ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - properly tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas et standard temperature and pressure). ............... ...............................................a' r' ............... t -e-...... s"?,.............................................................................................. 2 Does or will the applicant or present or Futuro building occupant need to file a registration form for acutely hazardous materials? ❑Yes ❑ No (Section 25533 of the California Health and Safety Code, with soma exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ............................................................................................................................................................................................................................................................................................................................................. 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ................................................................................................................................................................................................................................................................................................................................................................. 4 li an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No ........................................................................................................................................................................................................................................................................................................................................................................... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Il Yes H No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ......................................................................................ia' ............e,r"..............................w"i'th-i"n...............................................................rid,"r,I'...............s,'c.................[........................................-•----............................................... 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ©Yes ❑ ND (I1 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ......................................................................................................................................................................................................................................................................... ..-........... ..................................... ............... ...... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ..........................................................................................................................................................................................................•----•---------........................................................................................................ 8 (If "yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. i re Of Legal Owner(s) O ,Dto ndl r Au onzed Appllc8nt �v ale CODE #. INSPECTION TYPE J28IE INTmALS CODE I INSPEOgN TYPE WAN INTMAL$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool. Spa Final 208 Final Plumbing 200 Final Re -Root 210 Final Electrical 201 Final BlocklRetaining Wall. 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 ' Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 www.cl.costa-mesa.ca.us ELECTRICAL PERMIT Job Address: 3333 BRISTOL ST Suite No 1638 Vicinity: SPACE 1638 (POLO) Parcel Nunmber: 41250107 Applicant: BARTK EDDY Address: 140 LOMAS SANTA FE - SUITE 200 „' _ Phone: (858) 793-9104 SOLANA BEACH, CA' Zip: 92075 Owner:: -SOUTH COAST PLAZA. Address ' COSTA MESA CA Phone: 3315 FAIRVIEW ROAD Zip: 92626 Contractor: DICKINSON CAMERON CONSTRUCTION INC Address: 140 LOMAS SANTA FE 77 FAIR DRIVE, COSTA MESA, CA 92626 Status: ISSUED Applied: 05/26/2004 Issued: 05/26/2004 ISSUED BY: SUITE 200 Phone: (858) 793-9104 SOLANA BEACH, CA' Zip: 92075 License: 690239 SCOPE OF PERMIT INTERIOR 5389 SF STORE TI FOR "POLO RALPH LAUREN" IN SPACE 1638. 350 LIGHT FIXTURES, 76 OUTLETS, 4 SWITCHES, 1 SERVICE TO 1000A; 1 LOW VOLT WIRING SYSTEMICKT REF: B04-00790 FEE SUMMARY NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work Is not commenced within 180 days, or if work is suspended or abandoned for a period of 160 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result In the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 2446-0 (6/001 FA Quantity Quantity, ISSUE FEE $23.50 Temp Dist System/ Lighting $0.00 0' Temp service test $0.00 Busway 1100 ft $0.00 0, Res. alc package $0.00 Standing Section $0.00 0 New Res (1-2 units) $0.00 0�.' r Misc Electrical Equipment $0.00 , „ 0 , New Res,(3+units) $0.00 0 ` ^- Transformers up to 1 kva/kw $0.00 0 Pool 1 Spa -$0.00 0 ...up to 10 kvalkw . _ $0.00 ,' 0 Lighting Fixts $262.90 350 .............up to 50 kvalkw' $0.00 0 Recept Outlets` ; $62.88 76 .............up to 100 kvalkw $0.00 0 Switches $4.404 ` ::.......over 100 kvalkw ;," $0.00 0 Non Res Appl $0.00 01"Low 10 Voltage Equipment .- '` $0A0 : DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate o1 consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrear a�ndd �policy number aro: Carrier: r 11�1�1T1� Policy Number:! (This section need not be completed ff the permit !s valued atone hundred dollars ($100) or less.) ❑ I certify that in the performance e w for frith hl permit is is I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Califor a, gra if ! s ld be co Jec o the workers' compensation provisions of Section 37DO of the Labor Code, I shall forthwith comply with these provision Applicant Signature: 'Data -- Applicant G�iVY/ WARNING: FAILURE TO SECURE WORKERS' ID EN ATIO vFAAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINtPENALTIfS AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100.000), IN ADDITION TO THE T OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: 1 hereby affirm that I am Ilce e d rhapter 9 (comma ting with Section 7000) of Division 3 of the Business d Professions Code, one. my license is in full force and effect. be' a Class # Contractor's Signature: Date: CONSTRUCTION LENDING AGENCY. ❑ I hereby affirm that that is a constructs lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: _ _ Lender's Address: Signature: _._ Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ f, as owner of the property, or my employees wish wages as their sofa compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of Completion, the Owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ' ❑ f, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec, 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification o1 Ownership by (type of documeht, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feel in depth into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic foot of compressed gas at standard temperature and pressure). ...................—_..........................................................................._._.._............ .............. _ ................. ........... ...................................................... __F .................. ..................... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard lemperaturg and pressure}. ........................__...................._............................_........................_................._._.............__._.................---..........................................._.._.__.................._................................. _. .. 3 Does or will the applicant or present or future building occupant need to prepare en RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ..............................................................................................................................................................................................................................................................................................................................1.1...11............. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No _.._._..................._..._._..._............................................. _..................... ----...................... .......1.111 ........... .. . __........---................................................................... -... ---............... —............................. _........ 5 Does or will the applicant or prssent or future building occupant require for the work which is the subject of this application aermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes ENO (Section 65850.2 of the California GOVerhment Code requires that the requested information be furnished on applications for non-residential building permits). _ ......................__......................... .... _ ._ . ........ ..................... _..................... ----..................._........................... .......-...._.... ....................................... .............._...................... _..................... -........................... 8 Will any part of the lacility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes ❑ No (If yes', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ............................... _..................... ................ ...... ............-....... __................. ---..... _............. — .... _.......... ............ 1 ......._... ..................... .............................. _........................_............ ..._......_..._.................. 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by Callfomla Health and Safety Code Section 42303 been made? ❑ Yes ❑ No .....................................................C'S",,......... t'h".............'o'pria"'..................IuIi'o.*n._'o' n........off,i.._,.r').......................................................................................... ....... _..................... ........................... _......... ................... 8 (I1 'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIRCATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. ' n ure I Own (s} � Data Or pif t 7 Dat CODE P. INSPECTION TYPE p&. INTITIAL CODE INSPECTION TYPE QA19 INTjTALS 1616 Fixed System Fina ire Prevention 206 Final Mechanical 1266 Pool Spa Final 206 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final BlocklRetalning Well 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy CITY OF COSTA MESA BUILDING DIVISION y DEVELOPMENT SERVICES DEPARTMENT PERMIT PERMIT NUMBER E98-01045 (714) 754-5273 Fax (714) 754.4856 77 FAIR DRIVE, COSTA MESA, CA 92626 ,lob Address: 3333 BRISTOL ST Suite No 1638 Vicinity: Parcel Nunmber: 41250107 Applicant: HUNTER, MARK Address: ELECTRICAL PERMIT Phone: Status: ISSUED I' L''�.J Applied: 10/01/1998 Issued: 10/01/1998 SCOPE OF PERMIT "ELECTRICAL FOR EXISTING T. 1. AT BALLY'S IN SCP.: 5 FIXT., V REC., & 1 SW. . lig Zip: FEE SUMMARY- - �.3 \Quantity p rY Quantity ISSUE FEE Owner: S&COAST PLAZA --MAIN MALL %CJ SEGERSTROM & SONS Address FAIRVIEW RD', Temp service test $0.04 ,3315 $0.00 0 Res, alc package $0,00 Phone:}t� - Standing Section $0.00 COSTA MESA -CA % ' Zip: 92626 $0.00 0 Misc Elec6cal,Equipment $0.00 0 New Re6'(3+units) $0.00 0 Transformers up.to 1 kva/kw Contractor: ' HARBOUR ELECTRIC Pool 1 Spa �I Address: 05445 OCEANUS DR " 0 Lighting Fixts$5.00 ' Phone. .................up to 50 kva/kw ' HUNTINGTON BEACH CA _Zip:_ 92649 $1.00 1 ,. -License: 707899 0 Switches `. • , $1.00 1 :...:.:.:........over 100 kvalkw SCOPE OF PERMIT "ELECTRICAL FOR EXISTING T. 1. AT BALLY'S IN SCP.: 5 FIXT., V REC., & 1 SW. COMMENTS 1 SPECIAL CONDITIONS EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or it work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 FEE SUMMARY- - �.3 \Quantity p rY Quantity ISSUE FEE $22.00 _ , ` �, ---. Temp Dist Systein1! Lighting.r $0.00 0 1 Temp service test $0.04 _ Busway`l100.ft $0.00 0 Res, alc package $0,00 - Standing Section $0.00 01" New Res (1-2 units) $0.00 0 Misc Elec6cal,Equipment $0.00 0 New Re6'(3+units) $0.00 0 Transformers up.to 1 kva/kw $0.00 0 Pool 1 Spa $0.00 0 .... I....=: ... up to -10 kvalkw $0.00 0 Lighting Fixts$5.00 ' 5 .................up to 50 kva/kw $0.00 , ', 0 t Recept Outlets $1.00 1 ................up to 100 kvalkw $0.00 0 Switches `. • , $1.00 1 :...:.:.:........over 100 kvalkw $0.00^ 0 Non Res Appl. 1$0.00 0 Low Voltage Equipment $0.00 0 Res Appl $0.00,,, 0 „ ;, Low Volt Wiring System 1 Ckt $0.00 0 Service to 200a $0-00';;���_ 0' � Misc. Coriduit -' $0.00, 0 Service to 1006 1.$0.00 :� ; ��-0 ;. Misc., Conductor-, $0.00 '0 Service over 1000a $0.00 0 ,, Circus (gen or ride) ,' $0.00' 0 , Motors to 1 hp _ $0.00 0..' . ` .; ` Circus (Tech ride or lights) $0.00, 0' l' i Motors to 10hp $0.00, 0 Christmas Ti•ee Stand $0.00, Motors to 50hp $D.Oa 0 Fireworks Stand $0.00: ,' 0 Motors to 100hp $0.00 Il Other Electrical Fee $0.00 Motors over 100hp $0.00 0 Communication drops $0.00 0 Investigation Fee, $0.00 Sub panel to 200a $0.00 0 Plan Check Fee $0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $0.00 0 Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $29.00 Intermed Pole $0.00 0 COMMENTS 1 SPECIAL CONDITIONS EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or it work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3704 of the Labor Coda, for the performance of the work for which this permit is issued. ❑ 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed N the permit is valued at one hundred dollars ($100) or less,) ❑ €certify that in the performance of the coo or which this perrqfl is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California. and agree at if I sho a e s t7> L7 to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisions �3 _/QZZ /� Applicant Signature: !� Date: Z / WARNING: FAILURE TO SECURE WORKERS' COMPENSATI COVERAE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDrnON TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (comms Ing with Section 7000) of Division 3 of the Business and Professions Code, and my license Is in full force and effect. Lic. ff / Class fi Contractor's Signature -/ Dater— % 1� L� ' CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction tending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lenders Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to Its Issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant.to a qq€W penalty of not more than five hundred dollars ($500).): roti P n A "., ❑ 1, as owner of the property, or; my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for safe (Sec. 7044, Business and Professions,dae"The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her c_vn employees, provided that such improvements are not Intended or offered for sale. If, however, the building or improvement Is sold within one year of completion, th'e owner -builder wilt have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Lay; does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractors) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Exp€res: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet In depth Into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .................................. e. d' ....................Irit,...............................................................,................................................................ 2 Does or will the apps€cant or present or future building oxupant need to fits a registration form for acutely hazardous materials? ❑Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity at acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume o1 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ...................................................................................................................................................................................................................................................................... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ........................................................................................................................................................................................................................................... 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No ................................................•---.-.-.........................................................................................................s.u'b.......................'l1'c.............."r,m.1....................... t'r'u.............. n................... 5 Does or w€ll the applicant or present or future building occupant requ€re for the work which is the subject o} th€s a plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agent)? B Yes I No (Section 65650.2 of the California Govemment Code requires that the requested information be furnished on applications for non-residential building permits). ................................................................................................................................................................................................................................................................ 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If yes", the facility must meal the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ....... ...... .....................................••---..............................................................................................................................................................................•---.-.................-..........-... 7 II a permit from the South Coast Air Quality Management District or other air poltutlon control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ..................n .... i;I......-............................................................................................................................................................................................... 8 (It yes", attach certificate of compliance from the appropriate air pottuticn control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLJANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final Inspection. �Date� And/Or AujAorizod Applicant Date CODE INSPECTioNTYPE DAM MALS cue INSPECTIOHTYPE QAIE IfQiDALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 f=inal Building/Occupancy 244&46 Applicant --� - r to fill In all space% except those wlthlrt heavy border lines and sign all appropriate declarations, - " - - - - -- - ---• - I•�93---6f�3f�3� •�.�1:7 Tl �t CITY OF COSTA MESA, PERMIT NO.: /- TRACT NO. LOT NO. BJ�,A + CONSTRUCTION PERMIT ' ; TYPE'gF CONSTRUCTION: NEW ADD ALTERATIONIA - -ProjectAddrtss L Pa ma ve Applicant's Mailing Address 3333' Br1Sr01 Sp .]:7'4 'rear _I ? '❑ CONVERSION ❑ DEMOLISH ❑ QTHEA-Owner's'Name :raftOil Street none rDESCRIPTION OF WORK add f i re seri n 1 er p_rnn x nsion aarea .of store - -_ z I u iAddress TYPE OF PERMIT GRADING'- FOUNDATION STRUCT'A. P`.yfe ©S� ZONEArch/Eng.' = License No. ❑ TENANT ❑ ELECTRICAL ❑ PLUMBING ❑MECHANICA PLNG. REF.'S'Address BUILDING' ®OTHER rTO.BUILDINGALERT FIRE -PROTECT�I Name--- - - PROJECT DESCRIPTION, SQ: FT. OCCUPA CPR P Y I E• REAR YARD (TO PJL)Contractor's '4'3.08 !E.; -La Palma Aver Anaheim, s CONSTRUCTION TVPI° ! VALUATION $ I • Ct:EPT SIDE YARD } _AddrauIrnailingi RIGHT SID@ YARD3T'63'24ZQNj: GRADINGCU.YOS:. ACRESIPKG.SPACE REO. PROVIDEDLice__ " I STREET WIDTH ; PARK FEE:$I'hereby,affirm LICENSEDCONTRACTORpEGLARATION[Remarks: that I am licensed under provisions of Chartai,9 (commencing with section 7000) of Division 3of the f3uslness and Pro salons Cotle, and E ; !SPECIAL CONDITIONS: r y license is in full force and effect. I s License Ela - { License r PLUMBING + „ Date '+ - Signature Bar Sink Sewer Cap' ' [ ' ± ELECTRICAL WORKERS' COMPENSATION Dt3 LARATlON reby affirm.that I have a certificate of consent to selfInsu e a certlflcate r } _ Beckflaw Preventer Sewer COnneCtipn' ^' Automatic Washer 1- _ .' Meter-_ over 100 amps # i Norkers' Compensation Insurance,' or a Certified cop ereof (Section Lab. c.) ' Construction Pale ;Sub Panel' � i I _-.ro. P2 $ 84 3 -Zenith, Polity No. Compan Backflow Irrigation Solar Collectors + - - ❑ Certified copy Is hereby furnished. i I LX I + Bethtubs ? ' I Solar Pi m ! t P g t Cooking Unit ? $ j Sub Pole , ! I [ I rt lep cpppp��(( is filed with the cit i�i Q.�� i -ti S PROTECTIOr1 CEarifiers l .. I Solar Tank Dishwasher ,Motors 00-1 HP 07 h$ pat' AppllcantY,C.'1E ' EXEMPTION,FROM WORKERS' COMPENSATION DECLARATION [ Dryers ❑Gas" ❑Electric ❑ ❑16.15+ (This section need not be Completed if the permit is for one hundred ($100) or 1 Dishwasher t Swimming Pool w/Spa y i Inc,$Olar; 9;15 HP S less): j I certify that in the performance of the work for which thli permit is Issued ! Drinking Fountains I Urinal i Fan; , I Microwave , I ' shall; not employ any person in any manner so as to become subject to the workers'=Compensation Laws of California.! , , I I FIoOr Drainsi - - , {Nater Closet, F.A.U. i , ?POIe]Light Date �Ignature,_ NOTICE: If;after making this declaration; yoq shoWtl become subject to the •!- , I _. -� FIOOrSinks-1--- ` :Water•Weate_r - �� Fixtures ;_ ± - ' _ .,.p ' _ !Range,..-.4 - _ - Workers' Compensation' provisions of the Labor Code, you must forthwith comply 'withs Such '.provisions -;or ;thiS"pernmit Shall be 'deemed' revoked ; + P Y p [ - ' tQutlets ; - ' Ga's Servicer , i rylfatei Service j t.- ", ; S, Device Boxes f 'Sign ) ; CONSTRUCTION 4 LENDING AGENCY t r I hereby aNlrm that there is a,construction lending agency. for the performance] -issued a { ;� Interceptors : , ^ - _ r + - Q ( �_ I ,: •. ' f t Outlets I ( 1 t l l Standing 5ectionS i [ of the 'work for, which• this, permit -is (Section •.3097; Clv: C.j• i Lendar's� Name,--!-- I ° o _ , (itch' I :; :� _ i Switches i v [ rTrash Compactor l 1 Lender's Address°�'� i + ^' _+ _ s - , Lavatories-• _ o- , - Garbage Disposal + { OWNER BUILt]ER DECLARATION '� ! ' ; I hereby,iffirm.that I am exempt,from the'Contractor's"License l.aw forthe' I 1 I _ - y ] r .` y i i , Generator E10'5 KW ❑5-15 KIN following reason (Section.7031.5 Business and Professlonal'Code: Any city or 4 a P-Trap' y .county which, requires a permlUto construct, alter Improve demollsh•or'repair 'any structure, prior to its,issuance,;atso requires the applicant for such permit, I = 'Roof Dfains 1 ' " +�' ► - �• i ( ] ., [ ] a Transformer ❑ 15 50 KW ,.to file a slgned statement that he/she Is licensed pursuant to the'provislons of , the Contractor's License Law (Chapter 9 (commencingiwith;5ectlon 7000) of ' = : - I Rein $i5 { ❑5U+KW' , Rain titian Fee i S15 1 > i � s[on -3 of the Business and Professions Code)"or; that, he/She-Is'exempt �a:X',5" efrom and the' basis for the alleged exemptiortr•Any'violation-of•Section Showers etion'Fee Meter ❑up to 100 amps Issue Feet $ •`°.';1.5 by' any applicant for: a' permit -subjects ,the �appllcant to a. civil 1 natty of not more than five hundred dollars ($500): ; r • i ( 'ori `with l I Service Sink + :. 'f „ ' �- ( Issue Fee Zoning Approved By Date 1,1as'owner of. the 1property my Employees wageslas their sole compensation. do is not intended or offered ' :' MECHANICAL i I i will the work; and the structure for sale.(Sec41on 7044; Business; and, Professional Code: The Contractor's , { Application Approved By ----' — - ' Data ; : - License Law does not apply to an owner of a property,who builds or Improves 'does 11 Boiler I ; I i Refrigeration System I : Application Issued By L 'Date thereon,'and who such'work hlrriself/herself or through his or her own r employees, provided that SuCh improvements are'not intended or offered for sale, if, however, the building or Improvement Is sold within one year of com- , g p pletlan, the owner;will have the burden of proving he/she did not bulld or {m- r Duct - Under,Ground ❑0•,100,000BTU ❑100,006BTU'- ^ r "] t ; + i [ ( $UMMARY OF F£E5 I drove for the purpose of sale}t } t [ Duct - Struct_ural i i •, System Repair/Alteration �8U1 LDING PERMIT $ a eo ,MIP r $ r LJ I, as owner of the property, am exclusively contracting %wlth.licensed Con• Ventilating ,tractors to.construCt the'project,(Sect]on_7044, Business and Professions Code: _:- The Contractor's does to an Duct - -._ _ . -.i - _ _ ��•_ - r r^- _ : , PLAN CHECK $ `+, PERMIT ' , License Law not appl owner of property who ;builds or improves thereon, and who contracs for such protects with acan- r ) Exhaust System ❑ Multiple ❑ ; 4 j I [ ,PLUMBING $ ISSUANCE , $ t tractor(s) license pursuant to-the Contractor's I Icanse Law)-' ❑ I-am Exempt under Section B. & P, C. far this reason } 9 Fkepl/Fact, Bit. ICBG + l `PLAN CHECK. $ GRADING I $ �- i 'ELECTRICAL! I I } $ Date I * Owner? i I I I Heating�System&Ducting 1 - $ ! f 1 MICROFILM $ I-hereby-certify that-1 have read-this application -and state that-ttie•above (• Information ❑0100,000 BTU G�i00,0008T - c- - t ~� r IPLAN CHECK. $ [ Is correct. 1 agree to comply with all city and county ordinances antlt'state laws relating to b llding Constructlon,;and hereby authorize retire- sentative5 of this city t enter upon the above-mentioned , 1 Hood or Type I ❑ } , t , i i +MECHANICAL' $ I a ' I + I I TOTAL'FEE $•',� 1 ! r 1 ; { p property ,for j Inspection R ! ? € i CanO ' T e U ❑ } { Reinspection Feel I $15 IPLAN CHECK ' $, = LESS Slgnature ' r t Date 6-1'3-83 , , S j ; ; i 1 ADVANCED PC i $ l Drivers' V nse or 55 ' r t 1 { ; Registers , { ( I kk I t Issue Fee ' t f + { $ 3 r l 1 I I I l { FINAL FEE: {$ CMF 0865-46 rev. 12/82 White - iding; Canary - Applicant; Pink - Accounting; Goldenrod - Assessor ,u "CONSTRUCT 'e ', f.': F(F j .4. ,cz= rd-;,POOL�;',hr}k " - i .0 . � � < < �(� Date 7 � APPROVALS �, Permit-#,- = :Inspector s - e APPROVALS- _ Permit Date Inspector ' i Temporary#Electrical Service or•Pole ° ^;�; I o� _,°�, :52: Pool &equipment Location, 2: Soil Pipe Undrgrnd�,o i r53? Steel Reinforcement i 3: Electrical Conduit Uiifity-Undrgrnd: ' c ' �'; �;� 54 Forms;? _;. "? 4: Electrical Conduit-Undrgrnd' ° �,' - '55�'ElectricaI Bonding n a �: 5: ;Steel Reinforcement G - -. 56.• Rough Plumbing &Pressure Test , j w F. _ 6. 'Elects ical OF R Grnd.� c ' } C r L -Z _- 57: TO`60VER-GUNITE _APPROVAL E, 7. Footings 58.' Electrical.Conduit'Undrornrl. 1 t U 8. Foundation ! f > 6 �_ `59. Gas Pipe,-❑ 70 drgrnd., Test i- . 9. Water, Pipe-Undrgrnd. i _ } 60. Backwash Lines, P -Trap, ❑ Undrgrnd. , 10. Structural Floor System 61. APPROVAL TO -DECK , I a v 7 r.. 11. Property Sewer Line &House Connection,62. Backwash & Receptor -Final- 12. Sewer Cap , F %j ! `, `A 63. Heater, &,Vent -Final ► 13. RooUDrains i i r - '64. Plumbing:System - Final = , C, o 14. ,Rough Plumbing a p { ' Y65. Electrical-F+nal' ' 15.. Rough Electrical=Conduit-r - `r-' ` - { ; i ' ' t ? `,66., Sola�,Sysfem Final' " - : t -16� 'Rou h Eleciric,Wirin ' I' 9 g� a i i#= = i'� �"! ! ' - - "67� Fencing& Access Approval �. 1 y ^t r i C _ i y'17. -Rough.Wiring'SignP ' ji j,'`' f j '' i ' { '68,' APPROVED FORiPLASTERING f ' 18. tRiiugh Elegrical.,T=Ba`r Ceiling ir, . f69,l POOL/SPA SYSTEMS FINAL 19 'Rough'Heating &,Airbonditioning ` i! + i ; FIRE DEPT.,REQUIREMENT Permit � =+ Rough_Factory 1 �0. Fireplaces �j I j APPROVALS. 1 r {t 21bticts, in Strumure_s , f 1 i ,70.j Underground Hydro I ' 22. 'Ducts, Ventilating r cd # �� 1 i j ',71.1 Product Piping ❑ Gas ❑ Oil } , d 23. Gas Pi a-Rou h & Test ¢ { 4 r �- pl 9 �- ! - - -- I ,- -, - • 'rgro - r72.i Underground Flush ;-, f# 24. 'Roof Framing, tI i I= { ,� ca s •,, ( k- 73.E Undergrnd. Storage Tank.❑ Gas ❑ Oil 4' L' i,* I Y ' " 25. 'Roof Sheathing • I i! " i 1 u '= (U = I `7q,, Overtiead Hydro 26. T -Bar Ceil�irig iStruciuralY & Monocoat7 ! i „1 75.s Dr,y Chemical - - �{ i i 27. Frame and Flashing: _' t 1 {# (� i i 76.} Dry Standpipe 28. Lathing .&-Sidi'ng' ? ;, # { #t ii # [ i j77.` FIXED SYSTE`M;FINAL .3(�- 1 29. drisulatiori i` , " h € i i, i i '.7B: FIRE PREY. FINAL : r ;Drywall Nailing i i r i ;Notes:', T, , i y ; # i, . � ,Plaster Brown Coal .11. Meters Final j i' t ' i x`32. 'Electrical'Power r 33. Final Electric '. _ �_}; „ { 34. Final Heating &f Air', Conditioning I i 35. Final Gas. Pipe=Tesf� r ;;; L" #.` �'� - R + 36. Hood or ICanopy," n; 37. Final Factory Fireplace 38. Final PluMbi'n9 39. Water Servici,e-Final 40. Gas Sei-vi`ce-final 41. Solar p mesiic-Final 42. Backflow Prevented -- •43. Backflow Irrigation 44. LandscapeIrrigation System - =' 45. Sound Attenuation i 46. Handicap{Regufations ui f I s 47. FINAL STRUCTURE & BUILDING � 48. Special Requirements Corripleted ' � • ` I t , 49. Electric Releaseito 'Edisoni 50. Gas Release to Southern California Gas Co 51. CERTIFICATEOF�OCCUPANC{Y{ '_ Li_ _I C"'� - __i j�_;-_ ' No. Date 1 i I i� j 3� r t - St&: T ITY OF -COSTA MESA Development Services, Division of Building and Safety CERTIFICATE OF,�OCCUPANCY This certificate is issued pursuant to the requirements of the Uniform Building Code, Section 308 adopted by the City of Costa Mesa certifies that at the time of its issuance the building structure heeeiii below described was inspected and approved for occupancy as follows; Building Address 3333' 1001 Bristol St. ` ' Bldg. Permit Number B06-00323 Use Commercial - }, Group M Type of Construction �''Z� FRS'' ` 1.4e h t� Use Zone PDC Owner of Building South Coast Plaza -Tenant _Tf 6R)v` Address 3315 Fairview Rd;' Costa Mesa'°' CA 92626f-- BUILDING OFFICIAL-Khanh Q. Nguyen, C.B.Q. Date 5-22-06 REQUIRED TO BE POSTED IN A CONSPICOUS PLACE � wri���r-'++n�+.w'r1-r....i..".._r'-rr'`-fr._�rt_w. i...�.�h.-.f- �. •--_ v�-.r� .!' Cit"PofCCS.521)e5ata � Development Services, Division of Building and Safety 1 CERTIFICATE OF OCCUPANCY This certificate is issued pursuant to,, rtt-requiiements rof the- Uviform Building Code, Section 308 adopted by the City of Costa Mesa ceftifies.that-at-th'e tiii'e 6f its:issuance the building structure herein below described was inspected and;approxred;far•oc upancy as f � s: Building Address 3 3 BBiSTU S Bx UNIV 1001 ,' \. Bl , Peru- it No. B98-0 802 Use BBTAIi, GroetpM Type.of Construction - _r- Bire.Zone --- `� ---- Use Zane Owner of Building C. _J.' �Se er`strom`c&=*Sans =7 -Tenant 119$F13ORe Address 3315 Fairvie, kd- Hese, CA- 92626 Rick A. Brown,C$0 ��:Lv'� ��;� - By 1 � BUILDING OFBiC Y. � _ .. ; _ami mg�f?afe r ��l}ece bei 24 1998 REQUIRED TU BE POSTED"IlV A CONSPICOUS PLACE 3333 I001 BQ1,3TDL -qv' 8R City of Costa Mesa Development Services Department Building Safety Division CERTIFICATE OF OCCUPANCY No. () 0 '� ^ Z11 O 8 0 P. O. Box 1200 Costa Mesa, California The Building located at '1313 Reiatol Street, Soace_1.001_ has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group sal Occupancy. Use of Building po, t•ai l Legal Description A72-501-02 fSee reverse side for Metes and Bounds) Building Permit No B 51189 Electrical Permit No. E 51431 Plumbing Permit No. Mechanical Permit No. M r►iAi)Q Number of apartments and/or guest rooms ISSUED TO: Building Of ficial Tony CID- Baca Tho Gazebo 3333 Bristol Street, Space -LUUl by Costa Mesa, �:A 92626 � Date AQril 17, 1991 This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. 'CMF 1015.46 rev. 1/83 White - Owner; Canary - Numerical File; Pink - Bldg. Permit Fife 4r &?33 /190/D� I�T`oL >1 , S 3q 9.74 City of Costa Mesa Development Services Department Building Safety Division P. Q. Box 1200 Costa Mesa, California t.,,, may. CERTIFICATE OF OCCUPANCY The Building located at 3333 Bristol Street, Space 1401 has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group n? Occupancy. Use of Building 412-501.-02 Legal Description Retail (See reverse side for Metes and Bounds) Building Permit NoR34R7a,R353913 ._Electrical Permit No. E 34993 Plumbing Permit No. Mechanical Permit No. M'45025. M35203 Number of apartments Eire Prevention Permit bb. F 34853 Building Official George Edmiston .ISSUED TO: C. J. Segerstrom & Sons 3315 Fairview Rosa Costa Mesa, CA 92626 and/or guest rooms by Date November 20, 1989 This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. CMF 1015.46 rev. 1/63 White - Owner; Canary - Numerical File; Pink - Bldg. Permit File i3 L 00i BK4,57N- s� (714) 754-5273 • Fax (714) 754-4856 • www.ci.ccsta-masa-13L kLDING PERMIT .lob Address: 3333 BRISTOL ST $38.75 SMIP Res: Suite: 1001 $0.50 Other: Vicinity: 1001 $0.00 Total: Primary Occ: M Display/Sale Merchandise Type of Construction: I -FR Parcel Number: 41250107 Zoning: PDC Applicant: JOE GERARD Address: 2000 PLACENTIA AV Phone: 949-631-2499 COSTA MESA, CA Zip: 92627 Owner: SOUTH COAST PLAZA Address COSTA MESA CA Phone: 3315 FAIRVIEW ROAD Zip: 92626 Contractor: JOE GERARD SONS Address: 2000 PLACENTIA AV Phone: 949-631-2499 COSTA MESA.' CA Zip: 92627 License: 789424 Arch Eng: Address: Address: Phone: Zip: License: SCOPE OF PERMIT B06-00323 NON ILLUMINATED FRONT STORE ALUMINUM SIGN FOR THEORY Plan Check: $25.19 Permit: $38.75 SMIP Res: $0.00 SMIP Com: $0.50 Other: $0.00 Inspection: $0.00 Total: $64.44 SETBACKS MAIN STRUCTURE Front .0- 0� Rear 0-0 ACCESSORY Front 0- 01 , Rear 0-0 PARKING Existing:, 0' -Required: 0 FEE SUMMARY 77 FAIR DRIVE, COSTA MESA, CA 92626 ISSUED BY! Status: ISSUED Applied: 05117/2006 Issued: 05117/2006 Phone: License: Calc Valuation: $1,000.00 Claim Valuation: $1,000.00 PLANNING & ZONING Left 0-0 Right 0-0, Left 0-0 Right 0-0 Pronosed: 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced wifhin 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 zaaaas (6m) DECLARAVONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following doclaratio= ❑ I have and will maintain a certlficete of consent to self -insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this perinit is Issued. have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit Is Issued. works mpensatlon Insurance carrier and policy number are: �q 6C7' �� �"'t� _ _ licy Number. �� / /S %D /ZO 03 section need not be completed it the permft is valued at one hundred dollars ($100) or less.) ❑ I certify that in the performance of the work for which this permit Is issued, I shall not employ any person in any manner so as to become subject to the workers' econsualion laws C ifomla, agree that if I should become subject to the workers' compensation provisions of Section 3700 the Labor Code, I shall forthwith these rovi ns. e: TO RE W RV COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOY NAL PENALTIES D CML FINES UP TOONE HUNDRED E ( 00,000). IN ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby licensed un er rovslons o1 Chapter 9 (commencing with Section 7000) of Division 3 slness and Profession Code and my license Is in full force c. Lic. q �� C G Y 2 a ors SI nDate: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lenders Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to Its Issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an Owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ t, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractors) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, Le. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, Califomla Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ............... — ....... --- ---- ----------......---................—.............................._.._....--- .......... .....- ----- ... --- - ---.. 2 Dces or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressod gas at standard temperature and pressure). ................ _...................... _.._............ ........................................-........-....-...._._.................. ......_.......................... .......... .................................. ......... ........... _.._ 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ................................... .�_---.-.................—.....................-........................ -.......... .............................................................................--.................._.-_....._.. -- 4 Ii an RMPP Is presently required, has Section 25534 of the California Health and Safety Code been fully compiled with? ❑ Yes ❑ No ..................................... --- ............. ...........I •---.._..................... ......-......... .............. ...._......................... ...... ................-............................................ ....... ... .._...M......_.............._........... � ........... 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this application a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? UYes No (Section 65850.2 of the California Government Code requires that the requested Information be furnished on applications for non-residential building permits). _...................... - ............... _........... -. - ....................- ..... _� ....._... _ 6 Wiil any part of the faty to be constructed under this permit be within 1000 feet from the outer boundaries of a school? []Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). __...........................- ................. _ .. ----...----............--.............._.-..............-.... _ ............... - 7 If a permit from the South Coast Alr Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ................ .__........................— .............. --- --...-._...... _ _..._.............................I............--.__.-. 8 (If fres", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the Information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I cartity under penalty of perjury that I have read this application and state that the Information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for ins on purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Si ure Of L Owner(s) Date (Z�--) S/?/0, 6 An ori t Date CODE I INSWTIONTY 2&3 ]MAL 5 cool w lfl.S£ESIlQNTYPE 2M IITITIA�S 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 209 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block(Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place r 220 Final Planning Approval 203 Final Sign 222 222 Final Site 204 Final Demolition �� 250 Final Building/Occupancy 33:: � 001 RP/SrDI- %5"-T- n ., , — —.17 73 (714) 754-5273 • Fax (714) 754-4856 • www,ci.costa-mesaMLDING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 ,lob Address: 3333 BRISTOL ST suite: 1001 Vicinity: SPACE 1001 THEORY Primary Occ: M Display/Sale Merchandise Type of Construction: I -FR Parcel Number: 41254107 Zoning: PDC Applicant: EDDY BARTH Address: 140 LOMAS SANTA FE STE 200 Phone: 858-967.4325 SALANO BEACH, CA Zip: 92075 Owner: SOUTH COAST PLAZA Address COSTA MESA CA Phone: Permit: 3315 FAIRVIEW ROAD Zip: 92626 Contractor: DICKINSON CAMERON CONSTRUCTION INC $102.90 Address: 140 LOMAS SANTA FE $0.00 Inspection: SUITE 200 . I Phone: 858-793-9104 'SOLANA BEACH, CA MAIN STRUCTURE Zip: 92075 License: 690239 Arch : GSP Existing: ' 0 Required: 0 Eng: Address: KENNETH PRIEST Address: NASHVILE, TENNESSEE Phone: 615-770-8100 1400 NASHVILLE CITY CENTER511 UNION ST Zip: 97219 License: C29596 ISSUED BY: Status: ISSUED Applied: 02/27/2006 Issued: 03130!2006 Phone: License: SCOPE OF PERMIT 3,005SF INTERIOR T.t. FOR "THEORY" IN SPACE 1001. WORK TO INCLUDE: REMOVAL OF (E) NON -LOAD BEARING PARTITION WALLS AND CEI ORDER TO RECONFIGURE $PACE, RELOCATION OF BATHROOMS, STORAGE AREA, OFFICE, FITTING ROOMS, NEW STORE FRONT, EL MECh WORK. Plan Check: $516.39 Permit: $3,177.75 SMIP Res: $0.00 SMIP Com:. $102.90 Other: $0.00 Inspection: $0.00 Total: $3,797.04 SETBACKS MAIN STRUCTURE Front 0-0 Rear 0-0 ACCESSORY Front 0- 0 Rear 0- 0 PARKING Existing: ' 0 Required: 0 FEE SUMMARY Calc Valuation: $490,000.00 Claim Valuation: $490,000.00 PLANNING & ZONING Left 0-0 Right 0-0 Left 0-0 Right 0-0 Proposed: 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 2446.46 (sroo) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 3 I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. My workers' compensation Insur neo carrier and poll cy number are: J Carrier.— Poll cyNuSnber: 7�� �O1607 (This•secllon need not be completed if the permit is valued at one hundred dollars ($100) or less.) ❑ 1 certify that in the performance of the work for whi h this permit is Issue I shell not employ any person in any manner so as to become subject to the workers' compensation laws of Califomia, r t a I shout t to a workers' compensation provisions of Section 3700 of the Labor Code. I shall forthwith Comply with these provisions. % (Appllca� n JtSlgnatura: rDate::__— t WARNING; FAILURE TO SECURE WORK P SATION ERAGE IS UNLAWFUL AND SHALL Su9JECT AN EMPLOYE TO O CRIMINAL PENALTIES AND CML RNES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COSTO COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am lice ad der provisions Chapler Id (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in lull force and effect. Lic'N C)as # Contractor's Signature: Data CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction tending agency for the performance of the work for which this permit is Issued. (Sec. 3097, Civil Code). Lenders Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a Civil penalty o1 not more than five hundred dollars (5500).): ❑ 1, as owner of the property, or my employees with wages as their We compensation, WILL DO THE WORK, and the structure Is not intended or offered for safe (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner 10 verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more loot in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Set. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic foot of compressed gas at standard temperature and pressure). .................................................................................................................................................................................................................................................................................................................................................. . ........................ 2 Doos or wiSl the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .............................................................. ......... ---- --- ----.._.............................. .....-....... ............................... _.................................................. _...................................... .............. .............. .............. ............... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is prosently required, has Section 25534 of the California Health and Safety Code been fully oomplied with? ❑ Yes ❑ No .................... _................ __.................... _....................... ----.._................................. ----.................. ..............................................................................................................................................—_...........-............ 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this appllcation a ermif far such construction or modification from the South Coast Air Ouality Management District or from any other air pollution control district or agency? LJ Yes No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). -_ ._......... __.................................._....-...---._.................................._............ ..................................................................................... -............................... —........ --- ........ --.-_.......... _ 6 W111 any part of the facility to bo n�nstructed under this permit be within 1000 feet from the cuter boundaries of a school? ❑ Yes ❑ No (If yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). _.................— ........... __.__...__. _._ .............._._._ _........................................................................................... _...... _.......... — ...... 7 li a permit from the South (:cosi Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No .............................................................................................................................................................................._.........................-.............-..........-- ................. 6 {If yes', attach certificate of compliance from the appropriate air pollution control officer}. CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given Is correct. I agree 10 comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. n re I egal0 er(s) Date CODE /. INSPECTION TYPE pAU Imo$ CODE 1 INSPECTION TYPE 2AR 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Relalning Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Silo r 204 f=inal Demolition 250 Final Building/Occupancy J V 23 3,6 /0D f A'PIS7DL Sr RJ .- 1 4,-7✓t' (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca-us 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT .Job Address: 3333 BRISTOL ST Suite No 1001 Vicinity: SUITE 1001 THEORY Parcel Nunrnber: 41250107 Applicant: BARTH, EDDY Address: 140 LOMAS SANTA FE SUITE 200 SOLANA BEACH, CA owner: SOUTH COAST PLAZA Address COSTA MESA CA 3315'FAIRVIEW ROAD Phone: 858-793-9104 Zip 92075 Phone: - Zip: 92626 'Contractor: DICKINSON CAMERON CONSTRUCTION INC Address: 140 LOMAS SANTA FE SUITE 200 Phone: 858-793-9104 SOLANA BEACH, CA Zip: 92075 License: 690239 ISSUED BY: Status: ISSUED Applied: 03/30/2006 Issued: 03/30/2006 SCOPE OF PERMIT 3,005SF INTERIORT1. FOR "THEORY' IN SPACE 1001. WORK TO INCLUDE. REMOVAL OF (E) NON -LOAD BEARING PARTITION WALLS AND CEILING, IN ORDER TO RECONFIGURE SPACE, RELOCATION OF BATHROOMS, STORAGE AREA, OFFICE, FITTING ROOMS, NEW STORE FRONT, EL MECH AND PL WORK. REF: B06-00323 121 LIGHT FIXTURES, 18 OUTLETS, 10 SWITCHES, 1 NON RES APPL (INSTA HOT), 1 SERVICE TO 200A, 4 MOTORS TO 1 HP NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446.46 (6100) FEE SUMMARY Quantity _ Quantity ISSUE FEE~ $23.50 Temp Dist System / Lighting $0.00 0 Temp service test $0.00 Busway 1100 ft $0-00 0 Res. a/c package $0.00 Standing Section $0.00 0 New Res (1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0 New Res (3+units) $0.00 0 Transformers up to 1 kvalkw $0.00 0 Pool / Spa $0.00 0 ................up to 10 kva/kw $0.00 0 Lighting Fixts $95.73 121 -" ................up to 50 kvalkw $0.00 0 Recept Outlets ' $19.80 18 .................up to 100 kva/kw $0.00 0 Switches $11.00 10 ..................over 100 kva/kw $0.00 0 Non Res Appi $4.75. 1 Low Voltage Equipment $0.00 0 Res Appi $0.00 0' Low Volt Wiring System 1 Ckt $0.00 0 Service to 200a /, ",$30.50 �:, .. 1 Misc. Conduit $0.00 " , 0 Service to 1000a $0.000.. Misc. Conductor $0.00 , 0 Service over 1000a $0.00' 0. ' - Circus ( gen or ride) $0.00 0 Motors to Ihp $19.00 4 Circus (mech ride -or lights) $0.00 0 Motors to 10hp $0.00 0 Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 - 0 Fireworks Stand $0.00 0 Motors to 1 00h $0.00 0 Other Electrical Fee $0.00 Motors over 10t)hP $0.00, 0 Communication drops $0.000 Investigation Fee $0.00 Sub panel to 200a $0.00 0 Plan Check Fee $0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $0.00 0 Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $204.28 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446.46 (6100) WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a cerlificale of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. X—C.have and will maintain workers' compensation insurance, as required by section 3700 of the labor Code, for the performance of the work far which this permit is issued. My_workers' compensation Insurer e r er and olicy nu bar are: �— � M G' Carrier:cr Policy N_ umber. (This section need not be completed if the permit is valued atone hundred dollars ($100) or less.) ❑ 1 certify that in the performance of the work for which this permi 's issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of CaI'rfom• ,W�i houl a Jact to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provision . 7 `Applicant Signature: Date: l G `WARNING: FAILURE TO SECURE WORKERS' CDMPE TION COVERAGE IS UN W UL AND SHALL SUELIECT AN EMPLOYER CRIMINAL PENALTIES AND CAVIL FINES UP TO ONE HUNDRED THOUSAND DOUARE ($100,ODO), IN ADDITION TO THE T OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: 1 hereby affirm that I am licenseJ under provisi s o hapter 9 (commencing with Section 7000) of Division 3 of the Business nd Professions Code, and my license is in full force and effect. Llc-# Class fl Caritr� act's Signature `Date- L1 r CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code), Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of properly who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for safe. It, however, the building or improvement is sold within one year of Completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractors) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - properly tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION - 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ................................................................. ................................................ ................... ....................... ............................................................................................................................. -................................................................................. 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ....................................... _._........ ........................................ .............................. --­........................ ................. ........................................................................................... ........................................... ............. 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. If .............................................................. 4 an RMPP is' presently required, has Section 25534 of the California Health and Safety Code been fully Complied with? ❑ Yes ❑ No .............................................................................................................................................................................................................................................................................................................. 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ormit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution Control district Or agency? Yes No (Section 65850.2 of the California Government Coda requires that the requested information be furnished on applications for non-residential building permits). ..................................................................................................................................................................................................................................................................................................................................................................... 6 Will any parl of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (it'yee, the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). "I'll, ........................................................................ 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ......y..........--........................... _........................................................................ ...................................... ................................ _................................................. ............................................. .. 8 (If es", attach Certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purpos I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. u al er(s) ate A `Authorized Applidant "Das.-�?' CODf<1. IN§PECTION TYPEj TINTt IALS CODE I INSPECTION TYPE ATS, INTMAL,S 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing rr 1200 Final Re -Roof 210 Final Electrical 1 Y/ 201 Final BlockfRetaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval i 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy 3,333 1001 BR(srDL sr RnI.-.nn;?-):I -r (714) 754-5273 • Fax (714) 754-4856 - www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Status: ISSUED Suite: 1001 Applied: 03/3112006 Vicinity: SPACE 1001, THEORY Issued: 04/24/2006 Parcel Nunmber: 41250107 Zoning: PDC PDC Applicant: PONTOLILLO, CAROL ISSUED BY: Address: 4208 PHELAN ROAD Phone: 760-868-6200 PHLAN, CA Zip: 92371 Owner: SOUTH COAST PLAZA Address' 3315 FAIRVIEW ROAD Phone: COSTA MESA, CA; Zip: 92626 Contractor: DUFY, BRIAN Address: Phone: ; Zip: License: 803096 SCOPE OF PERMIT FIRE SPRINKLER PERMIT. FOR 3,005SF INTERIOR T.I. FOR 'THEORY" IN SPACE 1001. REF#: B06-00323 FEE SUMMARY Plan Check: $72.31 , Permit: $.111.25 Other: $0.00 Total: $183.56 5•ji•06 Fres ow Calc Valuation: $5,000.00 Claimed Valuation: $5,000.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12.21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable Codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 t44s46 (sroo) <�� rS 146, m DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm lander penaltVof perjury one of the following declarations: ❑ I have and w(Il maintain a certificate Of Consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the ":ork for which this permit is Issued. have and will maintain workers' compensation insurance, as required by section 3700 Of the Labor Code, for the performance of the work for which this permit is Issued. My worke ' compensation Insurance carrier and p Ii7bar are: Carrier: P,6Il .NUrAber: 6VV S 0-0452 ?%-O (This section need not ba ompleted if the permit is valued at a hundred dollars ($100) or less.) ❑ I certify that in the perform a of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers'' compensation laws of CaFoq a, andagreeii I should become subject to the workers'compansation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provis �Applicanl'Stgnature: t (Date's Cv _ WARNING:-FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($10D,1000), IN ADDITION TO THE COST OF COMPENSATK)N, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provigi s of Chapter 9 (commencing with Section 7000) of Division 3 of the Business ppd Prof ssions Code, and my license is in full force and effect. Lic. # U �7 to Class ((vim Contra,�S€gn� a— tura: £DeY - G C, CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he Or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not Intended or Offered for sale (Sac. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law docs not apply to an owner of property who bullds of improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type Of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present Or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ......................................................................................................................I........................... ... .....................-.--.................................................................................................... -..-............... ........ .......... .......................................... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater then a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature& and pressure). .................................................................................................................................................................................................................................................................................................................................................................... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health ;and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ...................................................................................................................................................................................................................................................................................................................................................................................... 4 I1 an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No ............................................... .........•--....................... ......--...,..................................................................... I'll ..................... ....................................................................................................... -............................ ­----........................................ --... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application amrmit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes © No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ......_-- ................................ ............................... ................................. .......................... .................................. ..................................... .........---..--.................................................................................................................................................. 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If _fres", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code): 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject Of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No .............................................. .................. __........................................................... -----.. --------.................................-----------..-.......................................................................................................-----................................ 8 (It yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: _ Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described properly for inspection purposes. I agree not to occupy Or allow occupancy of any building authorized by this permit until final inspection. g t e Of al Owners Date Atld(Or.Authorixed Applicant G =Date CODE It. INSPEg1KWTYU 2AM IKTfTIALS CODER INSPECTIONTYPE4�Ili NI TRfALg 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical C 201 Final Block/Retaining Wall 212 Final Fire Prevention J i 01 ca 202 Final f=actory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demplition 250 Final Building/Occupancy 33 3 � 1001 B il� r STDt< S"T_ _7^)? . //1 (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 MECHANICAL PERMIT Job Address: 3333 BRISTOL ST Status: ISSUED Suite No 1001 Applied: 03/3012006 Issued: 03/30/2006 Vicinity: SUITE 1001 THEORY Parcel Number: 41250107 ISSUED BY: Applicant: EARTH, EDDY Address: 140 LOMAS SANTA FE SUITE 200 Phone: 858-793-9104 SOLANA BEACH, CA Zip: 92075 Owner: SOUTH COAST PLAZA Address: COSTA MESA CA Phone: 3315 FAIRVIEW ROAD Zip: 92626 Contractor: DICKINSON CAMERON CONSTRUCTION INC Address: 140 LOMAS SANTA FE SUITE 200 Phone: 858-793-9104 SOLANA BEACH, CA Zip: 92075 License: 690239 SCOPE OF PERMIT 3,005SF INTERIOR T.I. FOR "THEORY" IN SPACE 1001. WORK TO INCLUDE: REMOVAL OF (E) NON -LOAD BEARING PARTITION WALLS AND CEILING, IN ORDER TO RECONFIGURE SPACE, RELOCATION OF BATHROOMS, STORAGE AREA, OFFICE, FITTING ROOMS, NEW STORE FRONT, EL MECH AND PL WORK. REF: B06-00323 4 VAV BOXES, 1 VENT FANISINGLE DUCT, 1 VENTILATION SYSTEM FEE SUMMARY Quantity ISSUE FEE $23.50 Quantity Inst FAU <100 k BTU $0.00 0 Inst FAU >100 k BTU $0.00 0 Repair/Alt Cooling/Heat $0.00 0 Inst I Rep. Recess Wall Htr $0.00 0 Ref rig Sys <100 k BTU $0.00 0 Ref rig Sys >100 k BTU $0.00 0 Gas Piping $0.00 0 Factory Fireplace $0.00 0 Hood w/Mach Exhaust $0.00 0 VAV Box $42.60 4 Vent Fan I Single Dud $7.25- 1 Appliance $0.00 0 Fire Dampers $0.00 0 Smoke Dampers $0.00 0 Inst or Relocate Appl Vent $0.00 0 Air Handlers < 10000cfm $0.00 0 Air Handlers > 10000cfm $0.00 0 Floor Furnace $0.00 0 Floor or Suspend Heater $0.00 _0 FEE SUMMARY Quantity Repair/ Alt Absorbtion Unit $0.00 0 - Repair/ All Refrigeration Unit $0.00 0 Ventillation System $10.65 1 Evaporative Cooler $0.00 0 Commercial Incinerator $0.00 0 Domestic Incinerator $0.00 0 Compressors 1 Absorption Svstems Up to 3 hp 1 100 k BTU $0.00 0 3 To 15 hp 1500 k BTU $0.00 0 15 To 30 hp 11,000 k BTU $0.00 0 30 To 50 hp 11,750 k BTU $0.00 0 Over 50 hp / Over 1,750 BTU $0.00 0 Boilers Up to 3 hp $0.00 0 3 To 15 hp $0.00 0 15 to 30 hp ; $0.00 0 30 to 50 hp $0.00 0 Over 50 hp $0.00 0 Other Mechanical Fee Investigation Fee $0.00 Ptar% Check Fee $0.00 Reinspection Fee $0.00 TOTAL CALCULATED FEES $84.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12.21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2448.46 (6700) r� v l WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one Of the following declarations: ❑ '1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. - I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. r My workers' compensation Insurance`` carrier and policryy number are: Carrier: % fit { �Ar L _ C Polity` Nummber:.-4L/' (.Thin-section need not he completed if the pormif is valued atone hundred dollars (3 f 00) or less.) ❑ I certify that in the performance of the w for whic this pe ' Issued, i shall not employ any person in any manner so as to became subject to the workers' compensation laws of Callfornl comply with these provns re if I cul a ubject to the workers' compensation provisions o1 Section 3700 of the Labor Code, I shall forthwith isioW� AppNgria cant'Siture: Dale: 1 W 1 J WARNING: FAf�TO SECURE WORKERS, COMPENS ON COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER T CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE (SIOD.oc% IN ADDITION TO THE OCUT OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: ! hereby affirm that I am license un er provisi sof Chapter 9 (Commencing with Section 7000) of Division 3 of she Business nd Professions Code, and my license is in full force and effect. Lic-N fry Class r Contrpclors.Signature:_ - Date: CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there Is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name:Lender's Address: Signature: __ — — Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, aller, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is IiCensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of Completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No, Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, Califomia Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a porm'tt to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future Wilding occupant need to like and certify a Business Pian for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet• of compressed gas at Standard temperature and, pressure):...............................................................................................................................__..............._..........................-............_.—... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Ves ❑ No (Section 25533 of the Califomia Health And Safely Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater then a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ........................................................... _ _...........................................................------............................................................................................................................. _..... ........................ .-............... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire bepartmont of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. _................_.__.........----...........—._........._.:....._._.._....._......_...-- -- ----- ._............ _........................................... ................. .......----._..� ..........—......—._.� 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code boon fully complied with? ❑Yes ❑ No ....- ................. - - _......_..._:..__._- .... _..--- ................ --................ _..—............................... .... _..._......... ........... -- .......... —.... _-- 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this Application a6rmit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district Or agency? U Yes LJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ..................................................................... _......:..........................................................................----...............................................................................................................................................---......................................... _............ 6 W€11 any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ................. .............. .................... ............. ----•-.........................------_.................. -----._........_................................... ......................... .........................._..................- ................._........................--------....__........ 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures pfescribed by Califomia Health and Safety Code Section 42303 boon made? [:]Yes ❑ No 8 (If 'yes", attach certiTicate of compliance from the appropriate air pollution control ofticar). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Dale: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspe tion purppses. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Of al er(s) ate AndlOr•Authoriaed Applicant Date CODE 1, INSPECTION TYP 2 IE LKIMAL$ CODER INSPECTION TYPE WE 1616 Fixed System Final Fire Prevention 206 Final Mechanical •- -a 6 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy 3333 101)1 M 1 Stub '37 - &6 _ i90 3d­�-P 4`p5� F 9 CITY OF COSTA MESA BUILDING DIVISION Y DEVELOPMENT SERVICES DEPARTMENT PE IT NUMBER r PERMIT v Pos-ooz21 (714) 754-5273 • Fax (714) 754-41356 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92526 PLUMBING PERMIT Job Address: 3333 BRISTOL ST Status: ISSUED Suite No 1001 Applied: 03/30/2006 issued: 03/30/2006 Vicinity: SUITE 1001 THEORY Parcel Nunmber: 41250107 Applicant: BARTH, EDDY ISSUED BY: Address: 140 LOMAS SANTA FE SUITE 200 Phone: 858-793-9104 SOLANA BEACH, CA Zip: 92075 Owner: SOUTH COAST PLAZA Address COSTA MESA CA Phone: 3315 FAIRVIEW ROAD Zip: 92626 Contractor: DICKINSON CAMERON CONSTRUCTION INC Address: 140 LOMAS SANTA FE SUITE 200 Phone: 858-793-9104 SOLANA BEACH, CA Zip: 92075 License: 690239 SCOPE OF PERMIT 3,005SF INTERIOR T.I. FOR "THEORY" IN SPACE 1001. WORK TO INCLUDE: REMOVAL OF (E) NON -LOAD BEARING PARTITION WALLS AND CEILING, IN ORDER TO RECONFIGURE SPACE, RELOCATION OF BATHROOMS, STORAGE AREA, OFFICE, FITTING ROOMS, NEW STORE FRONT, EL MECH AND PL WORK. REF: B06-00323 2 FLOOR DRAINS, 2 WASH BASINS, 2 WATER CLOSETS, 1 WATER HEATERIVENT FEE SUMMARY AMT QTTY, AMT QTY AMT QTY ISSUE FEE $23.50 Laundry Tub-/ Washer $0.00 0 Sump Pump $0.00 0 Backflow irrigation $0.00 0 Landscape Irrigation $0.00 0 Swimming Pool $0.00 0 Backflow Preventer $0.00 0 P -Trap $0.00 0 Trap Primer $0.00 0 Bathtub $0.00 0 Pressure Regulator $0.00 0 Urinal $0.00 0 Clarifier System $0.00 0 Process Piping (per 10 ft) $0.00 0 Vacuum Brkr Bkflow(1-4) $0.00 0 Connect (Ice,Soda,etc) $0.00 0 Receptors .7 $0.00 0 Vacuum Brkr Bkflow(5+) $0.00 0 Dental Units $0.00 0 Septic Tank$0.00 0 Wash Basin" $19.60 2 Dishwasher $0.00 0 Sewer Cap for Demo $0.00 0 Wash Basin Set $0.00 0 Drain, Floor $19.60 2 Sewer Connect $0.00 0 Waste and Vent System $0.00 0 Drain, Rainwater $0.00 0 Sewer Private Line $0.00 0 Water Closet (Toilet) $19.60 2 Drain, Roof $0.00 10 } Shower $0.00 0 Water Heater 1 vent $12.30 1 Drinking Fountain $0.00 0 . Sink, bar. $0.00 0 Water Piping (Inst or Rep.) $0.00 0 Expansion Tank $0.00, 0 _'Sink, commercial $0.00 0 Water Re -pipe $0.00 0 Gas Earthquake Valve $0.00 0 Sink, Floor $0.00 0 Water Service $0.00 0 Gas (1-4 outlets) $0.00 0 Sink, kitchen $0.00 0 Water Softener $0.00 0 Gas (Over 4 outlets) $0.00 0 Sink, service/mop $0.00 0 OTHER $0.00 Gas Repipe $0.00 0 Spa (private) $0.00 0 VIOLATION $0.00 Gas Service $0.00 0 Spa (public) $0.00 0 PLAN CHECK $0.00 Interceptors (Grease, Oil) $0.00 0 REINSPECTION $0.00 0 Interceptors (Sand Auto) $0.00 0 TOTAL CALCULATED FEES: $94.60 COMMENTS 1 SPECIAL CONDITIONS NOTICE; The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446.49 (6100) DECLARATIONS, WORKERS' COMPENSATION DECLARATION: - hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier an policy numbs re: Carrier: �%1�—i 1 jC� , rPolicy-Number: (This section-heedif the permit is valued atone hundred dollars ($100) or less.) F' — ❑ 1 Certify that in the performance of the work for whie is i ' ued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Califomi ag t if o d bac a su 'ect to the workers' compensation provisions of Section 3700 of the Labor Code, i shall forthwith � comply ath these provision /O rCanlSi nature: Date: ►�/� 1 WARNING FAILURE TO SECURE W ERS' COMPEN TION COVERAGE IS UNLA FUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND GVIL FINES UA TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE T OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, )MEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licens9d un or provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business kid Professions Code, and my license is in full force and effect. LEDA Class Contractor's Signature: JCONSTRUCTION LENDING LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lenders Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Cade: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (Commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred d0ars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (See. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contraclor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, Califomia Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal 10 or greater than a weight of 500 pounds, or a volume o1 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .........................._........................................................................... ..........,..................-----...........--•---....................................................................................-------•.................................................. 2 Does or will the applicant or present or future budding occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 o1 the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ......................................................................................................................................................................................................................................................................---........................................ 3 Does or will the applicant Or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? Cl Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. .............................................................................................................................................................................................................. ............................................................................................................................................ M 4 If an RPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No .................................................................................................................................................................................................................... ......................... .......................... I .............. ....................................... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ffrmit for such construction or modification from the South Coast Air quality Management District or from any other air pollution control district or agency? U Yes LJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ............... ...... .............................. ............................................................................................................................................................................................................ ...................... .......-......................................................................... 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries o1 a school? ❑ Yes ❑ No (If 'fres", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ... ................. ........................................ .......... _.............. ......................... ...................---....................................................................... ....-•................................... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by Califomia Health and Safety Code Section 42303 been made? ❑ Yes ❑ No - - _.............._...._................................... ................................... ._...................... _. .......................... - ...-.-................. ...1..111........ ............. _... attach certificate at Compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. I atu O nor s)n Date s ,2'� � d/ rized ApplftfolZ ( Data CODE F. INSPECTION TYPE p INTRtALS CODE I INSPECTION TYPE 2&M 1616 Fixed System Final Fire Prevention 206 Final Mechanical 11266 Pool Spa Final 208 Final Plumbing 5- I �O% 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Suilding/Occupancy J333 1001 6PI.S-FOL S - O n/ _ /1 n / (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.Sb9LDING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 .lob Address: 3333 BRISTOL ST Status: ISSUED Suite: 1001 Plan Check: $72.31 Calc Valuation: $5,000.00 Applied: 03/03/2006 Vicinity: SPACE 1001 $0.00 N _ SMIP Com: issued: 03103/2006 Primary Occ: M Display/Sale Merchandise Type of Construction: I -FR Total, Parcel Number: 41250107 Zoning: PDC Applicant: BARTH,`EDDY Address: 140 LOMAS SANTA FE SUITE 200 Phone: 858-793-9104 ISSUED BY: SOLANA BEACH, CA -Zip: 92075 Owner: SOUTH COAST PLAZA Address COSTA MESA CA Phone: 3315 FAIRVIEW ROAD Zip: 92626 - 2626 -Contractor:, Contractor: DICKINSON"CAMERON CONSTRUCTION INC Address:' 140 LOMAS SANTA FE " SUITE 200 ..' Phone: 858-793-9104 SOLANA BEACH, CA Zip: 92075 License: 690239 Arch : ' Eng'.._ _ Address: Address: Phone: Phone: Zip: License: License: PLANNING & ZONING SETBACKS MAIN STRUCTURE Front '04,':, , Rear 0-0 Left, 0-0 Right 0- 0 ACCESSORY— Front ,0- 0 -,Rear 0-0, Left 0-0 Right '0' 0 PARKING Existing: 0 Required: 0 Proposed: 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21.92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 aaa-aa (SM) SCOPE OF PERMIT NON-STRUCTURAL. DEMO FOR ."THEORY", SPACE 1001, REF#: B06-00323 - FEE SUMMARY — Plan Check: $72.31 Calc Valuation: $5,000.00 Permit: $111.25 Claim Valuation: $5,000.00 SMIP Res:, $0.00 N _ SMIP Com: $1.05 Other: $0.00 Inspection: $0.00 Total, $184 61 PLANNING & ZONING SETBACKS MAIN STRUCTURE Front '04,':, , Rear 0-0 Left, 0-0 Right 0- 0 ACCESSORY— Front ,0- 0 -,Rear 0-0, Left 0-0 Right '0' 0 PARKING Existing: 0 Required: 0 Proposed: 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21.92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 aaa-aa (SM) 1 Ph Q " J 7_� RS' COMPENSATION DECLARATION: affirm under penalty of perjury one of the following declarations: ave and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the rk for which this permit is issued. ave and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. workers' compensation Insurance carrier and policy number are: / Pofcy N tion need notbe completed if the permit is valued atone hundred dollars ($100) or less.)r 1 ❑ 1 certify that in the performance of the k fo hic this permi ed, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Cal gr if hould b e sub ct to the workers' compensation previsions of Sect on 3700 of the Labor Code, I shall forthwith ply with these provisions. J� -APPnt'Si9nge -WARNING: FAILURE TO SECURE WORKERS'COMPENSFTON COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL" PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE OMT OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: Ithereeby affirm that I am license u er provisions o e Business hapter 9 (commencing with Section 7000) of Division 3 of the d Professions Code, and my license is in full force and effdCt:'tiC:-7:1 Class #� _ CenlractoYs.Sigrlature:s-----Z�- Dat CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code), Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW 10T the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year o1 completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. jJ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, Scaffolding, fatsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: „ , Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be tiled with the Costa Mesa Fire Department by every business which has at any One time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ..............................................-----.............................:......................................................................................................................................................................................................................................................................................... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? [:] Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). . .................. ............................................................. ... ....................... .......................................""'....................................................................................................................................................................... ......................... 3 Goes or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. .................................................................................................................................................... .........................................................................................................................................................................................­................. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? [:]Yes ❑ No .............................................................................................................................................................................................................................................................................................................................................. 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication aggermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? L l Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ......................................................................................-.............................................................. ............................... ....----•---.......................... ............... 6 Will any part of thefac III ty to be Constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). .................................................................................................................................................................................................................................................................................................................................................................. 7 If a permit from the South Coast Air Ouality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ............................................................................................................................................................................................................................................................................................................................................................................................ 8 (If "yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. i agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not 10 occupy or allow occupancy of any building authorized by this permit until final inspection. Signa e9VA nz =" (s) /OeD� ed App icaant� "" r��//'i7ate ' CODE 3, INSPECTION TYPE D INTI CODES IN+5PEGTI4N TYPE ISS 1616 Fixed System linal Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Relaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 1 222 Final Site 204 Final Demolition 5 r 250 Final Building/Occupancy 1i5 3333 fX01 P,gIETOL ST- Job T (714) 754-5273 • Fax (714) 754-4856 + www.cl.costa-mesa.6kNLDING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 - BRISTOL ST Suite: 1001 Vicinity: Primary Occ: M Display/Sale Merchandise Type of Construction: I -FR Parcel Number: 41250107 Zoning: PDC Applicant: BARTH, EDDY FEE SUMMARY i Address: 140 LOMAS SANTA FE Calc Valuation: $7,500.00 4 Permit: ' SUITE 200 Phone: 858-967-4325 CELL SMIP Res: SOLANA BEACH, CA Zip: 92075 . Owner: SOUTH COAST PL_ AZA Address. $0.00 - Inspection:' COSTA MESA CA Phone: Total: 3315 FAIRVIEW ROAD Zip: 92626 Contractor: DICKINSON CAMERON CONSTRUCTION INC Address: 140 LOMAS SANTA FE PLANNING & ZONING SUITE 200 Phone: 858-793-9104 SOLANA BEACH, CA Front ,0' _ Rear 0-0 Left 0-0 Zip: 92075 License: 690239 Arch Eng: Address: Address: Phone: Zip: License: SCOPE OF PERMIT INSTALL 8' STORAGE RACKS FOR 'THEORY" IN SPACE 1001. REF.: B06-00323 ISSUED BY: Status: ISSUED Applied: 04/12/2006 Issued: 04/20/2006 Phone: License: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work is not commenced wifhin 180 days, or If work Is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inepectlons and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 2448.48 (SM) FEE SUMMARY Plan Check: $24.90 Calc Valuation: $7,500.00 4 Permit: ' $153.25 Claim Valuation: $7,500.00 SMIP Res: $0.00 SMIP Com: $1.57 Other: $0.00 - Inspection:' $0.00 Total: $179.72 PLANNING & ZONING SETBACKS MAIN STRUCTURE Front ,0' _ Rear 0-0 Left 0-0 Right 070 ACCESSORY `, Front' 0- 0, , , ; Rear 0-0 Left 0-0 Right -%� 0- 0 PARKING Existing: 0 Required: 0 Proposed: 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work is not commenced wifhin 180 days, or If work Is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inepectlons and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 2448.48 (SM) O DECLARATIONS WORKERS' COMPENSATION DECLARATION: - I hereby affirm under penalty of perjury one of the following declarations. ❑ I have and will maintalri a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Cade, for the performance of the work for which this permit Is Issued. ❑ I have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. --t•,__Myworkers,00mpensatlon InsurancLecaar er and olicy nu r are: Carrier 1 1 /�f � l A I A � - Ptgjlcy'N�� � � moi' (This creed not be completed if the permit Is valued atone hundred dollars ($100) or less.) ❑ 1 certify that in,the performance of the w rk for whit it is Issued, 1 shall not employ any person in any manner so as to become subject to the workers' compensaff6ri laws of Callf and nee that I s Id bac a subject to the workers' compensation provisions of Sectlo 3700 of a Labor Coda, I shall forthwith comply with these provi _Appilcan .Signal ru e: ,��� \WARNING: FAILURE TO 9ECU ORKERS' F FINISATION COVERAGE IS UNLAWFUL AND S1f4LL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TOONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I_herreebyy�affirm that t am licensed nd r provi io o hapter 9 (commencing with Section 7000) of Division 3A;Bus1ns d Professions Code, and my license is in full Ori CB}'fl�nd effeGL.L1C,.ff. Ca��gnature:; .. Data CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Londel's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: 1 hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professlons Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more then five hundred dollars (S54%): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractors) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet In depth Into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Titto 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity o1 hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .........................W1;.........-----.---.....................................................................................................,...................................................................................................................................................................................................... 2 Does or wip the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with soma exceptions, requires registration with the Costa Mesa Fire Department by each business which a1 any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure), _..........................._............................... ....._.................................... ........... ...................---_._...................................................... --.... ................................. -•-............... _.................... _ ._. 3 Does or will the appplicant or present or future buitding occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? E] Yes [INo (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ..............d.................................................................... r'n...........-----.................................................n"i'...............................iih,.............................................................................................................. 4 If an RMPP Is presently required, has Section 25534 of the California Health and Safety Code been tu11y complied with? ❑Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification from the South Coast Air Quality Managoment District or from any other air pollution control district or agency? Ll Yes f No n applications for non-residential building permits). (section 65850.2 of the California Goverment Code requires that the requested information t>8 furnished o app Ca g pe ) 6 Will any pan of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (it yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). --.........._—........- --- _ _ ...._............_. _.... _.—.._.__ ................. .......- ._ ..._ _ _._...........__ ....... —..._.. _. 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes (' No 8 (if yes', attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the Information given above is correct. I agree to comply with all state taws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and cl ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspec 464h punto of to occupy or allow occupancy of any building authorized by this permit until final inspection. I Leg6l nor(5) D d App n _ - CODE 1. INSPECTIONTYPIt 266 INTITALCODE F INSPECTION TYPE 20 INTMALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy a 3353 tool 8)?/S7-PL ST - (714) 754.5273 • Fax (714) 754-4856 • www.ci.costa-mesagUILDING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 .lob Address: 3333 BRISTOL ST Suite: 1001 Vicinity: SPACE 1001 Primary Occ: M Display/Sale Merchandise Parcel Number: 41250107 Applicant: DEBBIE WATSON Address: 1260 LOGAN AVENUE Type of Construction: I -FR Zoning: PDC COSTA MESA, CA Owner: SOUTH COAST PLAZA Address COSTA MESA CA 3315 FAIRVIEW ROAD Contractor:, WATSON'CONSTRUCTION INC. Address:' 1260 LOGAN AVE UNIT 6002 ' COSTA MESA, CA Zip: 92626' Arch : PAUL BOZARTH e.aa.e��• 19RR1 Val r aV SANTA ANA, CA Zip: 92705 rnone: r i4-aaa-o�.r� License: C14800� Phone: 714-662-7933 Zip: 92627 Phone: Zip., 92626 Phone: 714-662-7933 License: 705797 Eng: Address: ISSUED BY: Status: ISSUED Applied: - 01/18/2006 Issued: 02/01/2006 Phone: License: SCOPE OF PERMIT DEMO PERMIT IN ORDER TO CREATE -2 SPACES OUT OF SPACE, 1001, WORK TO INCLUDE: CONSTRUCTION OF A NEW DEMISING WALL AND MALL NEUTRAL PIERS. :'PLANNING & ZONING SETBACKS MAIN STRUCTURE Front 0-.0 --,r Rear 0-0 Left 0-0 ACCESSORY Front 0-0 Rear. = 0-0 Left 0-0 PARKING ' Existing: 0 Re wired:. 0 Proposed: 0 Calc Valuation: Claim Valuation: Right 0-0 Right ' 0- 0-- $15,000.00 $15,000.00 NOTICE-. The work authorized by this permit shalt comply with all applicabla handicap access requirements under Calitomia statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or it work is suspended or abandoned for a period of 180 days. INSPECTIONS: in order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 zeas -as t6roof FEE SUMMARY Plan Check: $163.31 Permit: $251.25 SMIP Res: $0.00 _ SMIP Com: $3.15 Other: $0.00 Inspection: $0.00 Total: $417.71 :'PLANNING & ZONING SETBACKS MAIN STRUCTURE Front 0-.0 --,r Rear 0-0 Left 0-0 ACCESSORY Front 0-0 Rear. = 0-0 Left 0-0 PARKING ' Existing: 0 Re wired:. 0 Proposed: 0 Calc Valuation: Claim Valuation: Right 0-0 Right ' 0- 0-- $15,000.00 $15,000.00 NOTICE-. The work authorized by this permit shalt comply with all applicabla handicap access requirements under Calitomia statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or it work is suspended or abandoned for a period of 180 days. INSPECTIONS: in order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 zeas -as t6roof DECLARATiONS WORKERS' COMPENSATION DECLAAATION: _ I hereby affirm under penalty of perjury one of the following declaratlons: ❑ 1 have and will maintain a cerflficete of consent to self -Insure for workers' compensation, as provided for by section 3700 of the labor Code, for the performance of the work for which this permit is issued. 1'have and' U maintain workers' compensation insurance, as required by section 3700 of the tabor Code, for the performance of the work for which this permit Is lssued. -�My'workers' co ensaf on In nce c rrier and policy number are: . _ G - -- Policy.Numi3er: „ ,(This seclldn need not be completed if the permit is valued at one hundred dollars ($100) or less.) ❑ I certify that in the performance of the workQ for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Cahfomia, and agre that If I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith ' Comply with t provi W ApplicanPBignature: 2:016 ARNINCLFAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUWFCT AN EMPLOYER To CRtd4NAL PENALTIES AND CAVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADVITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am IiCense �igr�ro 5 f Chapter 9 (Commencing with Section 7000) of Division 3 of the Business an Professions Code, and my license is in full force and effec' t L'ic, q � �j �5Claw s Goittractor Signatures='' �Dat`re""r CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a Construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: _ Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, altar, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more then five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and ProfesSiorts Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided [hat such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractors) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: _ Date: Owner ID verified by drivers license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feel in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, l will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the Catifornig Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure), ................................................................................................................................................................................................................................................................................ 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑Yes ❑ No (Section 25533 of the Calilornia Heatth and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight o1 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure), .................................................................................................................................................................................................................................................................................................................... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ................................................................................................................................................................................................................................................. ..... I....................................................................................... 4 I1 an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No .............................................................................................................................................................................................................................................................................................................................................................................. 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency/? lU Yes No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). _....._..............................................---.........................................._.._......................................................................................._.................................................................................... 6 Will any part of the facility to be consttuctad under this permit be within 1000 feel from the outer boundaries of a school? ❑Yes ❑ No (11 'fres", the facility must meet the requirement o1 Sections 25534 and 42303 of the California Health and Safety Code). _.............. _................... _.. _........_...........................................................................----------------------------•-----.......................................-.-...-.......-------------------•-....... ....................._.......................................................................................... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject o1 this appticaticn, tiave atl of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No _................._................._....,.................................................................................................................................................................................................----.................................................................... 8 (If 'fres", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials grid Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is oorrect. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. ' ria ur f L 4 ner(s) Pate �/ hor srpplicant•- ,-- —�`� Data CODE 0• INSEECTION TYPE QAi fiQQ19L$ COPE[ INSPECTION TYPE INTITIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 , Final Planning Approval 203 Final Sign 222 Final Site Z Z 204 Final Demolition 250 Final Building/Occupancy 3333 l00/ BRISTb4 k -?T - A 149 (714) 754-5273 • Fax (714) 754-4856 • www,ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 BUILDING PERMIT ,lob Address: 3333 BRISTOL ST Suite: 1001 Vicinity: SPACE 1001 (SEPHORA) Parcel Number: 41250107 Zoning: PDC PDC Status: ISSUED Applied:. 04/05/2002 Issued: 05/03/2002 Applicant: SULLIVAN, JANE ISSUED BY: Address: 25 EDWARDS CT SUITE 206 Phone: 650-373-3930 BURLINGAME,.CA',Zip: 94010 Owner: SOUTH COAST PLAZA. Address COSTA MESA CA Phone: l 3315 FAIRVIEW ROAD = Zip: 92826 Contractor: CONTI-HURLEY ASSOC, INC Address:, 25 EDWARDS COURT STE 206-/ Phone:�fl650) 373-3930 ? BURLINGAME, CA e` Zip:. 94010-2424 ; License., 747287 Arch, : THOMAS BOND AND ASSOCIATES ling: Address: 14471. CHAMBERS RD Address: , STE 101 ,Y Phone: 774-669-1579 j Phone: TUSTIN. CA', Zip: 92780 License: C26209 License: SCOPE OF PERMIT. _. 2750 5F INTERIOR STORE TI FORY'SEPHORA'IN.SPACE 1001: '0 ✓ REMOVE AND RELOCATE EXIST. 4FT HIGH FIXTI'RES. DEMOLTION COVERS ONLY NON BEARING WALL, STORE FRONT ' PANELS AND FLOOR TILES. 44" MINIMUM CLEARENACE BETWEEN DISPLAY UNITS. CASH REGISTERS AND COUNTER IF ANY SHALL COMPLY WITH 1998 CBC. FEE SUMMARY - - Plan Check: $554.94 Calc Valuation: $80,000.00 Permit: $853.75 Claim Valuation:. . r $80,000.00 SMIP'Res: $0.00 SMIP Corn: $16.80 -„•:,' Other: $0.00 'P, Inspection: $0.00' PLANNING & ZONING SETBACKS MAIN STRUCTURE Front 0-0 Rear 0- 0 Left 0- 0 Right- 0- 0 � i ACCESSORY Front 0- 0 Rear 0-0 Left 0-0 Right-, ”-0-- 0 PARKING Existing: 0 Required: = 0 ProposedL�ei0O � NOTES: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and became void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CARL: (714) 754-5626 - 2446-46 (6=) I o�7 r� v / CC) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. have and will m ' work I's' tion insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. M workers' co n I s rence ca ner and number are: Carrier: y_ �.- �AM pf�_ _ _- __ - Policy Number: (This section need not be completed if the permit is valued of one hundred dollars ($100) or less.) ❑ I certify that in they erfor ante of the for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation taws o! Cal o la, and red tvi " Plshou� e subject I;otho workers' compensation provisions of Section 00 o the Labor Code, I shell forthwith comply with those pro Applicant Signatures64 Date: `-' WARNING: FAILURE T E W PMERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PE ALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,}, I ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am Iicerlunder provi f C apter Ing with Section 7000) of Division 3 of the Business and Professions Code, and my license is In full force and effect. Lic, N % ons Class ff Contractor's Signature: I Date: CONSTRUCTION LENDING NCY: ❑ I hereby affirm that there is a construction lending agency for the performanco of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lenders Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sea 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to Its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for safe (Sec. 7044, Business and Professions Code: The Contractors license Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement Is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Dale: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ...................................................................................___.... _........................................................................................................................................................ ............................._........................_............... 2 Qoes or wilt the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the Califomia Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 2DO cubic feet of compressed gas at standard temperature and pressure). ...................................................................................................... --_...............................-.....................................................................................-......................................................................._................-....................._ 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ....................................._ ......... .......................................__....................................... .............................. -........................................................................................... ..... ........................ ..............----................_..........-- 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No ................................--.............................. .11-1111--11-1---....... ......................... -_............................................................................................. ..... ..................... ........ ...............--.............. _.......... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ffrmit for such construction or modificatlon from the South Coast Air Quality Management District or from any other air pollution control district or agency?? [I Yes LJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). .......................................................................................................... ... - ........................._..................................................................................................................................-...................—........... fi Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ...................................... ................................ --..................... ----.............. 11 ......................... .............................. .....j...................................................... ... -h.....--. ................ _ ._.... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency s required for the workwhit is the subject of this application, have all of the disclosures prescribed by CaliforniaHealth and Safety Coda Section 42303 been made? ❑ Yes ❑ No ......................................................................................................................................................................................._.......................................................................................................... a (If yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state taws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signatu L nor(s) Date And/Or Authorized Applicant —err Data CODE INSPEC 2&R INTITIALS CODEa INSPECTION TYPE 2&3 ILLS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy s/ / - 3333 i cot ee1&To4:, ,r - (714) 754-5273 • Fax (714) 754-4856 • www.cl.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT .lob Address: 3333 BRISTOL ST Suite No 1001 Vicinity: SHOW ROOM Parcel Nunmber: 41250101 Applicant: KEOUGH, DOUG Address: 9750 MUSTANG WY Phone: 818-439-3505 SHADOW HILLS, CA Zip: 91040 Owner: -,SOUTH COAST PLAZA Address COSTA MESA CA Phone: 3315 FAIRVIEW ROAD Zip: 92626 Contractor. KEOUGH ELECTRIC CO Address: 9750 MUSTANG WY Phone: 818-439.3505 SHADOW HILLS, CA Zip: 91040 License: 639428 Status: ISSUED Applied: 06/18/2002 Issued: 06/18/2002 ISSUED 6Y: SCOPE OF PERMIT DISCONNECT AND RE -CONNECT 15 MOBILE DISPLAY CASES WHILE T.I. IN PROGRESS. 'SEPHORA' REF.: B02-00470 COMMENTS I SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all appllcable handlcap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days, or if work Is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable �c:odes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result In the expiratio v is permit. FOR INSPECTIONS CALL: (714) 7545626 2448-48 (&W) o-1 FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 Temp Dist System 1 Lighting $0.00 0 Temp service test $0.00 Busway 1100 ft $0.00 0 Res. a/c package $0.00 Standing Section $0.00 0 New Res (1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0 New Res (3+units) $0.00 0 Transformers up to 1 kva/kw $0.00 0 Pool / Spa $0.00 0 ................up to 10 kvalkw $0.00 0 Lighting Fixts $16.50 15 .................up to 50 kvalkw $0.00 0 Recept Outlets $0.00 0 .................up to 100 kvalkw • $0.00 ', 0 Switches $0.00 0 ..................over 100 kvalkw $0.00 0 Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0 Res Appl $0.00 0 Low Volt Wiring System / Ckt $0.00 0 Service to 200a $0.00 0 Misc. Conduit $0.00 0 Service to 1000a $0.00 0- Misc. Conductor $0.00 0 Service over 1000a $0.00 0 Circus ( gen or ride) $0.00 0 Motors to ihp $0.00 0 Circus (meth ride or lights) $0.00 0 Motors to 10hp $0.00 0 Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 0 Fireworks Stand $0.00 0 Motors to 100hp $0.00 0 Other Electrical Fee _$0.00 Motors over 100hp $0.00 0 Communication drops $0,00 0 Investigation Fee " $0.00 Sub panel to 200a $0.00 0 Plan Check Fee $0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $0.00 0 Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $40.00 Interned Pole $0.00 0 COMMENTS I SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all appllcable handlcap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days, or if work Is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable �c:odes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result In the expiratio v is permit. FOR INSPECTIONS CALL: (714) 7545626 2448-48 (&W) o-1 DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby Minn under penalty of perjury one of the following declarations: ❑) 1 have and will maintain a Certificate of consent to self-Insure for workers' compensallon, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. have and w4l maintain workers' oompsnsalion insurance, as required by section 3700 of the tabor Code, for the performance of the work for which this permit is issued. �My workers, comlensation Insurance carrier and policy number are: (Thiss ! PoliC (This section need not ba completed It the permlf is valued at one hundred dollars ($100) or less.) ❑ t certify that in the performance of the work for whit this permit Is Issued, I shall not employ any person in any manner so as to become subject to the workers' compensation Iaws a, and agr that If Ovid become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with thes rovisions. AppllSignature, C�De-je J /�! 7 v' F"l .. F,QLL RE-TO SE AE WORKE ' TION GEIS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PE TIES D CML RNES UP TOONE HUNDRED THOUSAND DO LARE (Sl 00.000). IN ADDITION TO THE OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR COOS, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: _I.heteby.affirm.that..am Ilce sed un or provisions of Chapter 9 (commencing with Section 7000) of Division 3 of.the.Business and Professions Code, and my license Is in full force and affect-Lie. a ZI Class a 0 Contrector:s,Sig uw JIf 4 ale: ' L A CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance o1 the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lenders Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of penury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License law (Chapter 9 (Commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or Offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, em EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to Construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuanl.t0 the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drfvers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet In depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (38) feet high. (Chap. 3.2, Grp 2, An 2, Sec. 341, Tllle 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person hes a permit to do such work from the division. Signature: Dale: Division of Industrial Safety Permit Number. HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 WIII the applicant or present or future building occupant need to file and certify a Business Plan tot emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costs Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _... __........................................................... ........1................... ......1111................ .._....... . ................. 2 Does or will the applicant or present or future building occupant need 10 file a registration term for acutely hazardous materials? ❑ Yes © No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any Ona time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ...................... ............... ---....... .._.........._....... _ 1111._. ___ _....... ......-............ .........................................._.. ._.._-1_ -- Does Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire bepartment of an RMPP by businesses which are required to register acutely hazardous materials with the Fire MDepartment. _ 1111..........................._...— ---- - ------.......... W...................................................... ............ ........ 4 If an RPP is presently required, Section 25534 of the California Health and Safety Code been fully complied with? ❑Yes ❑ No ................ 5 Does or will the applicant or present or future building occupant requirefor the work which is the subject of this a gge plication armit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes (--f No (Section 85850.2 of the California Government Coda requires that the requested Information be furnished on applications for non-residential building permits). _........................................................---..................... ........................... ,................,.......................111.1........................ . ..................1111.. ..-••--•---.................. _.................... _. 6 WIII any pan of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). _._ _ _... __...---.. ...................._—.............. --....................... --.— ............. __.............. 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this P, codon, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 6 (!f yes% attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of porjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for Inspection purposes. I agree not to occupy or allow occupancy Of any building authorized by this permit until final inspection. S eburLegal Owner(s) 4 ' Rate r u rized.Applieanl—� +� le DA. Sr9QE 1. INSPECnONTYPE 2lTlI16LS CODED INSPECTION TYPE 2AM IfiIIDAL� 1816 Fixed System Final Fire Prevention 206 Final Mechanical 1288 Pool Spa Final 208 Final Plumbing �1 200 Final Re-Roos 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Fina! Building/Occupancy loo/ )M1'-c3-roL Sr CITY OF COSTA MESA BUILDING DIVISION DEVELOPMENT SERVICES DEPARTMENT PERMIT (714)754-5273 • Fax(714)754-4856 BUILDING PERMIT Job Address: 3333 BRISTOL ST Suite: 1001 Vicinity: Parcel Nunmber. 41250107 Zoning: PDC PDC Applicant; BOB BRANDENBURG Address: 891392 77 FAIR DRIVE, COSTA MESA, CA 92626 Status: ISSUED Applied: 08/05/1998 Issued: 09106!1998 . Phone: Zip: Owner: SO COAST,PLAZA--MAIN MALL %CJ SEGERSTROM & SONS . Address 3315 FAIRVIEW RD , Phone:�� COSTA MESA, CA, " Zip: 92626 Contractor: FISHER DEVELOPMENT Address: 01485 BAYSHORE•BL I 1• PLANNING'& ZONING SETBACKS MAIN STRUCTURE Front 0-0 Rear 0-0 Left 0-0 Right 0-0 ACCESSORY Front 0-0 Rear 0- 0 Left 0- 0 Right 0-0 PARKING Existing: 0 Required: 0 Proposed: 0 NOTES: EXPIRATION: This permit shall automatically expire and become void it work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and flnal approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 Phone: , SAN FRANCISCO CA Zip: • 94124 License, 271781 Arch I Eng : ARCHITECTS PACIFICA Address: 17711-B MITCHELL NORTH , Phone: 714253-8525 IRVINE,CA Zip: 92687 License: SCOPE OF PERMIT TENANT IMPROVEMENT TO CONVERT SPACES 1001.8, 1007 INTO 1001, "SEPHORA" INTERIOR REMODEL FEE SUMMARY ; Plan Check: $306.68 Calc Valuation: $300,000.00 Permit: $1,887.25 ,, ,' / Claim Valuation: $300,000.00 SMIP Res: $0.00 SMIP Com: $63.00 Other: $0.00 Inspection: $0.00' Total: $2,256.93, % PLANNING'& ZONING SETBACKS MAIN STRUCTURE Front 0-0 Rear 0-0 Left 0-0 Right 0-0 ACCESSORY Front 0-0 Rear 0- 0 Left 0- 0 Right 0-0 PARKING Existing: 0 Required: 0 Proposed: 0 NOTES: EXPIRATION: This permit shall automatically expire and become void it work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and flnal approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 ,'DECLARATIONS WORKERS' COMPENSATION DECLARAI,_,.: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain A certificate of Consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is Issued. ;nt,,I have and will maintain workers' Compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: Policy Number. (777fs section need not be completed ff the permit is valued atone hundred dollars ($100)or less.) J• ❑ I certify that in the performance of the work for which this permit Is issued, I shall not ampJwany person in any manner so as to became subject to the workers' compensation laws of Califomla, end a ree that it I should become subject to the workers' pensatlon provisions of Section 3700 of the Labor Code, I shall forthwith comply with thesa visib s. c — Applicant Signature: Date: — T WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERA UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND GVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($1 00,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR OODE, INTEREST, AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: hereby affirm that I am livens under proo t Of Chapter 9 (commencing with Section 1O0) of Division 3 o1 the Business and Professions Code, and my license is in full force and effect. Lic. R ' Class a Contractor's Signature: Data: CONSTRUCTION LENDING AGENCY: `— ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is Issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter. Improve, demolish, or repair any structure, prior to Its issuance, also requires the applicant for such permit to fila a signed statement that he or she is licensed pursuant to the provisions o1 the Contractors Lloense Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code)'or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors Lloense Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or Improv_emant is sold within one year of Completion, the owner -builder will have the burden of proving that he or she did not build or Improve for purpose of sale.). ❑ I, as owner of the property; am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractors) license pursuant to the Cbntractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Driver's License No. Expires: Vorif1wilon of Ownership by (type Of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ l hereby certify that no excavation five (5) or more feet In depth Into which a person is required to descend, will be made In connection with work authorized by this permit, and that no building structure, scaffolding, falsawork, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Carp 2, Art 2, Sec. 341, Tltla 6, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Data: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND Ef4MISS10NS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the CatiIfomia Health and Safety Code requires, with some exceptions, that a Business Pian be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of Compressed gas at standard temperature end pressure). i" 'e' ......Ii'c"a...................................................... p. a. . 'n. a.. d.`t'..............................'o'_r,.."................................................"..................................................................... 2 Does or will the applicant qr present or future building oCCtrpant Head to file a registration form for acutely hazardous materials? ❑Yes ❑ No (Section 25533 of the Calilomia Health and Safety Code, with some exceptions, requires registration with the Caste Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume Of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ........ I ............................".............................................................................................. "."........................................................................................................................................ . 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No tSectlon 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ............... ......................................................... ................... .................................................................................................................................. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully compiled with? ❑ Yes ❑ No .............."."-•--.."..................................................................."...... 'w.'.............................................'s',._..............a..................................................................... 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this a pllcaiion a ermit for such construction or modification from the South Coast Alr quality Management District or lrom any other air pollution control district or agency? LJ Yes LJ No (Section 65650.2 of the California Government Code requires that the requested information bo furnished on applications for non-residendal building permits). ...................."........................................"....................................."............................................................................. "... ".. "..."..................................... 6 Will any pan of the facility to be constructed under this permit be within 1000 fast from the outer boundaries of a school? ❑ Yes ❑ No (If yes% the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ....... ... .....................------ ....................................."..... "."............................. ...............................".................................................................................................................... ". ". 7 11 a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑Yes ❑ No .... ....... ................................ .................................. ............. .... ..................................................................................................................................... 8 (If yes". attach Certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the Information given is Correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy Or allow occupancy of any building authorized by this permit until final inspection. Sig Lure CJf egal Owner(s) — G � Dae --- And/Or Authorize II O Date CODE -1" INSPECTION TYPE JIM I AL$ CODE.! INSPECTION TYPE peg ISL$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Flnal 206 Final Plumbing 200 Final Re -Root 210 Final Electrical 201 Final BlockfRetaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final BultdinglOccupancy 2446.46 11110, VU P (714)754-5273 - Fax(714)754-4856 BRISTOL ST CITY OF COSTA MESA BUILDING DIVISION DEVELOPMENT SERVICES DEPARTMENT PERMIT ELECTRICAL PERMIT Job Address: 3333 BRISTOL ST Suite No 1001 Vicinity: Parcel Nunmber: 41250107 Applicant: PERRY, RANDY Address: B9 -0139--E 1014 ie 77 FAIR DRIVE, COSTA MESA, CA 92626 Status: ISSUED Applied: 09/23/1998 Issued: 09/23/1998 � o i ' • `, � �, >��/� Owner: SO COAST'PLAZA--MAIN MALL _/oCJ_SEGERSTROM & SONS\ Address 3315 FAIRVIEW RD! Phone: ~` ��`� \���• \� %COSTA MESA -CA,-- Zip: 92626 Coniractor.' BR GGS EL CTRIC INC Address: " �16662MILLIICEN Phone�� 714-863 9901 IRVINE" CA :: Zip: -i_2713":'.'_ . eLicense:' 297836 SCOPE OF PERMIT 227 LIGHTS, 74 OUTLETS, 15 SWITCHES & 4 SUB PANELS. REF: B98-1392, SAPHORA. ' -FEE SUMMARY L ISSUE FEE \Quantity ' Quantity $22.00 r. ,r ?,` „' ti�Temp.Dist System Lighting,. $0.00 0 Temp service test $0.00 r _ .r _ - Busway 1100:ft� -1 = _ $0.00 0 ' Res. alc package $0.04 - - - -.� Standing: Section ' _ T ' $0.00 0;'. . New Res (1-2 units), $0.00 0 Misc Electrical Equipment $0.00 0 New Res (3+units) $0.00 0 Transformers up to 1 kvalkw $0.00 .0'.: Pool / Spa$0.00 D `...:up to ;10 kvalkw $0.00 '4 Lighting Fixts \,; $154.55 227 .................up to 50 kvalkw $0.00 r:0' Recept Outlets "N $55.10 74 ........up to 100 kva/kw $0.00 0 Switches $15.00 15.:: over 100 kvalkw �c �� :Low $D.00' 0 Non ResAppi;, $0.00 0' _,� Voltage Equipment $0.00'// 0 Res Appi $0.00 0" Wiring System 1 Ckt ; ; ��r LOW Volt Wirin $0:00 0 > / Service to 200a �= $0:00. N - 0 �' / , , _ ,' � ., Misc. Conduit � "$0:00 0 Service to 1000a �' / $0.00 � 0 Misc:•Conductor. Service over 1000a ., �', $0,000 "Circus (gen or ride),,' =�� � % $0.00 Motors to 1 hp $p.00�� =0- ' \`\' { Circus (meth ride or lights)' $0.00 0' j Motors to 10hp $0.00 0 ' - �; � ; `'Christmas Tree Sland Motors to SOhp �� _ , -$0.00; ,'� � 0- - Fireworks Stand '$0.00 0 - Motors to 100hp .$0A0 "'o/ _ _ Other Electrical Fee '$0.00', Motors over 100hp $0.00 1� Communication drops $0.00 0 ` r Investigation Fee ; $0.00 Sub panel to 200a $109.00.. 4_ %\. ' Plan Check Fee $D.00 Pole Light Pkg $0.00 0 " Reinspection Fee - ,. "% $0.00 Sign Circuits $0.00 0 - - ,, , • ,�, ' Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $355.65 Intermed Pole $0.00 0 COMMENTS 1 SPECIAL CONDITIONS EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 DECLARATiONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of porjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to sett -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the ori for which this permit is Issued. 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. y workers' compensation Insurance carrier and policy number are: Carrier: Policy Number. (This section need not be completed if the permit is valued at one hundred dollars ($100) or lass.) ❑ I Corti rformance o the work for which this permit is issued, I shall not employ any person in any manner so as to became subject to the workers' lawsbt Colifomi , a agree that 11 ould become subject to the workers' compensalio visions of Section 3700 of the Labor Code, I shall forthwith yw hese,provisionkff.,_Wnsatlon Signat Date: AILURE TO SECURE WORKERS' ENSATItJIV COV QE 65 UNLAWFUL AND SHALL SUf3t>:CT ANE NAL !'ENALTIES AND CIVIL ONES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION THE COST OF OOMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. LICENSED CONT =hCen RATTON: I hereby aer provisions of Chapter 9 (commencing with Section 7000) of D on 3 of the Busin d P fessions Coda, and my license is in full f d enact. U. ~/C) Co clot's Signet Date: CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is Issued. (Sec. 3097, Civil Code). Lender's Name: Londor's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031 .6, Business and Professions Code: Any city or county which requires a permit to construct, alter. Improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Protesslons Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (S50O).}: ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves theroon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not intended or offered for safe. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of safe.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or dead): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more foot in depth into which a person is required to descend, will be made In connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) foot high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Tltie 8, California Administrative Code), ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Dale: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify, a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Masa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic toot of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight o1 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ......................."I1,1.........................................................'d'in".......................................................................................................v.e.n............................................................................ 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materlals)7 ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department, a if .................................................................................................................................................................................................................................................. an .RMPP s presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No .................................................................................................................................................................................................................................................................................... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Li Yes No (Section 65850.2 of the California Government Code requires that the requested information be fumished on applications for non-residential building permits). ................................................................................................................................................................................................................................................................................ fi Wi!] any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 1-1-.1 ......................................................................................................................................................................................................... •............................................................. 7 If a Permit from the South Coast Alr Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have a!1 of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ...................................................................................................................................................................................................................... B (If yes', attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I Certify that under penalty of perjury the information given above is Correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the Information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. nahtr galOwner(s) di r Authciz#Applicant Data 02" INSPECT] 6N TYPE ;QDA! INSAECTION TYPE DATE 1H1'I1161� 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pod Spa Flnel 206 Final Plumbing � � .� 200 Final Re -Roof 210 Final Electrical 201 Final BlocklRetalning Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Flnal Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Bullding/Occupancy 2446-46 7 , J 3 l�01 �R 1 �TDL S -T- CITY OF COSTA MESA �.. s: BUILDING DIVINION DEVELOPMENT SERVICES DEPARTMENT ���,• PERMIT (714) 754-5273 • Fax (714) 754-4856 FIRE SUPRESSION PERMIT .lob Address: 3333 BRISTOL ST Suite: 1001 Vicinity: 77 FAIR DRIVE, Kt UMBER -00205 MESA, CA 92626 Status: ISSUED Applied: 09/17/1998 Issued: 09/23/1998 Parcel Nunmber: 41250107 Zoning: PDC PDC Applicant: ARGUMEDO, ALEX - - Address: l 'Phone: Owner: SO,COAST PLAZA --MAIN MALL,%C.t_SEGERSTRO M'& SONS / Address 3315 FAIRVIEW R Phone: ��- •� � � � ` �i1/i /y i � � � �� � ti• COSTA MESA CAy� i _� Zi 92626 Contractor: N &D FIRE"PROTECTION Address: /-3539 SAN�GABRIEL RIVER RD c CA. � Phone:, 562-908-1660 PICO:RIVERA Zip:'5�90660�, License:- 657954; x,i rfi a 1 '~' SCOPE OF'PERMIT<-. ' "'Sephora'=store ti, sprinkler system aft, reB98-01392. - - FEE SUMMARY r Plan,Check: $56.71 1; r �,� u, r.• r. , a / ' Calc ' t \ `�/., , .. ..L�'. Valuation: $0.00 ��_,,4 u �...... Permit: , $87.25 `-,. _, .,, - Claimed Valuation: $3,500.00 � Other: ' $0.00 \ i Total: $143.96 EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or If work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Fallure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 DECLARATIOMS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations, ❑ I have and will maintaln a certificate of consent to salt-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is Issued. Chave and will maintain workers' compensation insurance, as required by section 37DO of the Labor Code, for the performance of the work for which this permit is Issued. My workers' compensation Insurance carrier and policy number are: rier. Policy Number: (This section need not be complated It the permit Is valued at one hundred dollars ($100) or less.) ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' allgilaws of California, and ag at I1 I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith Comply with tr0 ' one. Applicant Signature: :;:D;ate-:ETOSECUREWORKERS'OOMPENSA ON RAGE IS UNLAWFUL AND SHALL SUSeJECT CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000). IN ADDITION TO THE COS TION, DAMAGES AS PROVIDED FOR IN SEF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic. # 19 S / Class # �_� L Lc Contractors Signature: Date: 9 - Z'3. — 9 g CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is Issued. (Sec. 3097, Civil Code). Lenders Name: Lenders Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of porjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7D31.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or Improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. 11, however, the building or Improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or Improve for purpose of sale.). ❑ i, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Coda: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet In depth Into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, faisework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 Cubic feet of compressed gas at standard temperature and pressure). .................................................................................................................................................................................................................................................................. 2 0085 or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ............................................ ................................................................................... ....... ............................................... ............................. ............................... ............. I........ I........ 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department, .................................................................................................................................a.f'e..............b.e.e...................ili'd,....................................................................... .................. 4 tf an RMPP is presently required, has section 25534 of the Califomla Health and Safety Code been fully complied with? ❑Yes ❑ No .................................................................................................................................................................................................................................................................................... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this ppplication a2ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes U No (Section 65850,2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the fedlity to be constructed under this permit be within 1000 feet from the outer boundaries of a 8-C. 1-7 ❑ Yea ❑ No (it 'Yee, the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ......................................................................................................................................................................................................................................................................... 7 If a permit from the South Coast Air Quality Management District or other air poltutlon control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No .................................................................................................................................................................................................................... 8 (I1 yes", attach Certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. 1 agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emiss ons. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given Is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. SI atu Of Legal Owner(s) 23e And/Or A o ed Applicant Date =M_L INSPECTIONTYPE QAiE IIfIIDALS CODE 1 INSPECTION TYPE 17AIE INTffIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 2DD Final Re-Roof 210 Final Electrical I ZIA 201 Final Block/Retaining Wall 212 Final Fire Prevention ��" IA) 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 FInal Site 204 Final Demolition 250 Final Building/Occupancy 2446-40 3 33 tool? 13:tam- ST ` CITY OF COSTA MESA BUILDING DIVISION DEVELOPMENT SERVICES DEPARTMENT ' PERMIT (714)754.5273 • Fax(714)754-4856 &TAWSKI PERMIT N R M 0433 77 FAIR DRIVE, COSTA MESA, CA 92626 MECHANICAL PERMIT Job Address: 3333 BRISTOL ST Status: ISSUED L'/t•p Suite No 1001 -JE� Applied: 09/22/1998 Issued: 09/22/1998 Vicinity: Parcel Nunmber: 41250107 Applicant: RISINGER, THOMAS $0.00 Address: - - $0.00 0 $0.00 _ Phone: 0 $0.00 .� Zip. 0 $0.00 0 '$19.00,' 2 $66.50 Owner: SO COAST PLAZA --MAIN MALL %C,) SEGERSTROM.& SONS $0.00 0 $19.50 3 Address: 3315 FAIRVIEW RD', $0.00. 0 $0.00 0 Phone: 0 $0.00 COSTA MESA CA - Zip: 92628 0 Contractor:,,-, AIR CONTROL SYSTEMS INC Address:- 5580 E: LA PALMA Phone:, 714 777-9685 ANAHEIM, CA Zip:'92807 - .. . s License. 639'0'03:. Arch f Eng : r �. -I I • �. Address: ISSUE FEE ' Inst FAU.<100 k BTU Inst FAU X100 k BTU Repair/Alt. CoolinglHeat Inst 1 Rep.'Recess Wall Htr Refrig Sys <100 k BTU Refrig Sys >100 k BTU Gas Piping Factory Fireplace Hood wlMech Exhaust VAV Box Vent Fan 1 Single Duct Appliance Fire Dampers Smoke Dampers Inst or Relocate Appl Vent Air Handlers < 10000cfm Air Handlers > 10000d rn Floor Furnace Floor or Suspend Heater Phone: Zip: License: ` SCOPE OF PERMIT,, MECH FOR T.I. 7 VAV UNITS (BOXES), 45 INLETS AND OUTLETS, 3 FIRE DAMPERS, AND 2 CEILING EXH. FANS. Quantity $22.00- 22.00$0.00 $0.00 $0.00 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 '$19.00,' 2 $66.50 "7 $0.0 $0.00 0 $0.00 0 $19.50 3 $0.00 0 $0.00. 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 FEE SUMMARY O' Repair I Alt Absorbtion Unit $0.00 Repair/Alt Refrigeration Unit $0.00 Ventillation System $0.00 Evaporative Cooler Commercial Incinerator $000 '` Domestic Incinerator $0.00 • ,. �� Compressors l Absorption Systems" _ Up to.3 hp 1100 k BTU ,$0.00 `3 To 15 hp 1500 k BTU �, . , i,. $0.00 15 To 30 hp 1 1,000 k BTU '"� $0.00 ` '30 To 50 hp 1 1,750 k BTU .x$0.00 Over 50 hp 1 Over 1,750 BTU $0.00 Boilers Up to 3 hp 3To15hp 15 to 30 hp 30 to 50 hp Over 50 hp Other Mechanical Fee Investigation Fee Plan Check Fee Reinspection Fee TOTAL CALCULATED FEES COMMENTS / SPECIAL CONDITIONS $0.00 $0.00 $0.00 $0.00 $0.00 $0,00 $0.00 $0.00 $127.00 Quantity 0 0 0 a' 0 0 0 0 0 0 0 0 0 0 0 0 EXPIRATION: This permit shall automatically expire and become void if work Is not commenced within 180 days, or if work Is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 DECLARAMNS WORKERS' COMPENSATION DECLARA. . . I hereby affirm under penalty of perjury one of the following dedarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the tabor Code, for the performance o1 the work for which this permit is issued. ❑ I have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. My workers' compensation Insurance carrier and policy number are: Carrier: Policy Number. {This section need not be completed It the permit is valued at one hundred dollars {5100} or less.} ❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Calif an 96 that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with thesepr n AV7_710 g Applicant Signature: � Date: T� WARNING: FAILURE TO SECUREGRIiERS' T1 COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARE (a10D,00D), N ADDITION TO TFROOST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that l am licensed under vis' 9hapter 9 (commencing with Section 7000) of 010slon 3 of the Business and Professions Code, and my license is in full force and effect. Lic.1f Class 4 Contractor's Signatu Date: ✓ CONSTRUCTION LENDING A ENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lenders Name: Lenders Address: Signature: T _ __ Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that Under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, after, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (5500).): ❑ 1, as owner of the property, or my employees with wages as their Sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractars License Law does not apply to an owner of property who builds or Improves thereon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not intended or offered for sale. If, however, the building or Improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property; am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts tot such project with a contractor(s) license pursul},nt to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: _ Date: owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or dead): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, wilt be made In connection with work authorized by this permit, and that no building structure, scaffolding, fafsework, or demotition or dismantling thereof, wiff be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, Celifomia Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Slgnalure: Date: Division of Industrial Safety Permit Number. HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the Califomia Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity o1 hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and prossure). ..................................................................................................................................................................................................................................................... 2 Does or will the applicant or present or future building occupant need to lite a registration torn for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the Califomla Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity o1 acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed 94s at Standard temperature and pressure). ................................................................................................................................................................................................................................................................................ 3 Does or will th applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes No (Section 25534 of the Califomla Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ............................................................................................................................................................................................................. 4 If an RMPP is presently required, has Section 25534 Df the Califomia Health and Safety Code been fully complied with? ❑ Yes ❑ No ..................................p.Ii,_a,_........................-...-.....................---.........................-.-...-......---•--..-.h.i's..............................................................-....................1'r'u.- .f............ 5 Goes or will the applicant or present or future building occlrpant require for the work which is the subject of this a p[icatiom a ertnit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes [TNI (Section 65854),2 of the Celifomia Govemment Code requires that the requested Information be fumished on applications for non-residential building permits). ................................................................................................................................................................................................................................ 6 Will any part of the facility to be constructed under this permit be within 1000 feat from the outer boundaries of a School? ❑ Yes El No (If yoV, the facility must meet the requirement of Sections 25534 and 42303 of the Califomia Health and Safety Code). ...............................................................................................................................................................................................•---.---.....-................................................... ,........ 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by Califomla Health and Safety Code Section 42303 been made? ❑ Yes ❑ No (If ................................................................................................................................................................................................................................................I.......................... 8 yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I Certify that under penalty of perjury the information given above Is Correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Data: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that 1 have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for' sp ctlon purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final Inspection. i at a Of Legal Owner(s) Data An ut rued Applicant Date CODE 1. ASPEC1110N TYPF QST jNTITIA CODE f INSPECTION TYPE 2&M I� 1616 Fixed System Fina! Fire Prevention 206 Final Mechanical4-749bbj 1268 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final BlooklRetaining Wall 212 Final Fire Prevention 2102 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy 244646 33 33 100/ B e (Z r0L_ ST- �} g 4 CIT/ OF COSTA MESA �! BUILDING DIVISION * DEVELOPMENT SERVICES DEPARTMENT PERMIT PERMIT NUMBER P98-00701 (714) 754-5273 Fax (714) 754-4856 77 FAIR DRIVE, COSTA MESA, CA 92626 PLUMBING PERMIT ,lob Address: 3333 BRISTOL ST Status: ISSUED Suite No 1009 Applied: 09/16/1998 Issued: 09/16/1998 Vicinity: Parcel Nunmber: 41250107 Applicant: BALDERRAMA, LAWRENCE Address: Phone: 714-835-1577 Zip. Owner: PLAZA_==MAIN:MALL %CJ SEGERSTROM & SONS � ,SO�COAST Address,/i3315 FAIRVIEW RD Phone: b�i. / COSTA MESA/ CA,,' Zip: 92626 Contractor: 'L B PLUMBING COMPANY Address:-- 1 1632",MARBLE ARCH DR I� i Phone' SANTA ANA CA '� •. -Zip: 92705 License: ` 287240 ArchlEng: j Address: f V j ,Phone: License: + -SCOPE OF'PERMIT REF B98-01392 REMODEL FOR 'SEPHORA' , INST 1 KIT SINKr2.WASH BASIN, 2 TOILET, 1 W.H. 1 MOP SINK, 1 EXPANSION TANK. FEE SUMMARY - - AMT QTY AMT QTY AMT QTY ISSUE FEE, $22.00 Laundry Tub /Washer" $0.00 0 Sump Pump ! $0.00 0 Backflow irrigation $0.00 0 Landscape Irrigation ;, $0.00 0 Swirnming'Pool $0.00 0 Backflow Preventer $0.00 '0 P -Trap'•.. $0.00 0 , Trap Primer $0.00 0 Bathtub $0.00 -0 Pressure Regulator $0.00 -0 Urinal $0.00 0 Clarifier System . ` $0.00 '0 -Process Piping (per 10 ft),, $0.00 0 ,Vac'uum'Brkrl Bkflow(1-4) ' $0.00 0 Connect (Ice,Soda,etc) $0.00 0 Receptors $0.00 0- Vacuum Brkr,Bkflow(5+) $0.00 0 Dental Units $0.00 10 Septic Tank $0.00 .0 Wash Basin' $17.50 2 Dishwasher $0.00 0 Sewer Cap.for,Demo -'$0.00 0 . Wash Basin /J $0.00 0 Drain, Floor $0.00 0 y Sewer Connect $0.00 0 ,Set, Waste and Vent System $0.00 0 Drain, Rainwater $0.00 0 Sewer Private Line $0.00 . '0 Water Closet'(Toilet) $17.50 2 Drain, Roof $0.00 0 Shower $0.00 0 Water Heater! vent $11.00 1 Drinking Fountain $0.00 0 Sink, bar $0,00 0 Water Piping (Inst or Rep.) $0.00 0 Expansion Tank $8.75 1 Sink, commercial $0.00 0 Water Re -pipe $0.00 0 Gas Earthquake Valve $0.00 0 Sink, Floor .$0.00 0 Water Service $0.00 0 Gas (1-4 outlets) $0.00 0 Sink, kitchen $8.75- 1 Water Softener $0.00 0 Gas (Over 4 outlets) $0.00 0 Sink, servicelmop $8.75 1 OTHER $0.00 Gas Repipe $0.00 0 Spa (private) $0.00 0 VIOLATION $0.00 Gas Service $0.00 0 Spa (public) $0.00 0 PLAN CHECK $0.00 Interceptors (Grease, Oil) $0,00 0 REINSPECTION $0.00 0 Interceptors (Sand Auto) $0.00 0 TOTAL CALCULATED FEES: $94.25 COMMENTS I SPECIAL CONDITIONS EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work Is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 1 DECURATIONS WORKERS' COMPENSATION DECLARATION: a1 141 I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to satf-Insure for workors' compensalion, as provided for by section 3700 of the labor Code, for the performanca of the work !2LVd9Gh this permit is issued. ve and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. My workers' cbmtion Ii nce carrier and policynumber are: Carrier: ' _ . �f _ _ Policy Number. , L C (This section need not be Completed it the permit Is valued at one hundred dollars ($100) or less.) ❑ I certify that in the performance of the work for which this permit is issued. I shall not employ any person in any manner so as to become subject to the workers' comps on laws of Ca'fomla, and agree that If I should become subject to the workers' compensation provisions of Section 3700 of the Labor Cade, I shall forthwith ase pro i ns. tp=ficantSignature: i Date:RE TO E WORKERS' COMAEN$AT1ON COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED SAND DOLLARE 00,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that i am licensed and rovfsl S f Ch to 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is In full force an . If 4U Class s tractor's Si a: Date: J CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lander's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that Under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the fallowing reason (Sec. 7031,5, Business and Professions Code: Any City or county which requires a permit to Construct, alter, improve, demolish, or repair any structure, prior to is Issuance, also requires the applicant for such permit to file a signed statement that he or she Ls licensed pursuant to the provisions of the Contractors License Law (Chapter B (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty o1 not more than five hundred dollars {$500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or Improves thereon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not intended or offered for sale. If, however, the building or Improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuent to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID vadfled by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, I.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made In connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, wiff be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? (] Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some excepflons, that a Business Plan be filed with the Costa Mesa Fire department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ................................................................... 2 Does or will the applicant or present or future building occupant need to file a registration form far acutely hazardous materials? ❑Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume o1 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ...................................................................................................................,...................................................................................................... 3 Does or will thea applicant or resent or future building occupant need to re are an RMPP Risk Management and Prevention Program for acute) hazardous materials)? PP P g P P P ( 9 og Y ) ❑ Yes Q No S{{Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire epartmont of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. .............. ','h. s" .........................'r'n,i ...-....-.---.n-d-*......................................-.-................................................................................................ 4 If an RMPP Is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑Yes ❑ No ..................................................................................................................................................................................'s' - ........................ r'm.I.............-....-........................... ff.1C......... 5 Does or will thg applicant or, present or future building occupant require for the work which Is the subject of this a pllCatlon a mmh for such construction or modKlcaticn from the South Coast Air Quality Management District or from any other air pollution control district or agency? 8 Yes ❑ No (Section 65850.2 of the California Goverment Code requires that the requested Information be fumished on applications for non-residential building permits). .................0-.1....-.-.-.---.......................................................................................-..........-.-.-.-..-................................-............................................... 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes ❑ No (If'yee, the facility must meet the requirement of Sections 25534 and 42303 of the Calilomia Health and Safety Code). ............................... ............................................................................... ...................................................... .-................. ........................................................ ................. I........ 7 If a permit frotn the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made ❑ Yaa ❑ No ....8.6..-1 ......... ... ............................................................................................................................................................................................................................................................ (If yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I can! that that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emiss ons. Signature: Data: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to Comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final Inspection. S lure UwallOrrner(s)Q! gate �� ft"Or Authonz d licant ! Date cool: r. JMff.GnQJMF 11M RITITI CODE f INSP.EMONTYPE DATE 1HIID•ALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing ID -2 l___: -9R 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retalning Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Fina) Planning Approval 203 Final Sign 222 Final Site 2D4 Final Demolition 250 Final Building/Occupancy 2446.40 CITY OF COSTA MESA BUILDING DIVISION DEVELOPMENT SERVICES DEPARTMENT PER IT NUMBER PERMIT 00-00767 (714) 754-5273 Fax (714) 754-4856 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT .lob Address: 3333 BRISTOL ST Status: ISSUED Suite No 2505 Applied: 08/03/2000 Vicinity: SPACE 2505 Issued: 08/0312000 Parcel Nunmber: 41250107 ISSUED BY: Applicant: SHIPLEY, JOHN Address: 618 S OAKHAVEN AVE Phone: (714) 961-8736 BREA, CA Zip: 92621 Owner: SOUTH COAST PLAZA Address %C J SERGERSTOM COSTA MESA, CA 3315 FAIRVIEW RD Contractor: SHIPLEY'S ELECTRfC Address: 618 S OAKHAVEN AVE BREA, CA Phone: Zip: 92626 Phone: (714)961-8736 Zip: 92621 License: 321182 SCOPE OF PERMIT ELECTRICAL PERMIT FOR RESTAURANT T.I. FOR "CAFE PASCAL" (SPACE 2505), INSTALL 24 LIGHT FIXTURES, 20 RECEPTACLE OUTLETS, 11 SWITCHES, 2 MOTORS TO 1 HP, i MOTOR TO 10HP, 2 SUB PANELS, 11 MISC CONDUCTORS, & 6 MISC CONDUITS, REF: 800-01019 COMMENTS ! SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such worts must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 , FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 Temp Dist System 1 Lighting $0.00 0 Temp service test $0.00 Busway 1100 ft $0.00 0 Res. a/c package $0.00 Standing Section $0.00 0 New Res (1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0 New Res (3+units) $0.00 0 Transformers up to 1 kvalkw $0.00 0 Pool 1 Spa $0.00 0 ................up to 10 kvalkw $0.00 0 Lighting Fixts $22.92 24 .................up to 50 kvalkw $0.00 0 Recept Outlets $22.00 20 .................up to 100 kvalkw $0.00 0 Switches $12.10 11 ..................over 100 kvalkw $0.00 0 Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0 Res Appl $0.00 0 Low Volt Wiring System 1 Ckt $0.00 0 Service to 200a $0.00 0 Misc. Conduit $109.20 6 Service to 1000a $0.00 0 Misc. Conductor $200.20 11 Service over 1000a $0.00 0 Circus ( gen or ride) $0.00 0 Motors to 1 h $9.50 2 Circus (mech ride or lights) $0-00 0 Motors to 10hp $12.30 1 Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 0 Fireworks Stand $0.00 0 Motors to 1 00h $0.00 0 Other Electrical Fee $0.00 Motors over 100hp $0.00 0 Communication drops $0.00 ❑ Investigation Fee $0.00 Sub panel to 200a $61.00 2 Plan Check Fee $0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $0.00 0 Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $472.72 Intermed Pole $0.00 0 COMMENTS ! SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such worts must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 , DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued, r mp I-Q�Fhave and will maintain workers' compensation insurance, as required by section 3700 of the Labor Coda, for the performance of the work for which this permit Is issued. My workers' compensation Insurance carrier an policy number are: C mer E aA%Or Policy Number -—�'J_(L11 �_z Z 7 (This section need not be completed it the permit is valued at one hundred dollars ($100) or less.) ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws ofC ' omia, agr that If I sh d come Jact to the workers' compensation provisions of Section 3700 of the Labor Code, t shall forthwith comply with these p,,F,,, ns. Appli�gnaturer-- Date: 0 WARNING: FAILURE TO SEC WORKERS' COMPENSATION COVERAGE UNLA L AND SHALL SUEUECT AN EMPLOYER TO CRIMINAL PENALTIES AN CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($1 ), IN ADDfTIDN TO THE COST OF COMPENSATION, GES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that•f•am•ficensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full %. 1� force and effect. Lic. # Class # .� Contractor's.Signelure:__� LData: CONSTRUCTION LENDIN GENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions o1 the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty o1 not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for Sala. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Cade: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Cade for this reason: Signature: Date: Owner 10 verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth Into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high, (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building Occupant need to file and certify a Business Plan for emergency response to release Or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Pian be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a welghl of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does Or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes Cl No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required, has Section 25534 of the Califomia Health and Safety Code been fully complied with? ❑ Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication aPermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes L.] NO (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-resldential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by Califomie Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (if 'Yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the Information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Sign re Le wner(s) Date 3—Oct �A dlOr Au ad cant-- _ - rDate----- CODE _. 4SPECTIONTYPE 2M INTMA^ CODE INSPECTIONTYPE 2M IHTmALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wali 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Sita 204 Final Demolition 250 Final Building/Occupancy 2446-46 (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us .lob Address: 3333 BRISTOL ST Suite No 2505 Vicinity: SPACE 2505 Parcel Nunmber: 41250107 Applicant: MORRIS, JIM Address: 16027 MARL INTON DR WHITTIER, CA Owner: , , SOUTH COAST PLAZA Address %C J SERGERSTOM COSTA MESA, CA 3315 FAIRVIEW RD Contractor: VICTORY MECHANICAL Address: 16027 MARLINTON DR WHITTIER, CA PLUMBING PERMIT Phone: (562)947-2747 Zip: 90604 Phone: Phone: Zip: License: Zip: 92626 Phone: (562)947-2747 Zip: 90604 License: 377587 77 FAIR DRIVE, COSTA MESA, CA 92626 Status: ISSUED Applied: 08/08/2000 Issued: 08/08/2000 ISSUED BY: Arch / Eng Address: Phone: Zip: License: SCOPE OF PERMIT PLUMBING PERMIT FOR T.I. FOR "CAFE PASCAL" (SPACE 2505), INSTALL 1 BACKFLOW PREVENTER, 1 DISHWASHER, 5 FLOOR DRAINS, 1 EXPANSION TANK, 2 COMMERCIAL SINKS, 7. FLOOR SINKS, 1 MOP SINK, 5 TRAP PRIMERS, 2 WASH BASINS, 8 1 WATER HEATER. REF: B00-01019 `. �. FEE SUMMARY AMT OTY _ " AMT QTY �; �; - , ' AMT QTY ISSUE FEE $23.50 ; Laundry Tub 1 Washer $0.00 0 Sump Pump $0.00 0 Backflow irrigation - $0.00/l/ 1 Landscape Irrigation $0.00 0 Swimming Pool ," $0.00 0 Backflow Preventer-" $9.80,', ' 0 P -Trap . $0.00 0 Trap Primer $49.00 5 Bathtub $0.00". 0, Pressure Regulator $0.00 0 Urinal, $0.00 0 Clarifier System $0.00 0 Process Piping (per 10 ft) '$0.00 0 " Vacuum Brkr Bkfi-4) $0.00 0 Connect (Ice,Soda,etc) $0.00 0 - Receptors $0.00 0 Vacuum Brkr Bkflow(5+) $0.00 0 Dental Units $0.00' 0 Septic Tank $0.00 0 Wash Basin $19.60 2 Dishwasher $9.80 1 Sewer Cap for Demo $0.00 0 Wash Basin Set $0.00 0 Drain, Floor $49.00 5' Sewer Connect $0.00 0 Waste and Vent System $0.00 0 Drain, Rainwater $0.00 0 Sewer Private Line $0.00 0 Water Closet (Toilet) $0.00 0 Drain, Roof $0.00 0 Shower-. $0.00 - 0 Water Heater l vent $12,30 1 Drinking Fountain $0.00 0 Sink, bar $0.00 0 Water Piping (Inst or Rep.) $0.00 0 Expansion Tank $9.80 1 Sink, commercial $19.60 2 Water Re -pipe $0.00 0 Gas Earthquake Valve $0.00 0 Sink, Floor $68.60 7 Water Service $0.00 0 Gas (14 outlets) $0.00 0 Sink, kitchen $0.00 0 Water Softener $0.00 0 Gas (Over 4 outlets) $0.00 0 Sink, service/mop $9.80 1 OTHER $0.00 Gas Repipe $0.00 0 Spa (private) $0.00 0 VIOLATION $0.00 Gas Service $0.00 0 Spa (public) $0.00 0 PLAN CHECK $0.00 Interceptors (Grease, Oil) $0.00 0 REINSPECTION $0.00 0 Interceptors (Sand Auto) $0.00 0 TOTAL CALCULATED FEES: $280.80 NOTICE: The work authorized by this permit s all comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of� r FOR INSPECTIONS CALL: (714) 754-5626 2446-46 (6/00) 11.1 el DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I h ve and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. My workers' compensation compensationst«a. Sehalm. era+nl�d .policy number are: ld_ Pol€Cy,Nuirtbr:"� ^��9Ofuam -(This section need not be completed if the permit is valued of one hundred dollars ($ f DO) or less.) p erlity that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Califomia, and agree that it I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, 1 shall forthwith comply with these proNL ions. Applicant S€gnature: - " Date:- .-��"U D� 'WARNING: FAILURE TO SECL44E VVO�IKERTCOIVIPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE (5100, IN DITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that .1-am-licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3;of.the.Business and Prof ssions Code, and my license is in full force and effect Lic. #, t'C(ass_- Cdn_tractor's,S€gnature: �t]ate:-—$'•-G� -- CONSTRUCTION LENDING A CY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, CMI Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Cade: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors UGense Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsawork, or demolition or dismantling thereof, will be more than thirty-six (36) feel high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 6, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reporled year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ......................................................_....................................................................................................................------------------..._................................................................................................................................... ................. ................... ... 2 Does or wit] the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 o1 the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ................................................................................................................................................................................................................................................................................................................... - ....................................... _ 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. .-... .............................................................. ....................................................................................................................-------...••----...........•--......................................_.................................... 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No ...........................................................................................................................................................................................................................................................................1111...............................1.111...................... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Ll Yes [ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ........................._•---....-•--... ................................................... ........................................_--------------•------------.........................._... -.......-•---...................................................... .................. .�........... 6 W'tll any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ............................... ....._.......... ..........................................................................................................................................................---....._•---...._.........................----------.---....................................._...... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No •-------..............................................................................................................................................................................................................--.................._........................ ----................................................ 1111 8 (If fres", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. S€ lure LagalOwner(s) p p Date And/ r Authorized Applicant CODE I. JNSPE6WMfYn 2AN DiTM&P CODE 0 INSPECTION TYPE ( 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 206 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final BuitdinglOccupancy 4 (714) 754-5273 • Fax (714) 154-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 MECHANICAL PERMIT Job Address: 3333 BRISTOL ST $23.50 Status: ISSUED Suite No 2505 $0.00 Applied: 08/16/2000 $0.00,. 0 $0.00. Issued: 08/16/2000 Vicinity: CAFE PASCAL (STE 2505) $0.00 0 Parcel Number: 41250107 $0.00 ISSUED BY: Applicant: ANDERSON, JOHN $0.00 0 Address: 1550 S SUNKIST ST SO.00 o $0.00 STE E, - Phone: (714) 937=5305" 0 $0.00 ANAHEIM, CA Zip: 92806 0 Ownef: SOUTH COAST PLAZA $0.00 0 Address: %C J SERGERSTOM COSTA MESA, CA " Phone: 3315 FAIRVIEW RD Zip: 92626 Contractor: H.V.A.C. MECHANICAL Address: 01550 S SUNKIST ST ANAHEIM CA Arch 1 Eng Address: Phone: Zip: 92806 License: 682002 Phone: Zip:. _ License: SCOPE OF PERMIT 1092 SF INTERIOR TI FOR "CAFE PASCAL" (STE 2505). 1 INET FAU< 100 K BTU, 2 VENT FAN/SINGLE DUCT, 1 3-15 HP/500 K BTU. REF: BOO -01019 ISSUE FEE Inst FAU <100 k BTU Inst FAU >100 k BTU Repair l Alt Cooling/Heat Inst 1 Rep. Recess Wall Htr. . Ref rig Sys <100 k BTU Refrig Sys >100 k BTU Gas Piping Factory Fireplace Hood w/Mech Exhaust VAV Box Vent Fan I Single Duct Appliance Fire Dampers Smoke Dampers Inst or Relocate Appi Vent Air Handlers < 10000cfm Air Handlers > 10000cfm Floor Furnace Floor or Suspend Heater FEE SUMMARY Repair /-Alt Absorbtion Unit Repair/ Alt Refrigeration -Unit Ventillation System Evaporative Cooler Commercial Incinerator, Domestic Incinerator, Compressors 1 Absorption Systems Upto3hp/100kBTU 3 To 15 hp 1500 k BTU 15 To 30 hp 1 1,000 k BTU 30 To 50 hp 11,750 k BTU Over 50 hp I Over 1,750 BTU Boilers Up to 3 hp 3To15hp 15 to 30 hp 30 to 50 hp Over 50 hp Other Mechanical Fee Investigation Fee Plan Check Fee Reinspection Fee TOTAL CALCULATED FEES $0.00 $0.00 $0.00 $O.OD $0.00 $0.00 $14.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $67.50 Quantity 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. - INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446.46 (6=) AL Quantity $23.50 $14.80 1 $0.00 01'., $0.00,. 0 $0.00. "0. $0.00 -",0 ' $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $14.50 2 SO.00 o $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 FEE SUMMARY Repair /-Alt Absorbtion Unit Repair/ Alt Refrigeration -Unit Ventillation System Evaporative Cooler Commercial Incinerator, Domestic Incinerator, Compressors 1 Absorption Systems Upto3hp/100kBTU 3 To 15 hp 1500 k BTU 15 To 30 hp 1 1,000 k BTU 30 To 50 hp 11,750 k BTU Over 50 hp I Over 1,750 BTU Boilers Up to 3 hp 3To15hp 15 to 30 hp 30 to 50 hp Over 50 hp Other Mechanical Fee Investigation Fee Plan Check Fee Reinspection Fee TOTAL CALCULATED FEES $0.00 $0.00 $0.00 $O.OD $0.00 $0.00 $14.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $67.50 Quantity 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. - INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446.46 (6=) AL C DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My gon rs' compensation Insurance Carrier and policy number are: Carrier:/^-Cef-� ,d- Policy Number: ��0�ULi (This sec need riot ba completed if the permit is valued at one hundred dollars ($100) or lass.) ❑ 1 certify that in the perfo rk for nr which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation al'Ifomia, and agr at If I should become subject to the workers' compensation provisions of Sectl n 3700 of the Labor Code, I shall forthwith comply ese provisions. / Applicant SigDate: L /hr� WARNING: FAILURE TO KERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE I$ ,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: 1 hereby affirm that I am licensed u der provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and affec Class # C1)__0 Contractor's Date: CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm_ that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builde( will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No, Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such parson has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ............................................................................................................................................................................................................................................................................................................................................................................................ 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ...................................................................................................................................................................................................................................................................................................................................................................................... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. .......................................---a'S......................._..................................._..............................._._.......................---._...................................................... ........................................................................................ 4 If an RMPP is presently requ€red, has Section 25534 of the Celifomia Health and Safety Code been fully complied with? ❑Yes ❑ No ................................................-- ............................. ........... ----...................................._---..............................................._........._..................._............................................................ ................... 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this a plication apermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be fumished on applications for non-residential building permits). ................................................................................................................................................................................................................................................................................................................................................................. 8 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'fres", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ........................................................................................................................................................................................................................................................................................................................................................... 7 a a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which Is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 boon made? ❑ Yes ❑ No - -...............I..................................................... -............................................................ .......................................................... .................... ... 8 (if jres", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certity under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Ignature Of Legal Owner(s) Date — 6 � And/Or Authorized Applicant Date CODE A. INSPECTION TYPE UZ INiMAL$ CODE# INSPECTION TYPE 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final BlocklRataining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Damot:llon 250 Final Building/Occupancy A& (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT Job Address: 3333 BRISTOL ST Suite No 2505 Vicinity: ESCADA ELEC ROOM (SUPPLY STE 2505) Parcel Nunmber: 41250107 Applicant: ROBERTS, STEVE Address: 12 SAND POINT Phone: 714-495-3541 LAGUNA NIGUEL. CA Zip: 92677 Owner: SOUTH COAST PLAZA Address %C J SERGERSTOM COSTA MESA, CA Phone: 3315 FAIRVIEW RD Zip: 92626 Contractor: ROBERTS ELECTRICAL Address: 12 SAND POINT Phone: 714-495-3541 LAGUNA NIGUEL, CA Zip: 92677 License: 380116 Status: ISSUED Applied: 08/25/2000 Issued: 08/25/2000 ISSUED BY: -Alv�, COMMENTS ! SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall autorriatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446-46 (6=) F SCOPE OF PERMIT 1092 SF INTERIOR RESTAURANT FOR "CAFE PASCAL" (STE 2505). 1 SERVICE TO 1000A, 1 MISC ELECTRICAL EQUIPMENT. (NOTE: WORK IN ESCADA BREAK THROUGH.) REF: 800-01919 8 E00-00767 FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 Temp Dist System ! Lighting $0.00 0 Temp service test $0.00Busway 1100 ft $0.00 01 Res. a/c package $0.00 Standing Section $0.00 , 0 New Res (1-2 units) $0.00 0 Misc Electrical Equipment $18.20 1 New Res (3+units) $0.00 0 Transformers up to 1 kvalkw $0.00 0 Pool / Spa $0.00 0 ................up to 10 kvalkw $0.00" 0 Lighting Fixts $0.00 0 .................up to 50 kvalkw $0.00 , 0 Recept Outlets �,-', $0.00 .............up to 100 kvalkw $0.00 ' ,- 0 Switches $0.00 0 ......over 100 kvalkw -'" $0.00 0 Non Res App] $0.00 0 Low Voltage Equipment $0.00 0 Res Appl $0.00 0 Low Volt Wiring System 1 Ckt $0.00 0 Service to 200a $0.00 0 Misc. Conduit $0.00 0 Service to 1000a $62:15 1 Misc. Conductor $0.00 0 Service over 1000a $0.00 0 Circus ( gen or ride) $0.00 0 Motors to 1 hp $0.00 0 Circus (meth ride or lights) $0.00 0 Motors to 10hp $0.00 0 Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 0 Fireworks Stand $0.00 0 Motors to 100hp $0.00 0 Other Electrical Fee $0.00 Motors over 100hp $0.00 0 Communication drops $0.00 0 Investigation Fee $0.00 Sub panel to 200a $0.00 0 Plan Check Fee $0.00 Pole Light Pkg $0,00 0 Reinspection Fee $0.00 Sign Circuits $0.00 0 Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $103.85 Intermed Pole $0.00 0 COMMENTS ! SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall autorriatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446-46 (6=) F DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury ane of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain workars' compensation Insurance, as required by section 3700 of the labor Code, for the performance of the work for which this permit Is Issued. My workers' compensation Insurance carrier and policy number are: Carrier: _ Policy Number: (This section need not be completed it the permit is valued at one hundred dollars ($ f 00) or less.) cel that in the performani work for wh s pe is is ad, I shall not employ any person In any manner so as to become subject to the workers' �.. compensation laws of Califo d agr 1 should object to the workers' compensetipn provisions Of Section 3700 Of the Labor Code, I shall forthwith comply with those provi-- Applicant Signature: Date: _ WARNING: FAILURE TO SECURE WORKERS' COMP TION COVET EIS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TOONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDrf1OH TO THE DOST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm [hat I am license lmder Proviso s of Chapter 9 (c mencing with Section 7000) of Division 3 of the Business d Professions Code, and my license is In full force and effect. Lie. q Class q Contractor's Signature: Date:._____ CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3047, Civil Coda), Lender's Name: Lenders Address: Signature: Date: - OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a cavil penalty of not more then five hundred dollars ($500).): ❑ I, as owner Of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself Or through his or her own employees, provided that such Improvements are not Intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractors) license pursuant to the Contractors License Laws.). ❑ I am exempt under ser:. Business and Professions Code for this reason: Signature: _ Date: Owner ID verified by drivers license. Cl Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this Permit, and that no building structure, scaffolding, faisewofk, of demotitton of dismantling lhereot, will be more than thirty-six t36) feet high. (Chap. 3.2, Grp 2, An 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: _ _ Date: DMslon of Industrial Safety Permit Numt)er. HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business flan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the Cafifonl Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gaa at standard temperature and pressure). 2 Doas or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic foot of compressed gas of standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPA (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department, 4 If an RMPP is presently required, has Sect€on 25534 of the Cel€fornla Wealth and Safety Code bean fully compo€ed with? ❑ Yes ❑ No ..............................................................................................................._.......... ........................... ......................................................... ,............................................................ ..._........... _.......... 1. ....... -............. _ ......... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a pllcation a ffrmit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? IU Yes LJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). _................._................................ _.....--.._... _. ..._. __.............. .................. .................. ............. _.... ...- _ 8 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a schaof? ❑ Yes ❑ No (If yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). --.........._ _...........—...__......................................................... - .............. _ ....._ .... _ 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes Q No .............._.............._ _..---- - -. .............. ..... -........................................................._ 8 {If yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and EmiSSIOn3. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct I agree to comply with all state laws and city ordi I relating to building construction, and authorize representatives of the City of Costa Masa to enter upon the above-described property for inspection pu r In occupy or allow occupancy of any building authorized by this permit until final inspection, S nature' 1 Le r(s)/ 4F-7-,S�aEe AlA oriz Applicant F. Date CODE R. INSPECTION TYPE Un 1!TITIA CODE INSPECTION TYPE 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Root 210 Final Electrical - 201 Final BlocklRetalning Wall 212 Final Fire Prevention 202 Final Factory Fire Place 224 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy N (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mMAre jjPRESSION PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Status: ISSUED Suite: 2505 Applied: 08/07/2000 Vicinity: CAFE PASCAL (STE 2505) Issued: 08/21/2000 Parcel Number: 41250107 Zoning: PDC PDC ISSUED BY: Applicant: MANCINO, RANDY Address: 818 N GRAND AVE Phone: 626-332-7066 COVINA, CA Zip: 91724 owner: 'SOUTH COAST PLAZA Address %C J SERGERSTOM COSTA MESA, CA Phone: 3315 FAIRVIEW RD Zip: 92626 Contractor: ALLREADY FIRE SPRINKLER CO Address? 818 N GRAND AV Phone: (626) 913-6720 COVINA, CA Zip: 91724 License: 358795 SCOPE OF PERMIT RELOCATE 19 SPRINKLER HEADS FOR "CAFE PASCAL." REF: B00-01019. FEE SUMMARY - Plan Check: $54,11 Calc Valuation: $2,375.00 Permit: $83.25 Claimed Valuation: $2,375.00 Other: $0.00 Total: $137.36 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 / 2446.46 (6/00) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of pedury one of the following declarations: ❑ r have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. f have and will maintain workers' compensation Insurance, as required by section 3700 of the labor Code, for the performance of the work for which thispennit is Issued. My wo rs' compensation Insurance carrier and policy number are: "Carrier:- _1>iii- AJ 'i-e Policy Numt�er_ /'��7L L�L�_ (This section need not ba complated if the permit is valued stone hundred dollars ($100) or less.) ❑ I Certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that III should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply_with.these pr siooys. _ �plicant Signature: __1 __1_._— Date: ZJ ?>IJ WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS IS1OD,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that, 1, am -licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. ff Lk.,, - class # e"-7G ContractorsSignafure:_�_�r,..f,�rDate:— CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lenders Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031 .5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or She did not build or Improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contrector(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property fax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMrr CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Masa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater then a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas et standard temperature and pressure). ........................._......................................................................_.......................................__..............................._.............................._._................................................................................_...................................................................... 2 Does or will Lha applicant or present or future building occupant need to file a registration form for acutely hazardous materials? © Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ......... ...................................•--•--................................................................................ ................................. .............................. ......................................................................... .................._............................................................. _.. 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ............................................................................................................................................................................................................................................................................... 4 Ii an RMPP Is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No ........ ................................................. ................._............................................................... ....................................... ........................... I'll ................................................................................. .................. ........................................................ 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application a germit for such construction or modification from the South Coast Air Quality Management District or from any other air pollutlon control district or agency? U Yes LJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under tills permit be within 1000 leaf from the outer boundaries of a school? ❑Yes ❑ No (If yes", the facility must meet the requirement o1 Sections 25534 and 42303 of the California Health and Safety Code). ............................................................................................................................................................................................................................................................................................................................................................................................ 7 It a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which Is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ............................................................................................................................................................................................................................................................................................................................................................................................ B (If yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above Is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances releling to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. S'gnature Of Legal Owner(s) Date Aud/Or, thorizedApplicant ";:� _ L tam_ CODE i;. INSPECTION TYPE rr 210 1tiII1IAL9 CODE 9 INSPECTION TYPINMIAj,$ 1616 Fixed System Final Fire Prevention y! -af • i W� 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical p `, 201 Final Biock/Retaining Welt 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy CITY OF COSTA MESA a BUILDING DIVISION r DEVELOPMENT SERVICES DEPARTMENT ''• PERMIT (714)754-5273 • Fax(714)754-4856 BUILDING PERMIT Job Address: 3333 BRISTOL ST Suite: 2505 Vicinity: 2505 Parcel Number: 41250107 Zoning: PDC PDC Applicant: RATCLIFF, VIRGIL Address: 31716 PACIFIC COAST HWY SOUTHLAGUNA,CA Zip: 92677 Phone: (949) 499-9700 License: 624235 IT NUMBER VI Boa -09019 _ 77 FAIR DRIVE, COSTA MESA, CA 92626 Status: ISSUED Applied: 07/06/2000 Issued: 08/02/2000 ISSUED BY: _2u" 10, Arch : OLSON, DAVID Eng: Address: 15375 BARRANCA PRKWYAddress: F101 Phone: 949-450-0093 Phone: IRVINE, CA Zip: 92718 License: C19424 License: SCOPE OF PERMIT 1,092 SF INTERIOR STORE Tt FOR "CAFE PASCAL" (STE 2505). FEE SUMMARY Phone: 949-499-9700 $133.05 Calc Valuation: $75,000.00 SO LAGUNA, CA Zip: 92677 Owner: SOUTH COAST PLAZA SMIP Com: Address %C J SERGERSTOM $0.00 Inspection: COSTA MESA, CA Phone: 3315 FAIRVIEW RD Zip: 92626 Contractor: SUMMIT GENERAL CONTRACTOR Address: 31716 PACIFIC COAST HWY SOUTHLAGUNA,CA Zip: 92677 Phone: (949) 499-9700 License: 624235 IT NUMBER VI Boa -09019 _ 77 FAIR DRIVE, COSTA MESA, CA 92626 Status: ISSUED Applied: 07/06/2000 Issued: 08/02/2000 ISSUED BY: _2u" 10, Arch : OLSON, DAVID Eng: Address: 15375 BARRANCA PRKWYAddress: F101 Phone: 949-450-0093 Phone: IRVINE, CA Zip: 92718 License: C19424 License: SCOPE OF PERMIT 1,092 SF INTERIOR STORE Tt FOR "CAFE PASCAL" (STE 2505). Total: $967.55 SETBACKS MAIN STRUCTURE Front 0-0 ACCESSORY Front 0-0 PARKING Existing: 0 NOTES: PLANNING & ZONING Rear 0-0 Left 0-0 Right 0-0 Rear 0-0 Left 0-0 Right 0-0 Required: 0 Proposed: 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION. This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 FEE SUMMARY Pian Check: $133.05 Calc Valuation: $75,000.00 Permit: $818.75 - Claim Valuation: $75,000.00 SMIP Res: $0.00 SMIP Com: $15.75 Other: $0.00 Inspection: $0.00 Total: $967.55 SETBACKS MAIN STRUCTURE Front 0-0 ACCESSORY Front 0-0 PARKING Existing: 0 NOTES: PLANNING & ZONING Rear 0-0 Left 0-0 Right 0-0 Rear 0-0 Left 0-0 Right 0-0 Required: 0 Proposed: 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION. This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: 0/1 have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the wo or which this permit is issued. have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the worklor which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed if the permit is valued at one hundred dollars ($100) or less.) ❑ 1 certify that in the performance of the work which this permit is issued, t shall not employ any person in any manner so as to become subject to the workers' compensation laws of Califoyd agr a thshould become subjeG to the workers' compensation provisions of Section 37 of the bor Code, I shall forthwith comply with these r 'sions Applicant Signature: Date: WARNING: FAILURE TO SECURE W RS' MPENSATION COVE G I NLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PE TIES CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE (5100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisio of ler 9 (commencing with Section 7000) o1 Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic. # Class # Contractor's Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, Or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. It, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, Or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight o1 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication aPgermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Ll Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential bullding permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (11 'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty Of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for Inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final Inspection. Sf re O er s) Dat ndlOr Authorized Applican ate CODE 1. INSPECTION TYPE PAN INTmALS CODE N INSPECTION TYPE Qaj$ INTITIAL$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy 2446-46 , _ -`..• ..... •.... , , :• .•,. �'-aa.µ, •. • "mss ' .. .: .. - _.. L ; -. _ ...-` , � r: • _ 1•'�t...:=�: �.�-§�����^yi�S�•.`Cf �?�•Di r;f�ti.�Xu ice"'• y � .. �. �eSr�' �K�fY r�r �s. °�i�=:'f= .. tti, :''r. Yjd���•/. _rr`�l�• - ' � .-f `.t I_1_:c �}��_;^ti. � • .. .}r���•i3.i"'�i �`la:l+w.y-'7 � i..,n ..-::0••.,.�I:..F`I.�'.'�?`,:.,°r'� ..r i.1��,iYJ tip:' .i.1[i�.. � iid`�.'•.•rV jr�K .. . 3333 BRISTOL SUITE;#2508' Am own= Pgaujac= B30589 $170, 000.-G-9ir E30 a7��� Meter -Sub paneinit 2508 'AM��.•,My'ry� - E 30827 Unit 2508 - MISC. f 1 w f �/ ,Mi~i1`J ,' •`. —'- Fire sprinkler $6,243 P 315 6 2/ -- Floar'^drains,Lavatories ,_� Iater heater _ --- System repair l !�/ X• - .. B68665 UNIT2508 PC#2895•-94A T.I �''-•�•-_- . - r M69040 Unit 5 B (B-68665 T.I) ! *4�-I- E69051 Unit 250 E69051 (868665--T.I) F69142 PC#3630-94L Unit 2508 r f (Fire Sprinkler) — B68474 UNIT 2508 (Demo) , (714) 754-5273 • Fax (714) 754-4856 • www.cLcosta-mesa.'khLDING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 .lob Address: 3333 BRISTOL ST Status: ISSUED Suite: 2508 Applied: 10/24/2000 Vicinity: Issued: 10/24/2000 Parcel Number: 41249102 Zoning: PDC PDC 4 Applicant: BOWERS, JOHN ISSUED BY: Address: Phone: 883-5172 Zip. Owner: SOUTH COAST PLAZA Address ,331 51 FAIRVIEW AVE MISC. Phone: COSTA MESA, CA Zip: 92626 Contractor: SNEDEN & BOWERS GEN BLDG CONTRACTORS Address: 1081 ST. REGIS PL. Phone:- (714) 350-2415 SANTA ANA, CA Zip: 92705 License:- 635444 Arch Eng: Address: Address: Phone: Phone: Zip: License: License: SCOPE OF PERMIT CONSTRUCT INTERIOR WALLS TO CREATE THREE TENANT SPACES IN EXISTING MEZZANINE AREA AT SCP. ADDRESSES WILL BE ASSIGNED WHEN SPACES ARE LEASED AND TENANT IMPROVEMENTS ARE SUBMITTED. FEE SUMMARY Plan Check: $63.21 _ - Calc Valuation: $4,000.00 Permit: $97,25 - Claim Valuation: ' $4,000.00 SMIP Res: $0.00 SMIP Cam: $0.84 Other:, $0.00 Inspection: $0.00 . Total: $161.30 ; PLANNING& ZONING SETBAC KS ♦ < <� ♦ lti MAIN STRUCTURE f=ront - ' 0.0 Rear 0= 0Left 0-0 - Right, p= p;, ACCESSORY Front, 0- 0 Rear 0- 0 Left 0- 0 Right; 0-,0 , PARKING Existing: 0-Required: 0 Proposed: 0, NOTES: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2448-46 {BM) ` / DECLARATIONS WORKERS' COMPENSATION DECLARATION. I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed if the permit is valued at one hundrad dollars ($100) or less.) ❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws o1 California. and agree that it I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provis' `s. Applicant Signature: Date: / JUCyIJl WARNING: FAILURE TO S AE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AAD CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE 1S ,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: 1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license Is in full force and effect. tic. # 42Class # Contractor's Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ t hereby affirm that there is a construction lending agency for the performance of the work for which (his permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BWLDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. It, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). © As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet o1 compressed gas at standard temperature and pressure). ................................................................................................................................................................................................................................................................................................................................................ 2 Does or will Lha applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ........................................................................................................................................................................................................................................................................................................................................ . 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No Section 25534 of the California Health and Safety Code provides that the Costa Mesa s=ire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ................................................................'------•-..................................................d...............................................lily............. ..c ....................................................................................... 4 I! en RMPP is presently required, has Booboo 25534 of the Califomia Heelfh and Safety Coda been fully complied with? ❑Yes ❑ No 5 DOas or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? IJ Yes LJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ................................................................................................................................................................................................................................................................................................................................................................................ 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? [:]Yes ❑ No (if 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). .................. ...1.1'.-•---..................................................... .................................. --...............................................---.................................................................................................................. ----.................................................................. 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ........................................................................................................................................................................................................................................................................................................................ .................... 8 {If 'fres', attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of pedury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Si re Of Legal Owner(s) /D (� r-� jtte� And/Or Authorized Applicant Date CODE R. INSPECTION TYPE DATE INTMA4§ CODE# Iff$EEg]JPNnEE IN��L$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Root 210 Final Electrical 201 Final Block/Retaining Well 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT Job Address: 3333 BRISTOL ST Suite No 2508 Vicinity: SPACE 2508 Parcel Nunmber: 41249102 Applicant: SMITH, KEVIN Address: 4701 VON KARMON AV#100 Phone: (949) 724-1569 NEWPORT BEACH, CA Zip: 92660 Owner: , 'SOUTH COAST PLAZA Address 3315-FAIRVIEW AVE -MISC. Phone: COSTA MESA; CA Zip: 92626 Contractor: SASCO ELECTRIC Address: 4701 VON KARMON AV#100 Phone: (949)724-1569 NEWPORT BEACH, CA Zip: 92660 License: 125897 ISSUED BY: Status: ISSUED Applied: 09/01/2000 Issued: 09!0112000 COMMENTS /SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446-46 (6100) SCOPE OF PERMIT ELECTRICAL PERMIT FOR STORE T.I.,FOR "LORO PIANA" (SPACE 2508). INSTALL 30 LIGHT FIXTURES, 10 RECEPTACLE, OUTLETS, 6 SWITCHES, &,1-200 AMP SUBPANEL. FEE SUMMARY . Quantity Quantity ISSUE FEE $23.50 - - Temp Dist System !_Lighting $0.00 0 Temp service test $0.00 Busway 1100 ft $0.00 0 Res. a/c package $0.00 Standing Section $0.00 0 New Res (1-2 units) $0.00 0 Misc Electrical Equipment $0.00 , 0- New Res (3+units) $0.00 0 Transformers up to -1 kvalkw $0.00 0 , Pool 1 Spa $0.00 0 .............up to 10 kvalkw $0.00 0, Lighting Fixts $27.30 30 ............up to 50 kvalkw $0.00 0 Recept Outlets - $11.00 10 100 kvalkw $0.00 0 ' Switches $6.60 6 .. . . ...........over -100 kvalkw $0.00 0 Non Res Appl $0.00 0 . Low Voltage Equipment = , -$0.00 0 Res Appl $0.00 - .` 0 Low Volt Wiring System 1 Ckt` $0.00 0 Service to 200a $0.00 0 Misc. Conduit • $0.00: - 0 Service to 1000a $0.00 0 Misc. Conductor $0.00 0. Service over 1000a $0.00 0 . Circus ( gen or ride) $0.00. 0 - Motors to 1 hp $0.00 0 Circus (mech ride or lights) , . $0.00 0 Motors to 10hp $0.00 0 Christmas Tree Stand � $0.00 0 Motors to 50hp $0.00 0 Fireworks Stand $0.00 0 Motors to 1 00h $0,00. 0 Other Electrical Fee $0.00 Motors over 100hp $0.00 0 Communication drops $0.00 0 Investigation Fee $0.00 Sub panel to 200a $30.50 1 Plan Check Fee $0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $0.00 0 Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $98.90 Intermed Pole $0.00 0 COMMENTS /SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446-46 (6100) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to selMnsure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued, t.ha nv9 a d will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ~My work 'compen tion insurance carrier and policy number are: FCamat. �T Policy Number: 7� � l / y'Mls section need not be completed if the permit is valued at one hundred dollars ($100) or less.) ❑ I certify that in the perfo ance of the work for which th permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of all a. an agree that I s Id become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these visions. q .Applicant Signature - WARNING: FAILURE TO S CURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000►, IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirrrtthat.l.am.licans dun ovisions of Chapter 9 (commencing with Section 7000) of Division 3 of.the Business and Professions Code, andmy license is in full force and effect. Ltc. # 1 % r. 4,01 Class q �— �� �-tract­Sig_natr7 rt;onorsue: ,n��'..%.t.=. �� Data'�_r -~ - CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Coda) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of not more than five hundred dollars ($500).): ❑ 1, as owner o1 the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of safe.). ❑ 1, as owner o1 the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, ialsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 6, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 WIII the applicant or present or future building occupant need to lila and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ............._...................._....._._._..................... ..._........ .................. .............................................. ................... _.._................ __.............. _........ — 2 0050 r witl the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet o1 compressed gas at standard temperature and pressure). "I'll, 3 Does or will the applicant or present or tutu re building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ...................................................................... ..__........................................................................................................................................................... .....................•...............................................-----•......._... 4 if an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No ................................................................................................ ................................ ........ ............................... ............•..................................................................................................................................................................................... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a emmil for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes f No (Section 65850.2 of the California Government Code requires that the requested Information be furnished on applications for non-residential building permits). 6 WIII any part of the citify to be constructed under this permit be within 1000 feet from the outer boundaries of a school? C3 Yes [I No (if 'fres the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). --........... _ .................. _.. ....._.._..... - ... -..... --......... -........... -•--................... _.— ...... -...... - ......_............_.._......................—_........---....__.. 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes [:1 No _ ........_ __......_..__......_.._......-- .... _ _ .......... _._............................_............__.................--............... — .......... _—....... 8 (If 'res', attach certificate of compliance tram the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this applicaticn and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above- d cribed property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Sig a Legal Owner(s) _ A Date 6_And/Or•Authorized Applicant - — — r Date CODE N, INSPECTIOU TYPE lAN QITi IALS CODE I IMSPEMN TYPE Q INTITIA 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical er%' r' -AO IQ L e- 201 Final BlockfRotaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714)754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE,:COSTA MESA, CA 92626 ELECTRICAL PERMIT Job Address: 3333 BRISTOL ST Staius: ISSUED' -�"O Suite No 2508 Applied: 10/30/2000 Vicinity: Issued: 10/30/2000 Parcel Nunmber. Applicant: Address: 41249102 SCHELIN, KEVIN Owner: SOUTH COAST PLAZA" Address 3315 FAIRVIEW AVE MISC, COSTA MESA, CA Phone: 714-556-8591 Zip: Phone: Zip: 92626 Contractor: SMALLCOMB WIRING CORPORATION Address: 136 E GARRY Phone: (714)556-8591 SANTA ANA, CA Zip: 92707 License: 145961 ty ISSUED BY: SCOPE OF PERMIT 10 LIGHT FIXTURES AND 3 SWITCHES FOR DIVISION OF THREE SPACES INSIDE AN EXISTING MEZZANINE IN SCP. AREAS TO -BE USED AS STORAGE AREA PER APPLICANT. 13o()- Q j -7 1 `4 OK TO ISSUE PER BURT MORGAN FEE SUMMARY Quantity Temp Dist System l Lighting $0.00 0 Quantity ISSUE FEE $23.50 $0.00 0 Temp service test $0.00 Transformers up to 1 kvalkw Res, a/c package $0.00 WOO 0 New Res (1-2 units) $0.00 0 New Res (3;units) $0.00 0 Pool / Spa $0.00 0 Lighting Fixts 511.00 10 Recept Outlets $0.00 0 Switches - $3.30 3 Non Res Appl $0.00 0 Res Appl $0.00 -0 Service to 200a $0.00 0 Service to 1000a $0.00 0 Service over 1000a $0.00 0 Motors to 1 hp $0.00 0 Motors to 10hp $0.00 0 Motors to 50hp $0.00 0 Motors to 100hp $0.00 0 Motors over 100hp $0.00 0 Communication drops $0.00 0 Sub panel to 200a $0.00 0 Pale Light Pkg $0.00 0 Sign Circuits $0.00 0 Temp Pwr Pole $0.00 0 Intermed Pole $0.00 0 FEE SUMMARY Quantity Temp Dist System l Lighting $0.00 0 Busway 1100 ft $0.00 0 Standing Section $0.00 0 Misc Electrical Equipment $0.00 0 Transformers up to 1 kvalkw $0.00 0 ................up to 10 kvalkw WOO 0 .................up to 50 kvalkw $0.00 0 .................up to 100 kvalkw $0.00 0 ..................over 100 kvalkw $0.00 0 Low Voltage Equipment $0.00 0 Low Volt Wiring System / Ckt $0.00 0 Misc. Conduit $0.00 0 Misc. Conductor $0.00 0 Circus ( gen or ride) $0.00 0 Circus (mech ride or lights) $0.00 0 Christmas Tree Stand $0.00 0 Fireworks Stand $0.00 0 Other Electrical Fee SO.00 Investigation Fee $0.00 Plan Check Fee $0.00 Reinspection Fee $0.00 TOTAL CALCULATED FEES $37.80 COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446-46 (6/001 / / DECLARATIONS WORKERS' COMPENSATION DECLARATION: 1 hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. ❑ I have and will maintain work ' cch'npensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' co p nsatlon sur a mer and policy number are: U V Carrier: Policy Number: (This section need not be coted it the permit is valued at one hundred dollars ($ f 00) or less.) ❑ I certify that in the pert ante of the work for which this permit is issued, I shall not employ any person in any manner so as to beca subject to the workers' compensation taws t California, a agree That if I should become subject to the workers' compensation provisions of Section 3 DO of the Labor Code, I shall forthwith comply with these vlslon f q� .Appllcant•Signatuta:� � Date: �/ L �� ARNING: FAILURE TO SECURE WpRKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL P114ALTIES A413 CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE DOST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'$ FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under prqo'slogs of ha r 9 m encing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic. # Class # Eemmacto s sunat_rtry Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lenders Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License taw does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ......................... . .. .... ............. ..................................................................................................................................................... I.................-----........................................................................................ 2 Does or wit! the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal io or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ....................................................•................................................................................................................................................................................................................................................................................ 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. .........................-................................................................................................................................................................................................................................................................................ .............................. .... 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? El Yes EJ No ................................................................................................... ................................................ ..................................................... ... .................. ..................... ...................._....... ........................ I .................. ................................................... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this aalplication a ermit for such Construction or modification from the South Coast Air Quality Management District or trom any other air pollution control district or agency?. ❑ Yes No (Section 65650.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ........................................................................................................................................................................................................................................................................................................ ............... 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if -yes-, the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ...................................1.............................................................................--.....•--........................................................................................._....................................................................._.�------.........-------............................... 7 tf a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ............................................................................................................................................................................................................................................................................................................................................. 6 (If yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature Of Legal Owner(s) � VODbn -- — t And/Or Authorized Applicant 1/1 � - (h � e CODE /. INSPECTION TYPE QM IM]AL CODS: t INSPECTION TYPKnTIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical ��, —©d TLG 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 BUILDING PERMIT, ,lob Address: 3333 BRISTOL ST Suite: 2508 Vicinity: 2508 Parcel Number: 41249102 Applicant: WATSON, DUSTY Address: Zoning: PDC PDC Phone: Zip: Status: ISSUED Applied: 08/04/2000 Issued: 08/23/2000 ISSUED BY: owner: SOUTH,COAST PLAZA- ' l � Address 3315 FAIRVIEW AVE ' MISC.,Phone: -COSTA MESA, CA Zip: 92626 Contractor: 'WATSON CONSTRUCTION INC. Address: 1260 LOGAN AVE. B-2 Phone: , (714) 662-7933 - COSTA,MESA, CA - Zip: 92626 License: -'705797 Arch : PAUL J RUFFING, AIA _ Eng: Address: 1101 DOVE STREET ; , Address: SUITE 140 Phone: 949-660-8062 Phone: NEWPORT BEACH, CA Zip: 92660 License: 04264 License: SCOPE OF PERMIT _ INTERIOR 2000SF STORE T.I. FOR LOBO PLANA. UNIT 2508. . FEE SUMMARY Plan Check; .$166.04 Calc Valuation: $105,000.00 Permit: $1,021.75 -Claim Valuation:.$105,000.00 SMIP Res: $0.00 - ,SMIP Com: $22.05 Other:', $0.00 Inspection:' $0.00" ' ,Total: $1,209:84 . ` PLANNING & ZONING ° SETBACKS',-.� , MAIN STRUCTURE Front 0- 0 '� Rear ; . 0- 0 Left 0- 0 Right . �0- 0' ,'' - r� i ACCESSORY Front, 0-0, - Rear 0-0 Left -0-0 Right" PARKING Existing:,- 0- Required: 0 Proposed: 0" , NOTES: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained, Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446-46 (6/00) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the rk for which this permit is issued. Pahave and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. _4My workers' compensation Insurance carrier and policy number are: Carrier. / Policy Number: (This section need not be completed if t permit is valued alone dred dollars ($100) or less.) ❑ 1 certify that in the performan o he work for w ' thi a it is issued, I shall not employ any person in any manner so as to become subject to the workers' Compensation laws of CaliF that sh I e subject to the workers' compensation provisions of Section 3790 of the Labor Code, l shall forthwith comply with these provisi Applicant Signature: Date: WARNING: FAILURE TO SECURE WO S' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES ANCV6VIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 37M OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DEC TION: I hereby affirm that I am licensed u provisions ofap {commencing with Section 7040) of Division 3 of the Business and Professions Code, and my license is in full rce and effect. Lic. # Class # Contractor s Signature: Date: CONSTRUCTION LENDING AGENCY. ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lenders Name: Lenders Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant'for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation Five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than Thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ....... ............... ..................................................................................................... ........................................................................... ............................................................................ ......-......................................... ................................... ................ 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feel of compressed gas at standard temperature and pressure). ............................................................................................................................................................................................................................................................................................................................................................................... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ............................. - .............. ....................._..................................... ......�.........._.............................-.......................................................................... 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No .........................1.................................................................................... ................................. ........................... -...................................... _._.....--......-._._............................ _.................. ................ ..................... ... 5 Goes or will the applicant or present or luture building occupant require for the work which is the subject of thisa plication aPermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Byes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). .......... ................................... ............................................ I •--•-------.................................................................................................................................................................. -........................................................ ............... 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (it "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ..................................................................................................................................................................................................................................................................................................................................................... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No .......................................................................... .• 1.111111.1111111-­-.1 �..................... ....................................... ...................................................................................................... ............... 1111.... 8 (If fres", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF CO CE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to p with all state laws and ' ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described pr pe for inspection tp�� not to occupy or allow occupancy of any building authorized by this permit until final inspection. Si natur f I Owners)) SfKDa n&Or Authorized Applicant Vate COQF #. INSPECTION TYPE RM ItTMALCODE# INSPECIIQHTYEE Qct¢ INTM 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Fine[ Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 PLUMBING PERMIT Job Address: 3333 BRISTOL ST Suite No 2508 Vicinity: LORO PIANA (STE 2508) Parcel Nunmber: 41249102 Status: ISSUED Applied: 09/19/2000 Issued: 09/19/2000 ISSUED BY: Applicant: BELLOWS, PATRICK Address: 1433 LINDEN ST I FLOOR DRAIN, 1 TRAP PRIMER, 1 WASHBASIN, -1 UNIT L - . Phone: (909) 689-5830. RIVERSIDE, CA Zip: 92507 Owner:, SOUTH COAST PLAZA Address 3315 FAIRVIEW AVE MISC. - Phone: COSTA MESA, CA Zip: 92626 Contractor: COMMERCIAL PLUMBING CO _ Address: 1433 LINDEN ST UNIT L Phone: (909) 689-5830 RIVERSIDE, CA Zip: 92507 License: 568001 Arch / Eng Address: Phone: Zip: License: SCOPE OF PERMIT TOTAL CALCULATED FEES: $75.00 NOTICE: The work authorized by this permit sWMM.F RWbwmm requirements under California statutes and related regulations. (Ord. No. 92,28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446.46 (6=) NEW PLUMBING INSTALLATION FOR "LORO PIANA" IN STE 2508. I FLOOR DRAIN, 1 TRAP PRIMER, 1 WASHBASIN, -1 WATER CLOSET, 1 WATER HEATERNENT, REF: B00-01195 , FEE SUMMARY AMT QTY AMT QTY / . ` AMT QTY ISSUE FEE $23.50 Laundry Tub 1 Washer $0.00 0Sump Pump $0.00 0 Backflow irrigation $0.00 0 Landscape Irrigation $0.00 0 , Swimming Pool $0.00 0 Backflow Preventer $0.00 0 P -Trap $0,00 0 Trap Primer $9.80 1 Bathtub $0.00 0 Pressure Regulator $0.00 0 Urinal$0.00 0 Clarifier System $0.00 0 Process Piping (per 10 ft) $0.00 0 Vacuum Brkr Bkflow(14) $0.00 0 Connect (Ice,Soda,etc) $0.00 0. Receptors. $0.00 0 Vacuum Srkr Bkflow(5+) $0.00 0 Dental Units $0.00 0 Septic Tank $0.00 0 Wash Basin $9.80 1 Dishwasher $0.00 0 Sewer Cap for Demo $0.00 0 Wash Basin Set $0.00 0 Drain, Floor $9.80 1 Sewer Connect $0,00 0 Waste and Vent System $0.00 0 Drain, Rainwater $0.00 0 Sewer Private Line $0.00 0 Water Closet (Toilet) $9.80 1 Drain, Roof $0.00 0 Shower $0.00 0 Water Heater 1 vent $12.30 1 Drinking Fountain $0.00 0 Sink, bar $0.00 0 Water Piping (Inst or Rep.) $0.00 0 Expansion Tank $0.00 0 Sink, commercial $0.00 0 Water Re -pipe $0.00 0 Gas Earthquake Valve $0.00 0 Sink, Floor $0.00 0 Water Service $0.00 0 Gas (1-4 outlets) $0.00 0 Sink, kitchen $0.00 0 Water Softener $0.00 0 Gas (Over 4 outlets) $0.00 0 Sink, service/mop $0.00 0 OTHER $0.00 Gas Repipe $0.00 0 Spa (private) $0.00 0 VIOLATION $0.00 Gas Service $0.00 0 Spa (public) $0.00 0 PIAN CHECK $0.00 Interceptors (Grease, Oil) $0.00 0 REINSPECTION $0.00 0 Interceptors (Sand Auto ) $0.00 0 TOTAL CALCULATED FEES: $75.00 NOTICE: The work authorized by this permit sWMM.F RWbwmm requirements under California statutes and related regulations. (Ord. No. 92,28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446.46 (6=) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a Certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. ❑ t have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Cade, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed if the permit is valued at one hundred dollars ($100) or less.) I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these p�woR�E;Rs- ' Applicant Signature: _— Date: WARNING: FAILURE TO CPENSATION COVERAGEIS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE (5100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic. # Class N Contractor's Signature: Date: CONSTRUCTION LENDING A ENCY: ❑ 1 hereby affirm that there is a Construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or Improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. 11, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractors) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner 10 verified by drivers license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or dead): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth Into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I'will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the Caiifomia Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _ .... ... ...........................................................................__.................................. .............................. __...................... _._........................................................ __................... --.............. —............... .�............... _ ... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ................................................•-•--................--•--•....................................... ................................. ................................................................... ............................................................................-•------.................................................. _.................. 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RM PP by businesses which are required to register acutely hazardous materials with the Fire Department. ............................................................................................................................................................................_......................_........................... ......--......................................._................._..................._................. 4 If an RMPP is presently required, has Section 25534 of the California Heaith and Safety Code been fully complied with? ❑ Yes ❑ No .................................................................................................................................................................................................................................................................................................................•---........................... .......... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of thisa plication a ormit for such construction or modification from the South Coast Air (Duality Management District or lrom any other air pollution control district or agency? N Yes .8 No (Section 65850.2 of the California Goverment Code requires that the requested information be furnished on applications for non-residential building permits). ................................................................................................................................................................................................................................................................i---•.•............................................................. 6 Wil( any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes ❑ No (If "yes, the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ..................._....—_......................__--------- ....... ....----...................................._..---.._..................... _._... _............. _..__ ............ —._....... _.__.._.. 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures proscribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (If'yaV, atlach certificate of compliance from the appropriate air pollution control (;fficer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certity under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. L ature Of Legal Owners) Date s`�`// i /S=C"_2 AndlOr Authorized Applicant Date CODE I. INSPECIMIMPE 2M iNTITI6LS �QQC t INSPECTION TYPE f INTITAL$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 206 Final Plumbing - ro a as 200 Final Re -Roof 214 Final Electrical 201 Final Block/Retaining Wail 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 MECHANICAL PERMIT .lob Address: 3333 BRISTOL ST Status: ISSUED Suite No 2508 Applied: 08/28/2000 Issued: 08/28/2000 Vicinity: LORO PIANA (STE 2508) Parcel Number: 41249102 ISSUED BY: Applicant: SANDERS, BILL Address: 1140 RED GUM ST Phone: (714)630-3200 ANAHEIM CA Zip: 92806 Owner: SOUTH COAST PLAZA Address: 3315 FAIRVIEW AVE MISC. Phone: COSTA MESA, CA Zip: 92626 Contractor: THERMALAIR INC Address: 1140 RED GUM ST Arch 1 Eng : Address: Phone: (714)630-3200 ANAHEIM CA Zip: 92806 License: 102216 Phone: Zip: License: SCOPE OF PERMIT INTERIOR 2000 SF TI FOR "LORD PIANA" IN STE 2508 TO INSTALL 1 EXHAUST FAN & 2 VAV BOXES. 1 REPAIRIALT COOLING/HEAT, 2 VAV BOX, 1 VENT FAN/SINGLE DUCT. REF: B00-01195. FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 Repair 1 Alt Absorbtion Unit '$0-00 0 Inst FAU <100 k BTU $0.00 0 .' Repair / AIL Refrigeration Unit $0.00 0 Inst FAU >100 k BTU $0.00 0 Ventillation System $0.00 0 Repair /Alt CoolinglHeat $13.70 1 Evaporative Cooler $0.00 0 Inst 1 Rep. Recess Wall Htr ` $0.00 0 Commercial Incinerator ' $0.00 0 Refrig Sys <100 k BTU $0.00 0 Domestic Incinerator $0.00 0 Refrig Sys >100 k BTU,,,, $0.00 0 Compressors 1 Absorption_ Systems Gas Piping $0.00 0 Up to 3 hp 1 100 k BTU $0.00 0 Factory Fireplace $0,00 0 3 To 15 hp / 500 k BTU $0.00 0 Hood wlMech Exhaust $0.00 0 15 To 30 hp 1 1,000 k BTU $0.00 0 VAV Box $21.30 2 30 To 50 hp 1 1,750 k BTU - $0-00 0 Vent Fan I Single Duct $7.25 1 Over 50 hp 1 Over 1,750 BTU $0.00 0 Appliance $0.00 0 Boilers Fire Dampers $0.00 0 Up to 3 hp $0.00 0 Smoke Dampers $0.00 0 3 To 15 hp $0.00 0 Inst or Relocate Appl Vent $0.00 0 15 to 30 hp $0.00 0 Air Handlers < 10000cfm $0.00 0 30 to 50 hp $0.00 0 Air Handlers > 10000cfm $0.00 0 Over 50 hp $0.00 0 Floor Furnace $0.00 0 Other Mechanical Fee Floor or Suspend Heater $0.00 0 Investigation Fee $0.00 Plan Check Fee $0.00 Reinspection Fee $0.00 - TOTAL CALCULATED FEES • $65:75 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446-46 (6/00) DECLARAMNS WORKERS' COMPENSATION DECLARATION: hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is Issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed if the permit is valued at one hundred dollars ($100) or lass.) ❑ I certify that in the performance of the work for which this permit Is Issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Califomia, and agree that If I should become subject to the workers' compensation provisions of Section 3700 of the tabor Code, I shall forthwith comply with these visions. Applicant Signature: _rib Date: WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($10D.0001, IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. tic. # Class # Contractor's Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lenders Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, atler, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or improvement is sold within one year of Completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, fatsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, Califomia Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industria! Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 W ill the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the Califomia Health and Safety Code requires, with some exceptions, that a Business Plan be Tiled with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight 01500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ...................................................................................................................................c'c' ............................... iio,.......................................................................... r'd"..............t'e"........................................................................... ............................... 2 Does or will the applicant or present or future building occupant Head to file a registration form for acutely hazardous materials? ❑Yes ❑ No (Section 25533 of the Callomia Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feat of compressed gas at standard temperature and pressure). ............................................................................................................................................................................................................................................................................................................................................................................................ 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the Califomia Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. Y....__................__....................................................__........................._............................... _.................. _.—........................................... -.-.—..................... _.—........................... .._............. ........ ............... .... 4 If an RMPP is presently required, has Section 25534 of the Califomia Health and Safety Code been fully comptied with? ❑ Yes ❑ No ........... ..........................................................................................................__............................_................................_....................._.............................................._—........_............................._........................_-•---...................................... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication aQQermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Ll Yes ❑ No (Section 65850.2 of the Califomia Government Code requires that the requested information be fumished on applications for non-residential building permits). __......... ..........----.............___.......__..._..---........................—_.........................—...................._................................_._....---..__............---------------..................._.............. ---.................._ 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'fres', the facility must meet the requirement of Sections 25534 and 42303 of the Califomia Health and Safety Code). ............... ............................... .-................................ --..............•......................................................................................_....................................._................-............................................................................................... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by Califomia Health and Safety Code Section 42303 been made? El Yes [I No _._................................_...................................__............................__._.................. ---........................... —.................... _............. _._.__....................... — .................. ......... -._ _ _............ B (lt yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. �ignature Of.Legal Owner(s) Data And/Or Authorized Applicant Date CODE f, INSPEGBO"r(RE 11M fNTITIA CODE IN§PEcnoN TYPE iQ Q � 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Sita 204 Final Demolition 250 Final Building/Occupancy TI. (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca-ur,LDING PERMIT Job Address: 3333 BRISTOL ST Suite: 2508 Vicinity: Parcel Number: 41250106 Zoning: PDC PDC Applicant: PAUL BOZARTH Address: Phone: 714-538-5777 Zip: 77 FAIR DRIVE, COSTA MESA, CA 92626 Status: ISSUED Applied: 04/11/2000 Issued: 07/27/2000 ISSUED BY: Owner: SOUTH COAST PLAZA Address Phone: Zip: Contractor: SNEDEN & BOWERS GEN BLDG CONTRACTORS Address: 1081 ST. REGIS PL. Phone: (714) 350-2415 SANTA ANA, CA Zip: 92705 License: 635444 Arch : PAUL BOZARTH Eng: Address: 18661 VALE AV c Address: Phone: 714 669-5790 Phone: SANTA ANA CA Zip: 92705 License: C14800 License: SCOPE OF PERMIT DEMOLISH MEZZANINE AND WALL FIXTURES, CONSTRUCT WALL BETWEEN UNITS 2508 AND 2512 IN PREP FOR FUTURE Plan Check: Permit: SMTP Res: SMIP Com: Other: Inspection: , Total: $117.81 $181.25 $0.00 $2.10 $0.00 $0.00 $301.16 FEE SUMMARY Calc Valuation: $10,000.00 Claim Valuation: $10,000.00 PLANNING & ZONING SETBACKS MAIN STRUCTURE "Front 0'0 Rear 0-0 Left 0-0 Right 0-0 ACCESSORY Front 0-0 Rear 0-0 Left 0-0 Right 0-0 PARKING Existing: 0 Required: 0 Proposed: 0 NOTES: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 2446 46 (6=a DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. My workers' compensatioj'lasurance carrier and policy number are: Carrier: <"rafr--_U'JQ _ _„_ ,. Policy Number: l � � —0 q Z - l Q 1 (This section need not be Completed if the permit is valued at one hundred dollars ($100) or less.) ❑ I certify that in the periormaDw of the wo hich this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation lawsK9AK66rnia, and agr a if I should become subject to the workers' compensation provisions of Sect! n 3700 the Labor Code, I shall forthwith comply with these '^'� Applicant Signature: Date: r ! G tJ WARNING: FAILURE TO SECURE O KE PENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMi PENALTIE AND CIVIL PINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES A5 PROVIDED FOR IN SECTION 3706 OF THE R CODE, TEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed undo i ns of Chapter 9 (commencing with Section 7000) of Division 3 of the Business Professions Code, and my license is in full force and effect. Lic. # r p ov' 3 S Class # Contractor's Signature: Date: �_10• ✓ CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason {Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ........................................................................................................................................................................................................................................................ ..........................1.11.11.111.................................. 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires. registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ........... .................................................................... ................................................................................................. ............................................................................................................... ...................... .................................................................... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ,i'r.................................'2,5.................................................. al' .....rid, ..... f-e-........o*'d-..............f'u"......................................................a.......................-------.........................------............_................ 4 If an RMPP is presently required, has Section 25534 of the Cal.fornls Health and Safety Code been fully complied with? ❑Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of thisa plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? 5 Yes H No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). .................................................................... .................................................... .... .......................-.111........1........................... ................ fi Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ........................................................ ........................................................................ -.......................",............................................. ............................................................... .....------.................... --............... ........................................ 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? [3 Yes [I No ......................................................................... .................................................................................................................................................................................................................................................................................................... 8 (If "yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree toomply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above -d scribe roperty for inspe ' n urposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. re Lage wner(s) Date p n pp (cant Date CODE 0 INSPECTtkN TYPE 2AM INMAL CODE [ INSPECTION TYPE Imo$ 1616 Fixed S tem Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy Kcrn "f 118 Patrician Way Pasadena, CA 91105 626-795-0770 October 23, 2000 To: Building Official, Orange County Department of Building & Safety Re: Final report for 333 Bristol St., Costa Mesa Permit #: 00-00872 Contractor: Fisher Development All of the special inspections for this project are now complete. This includes welding and Fireproofing. Final incnectnr'c rent per 1701.3 uniform building code. inspection, was to the best of my knowledge, in conformance to the approved and the applicable workmanship provisions of the code_ .,^�:,�xayr`E�a,-.r-S:`�•t' �� :'r�»3`a%�3�'^wst: "�?Y='..w :& 'kis. .•1 i 'i �t,' �, ; ,��^-'�?✓y`� � 3"�`+; �d'�,. � � ; ,.;; .� rx� `�^ •'k,• � •t -,.i cif • • • • • • • • • • • • • f:.;�v��;hz;':=.-`� '.•ter. _ 8rtr a,�-;;:^-=�sr`�,` .��'°'s"�"�rk, a':� .,�'� �"'��>�3 �?�• Sincerely, tKeeth. Balcomuty cspeor License #: 058 (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mMT- UPRESSION PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Status: ISSUED Suite: 2508 Applied: 0 911 212 000 Vicinity: SPACE 2508 Issued: 09/25/2000 Parcel Number: '41249102 Zoning: PDC PDC ISSUED BY: Applicant: PONTOLILLO, TOM Address: 23881 VIA FABRICANTE Phone: (949) 472-3186 MISSION VIEJO, CA Zip: 92692 Owner: ,' SOUTH COAST PLAZA Address . 3315 FAIRVIEW AVE , MISC. Phone: COSTA MESA, CA Zip: 92626 Contractor: TRI COUNTY FIRE Address: 23881 VIA FABRICANTE Phone: (949)472-3186 MISSION VIEJO, CA Zip: 92692 License: 659326 SCOPE OF PERMIT FIRE SPRINKLER PERMIT FOR STORE T,I. FOR "LORD PIANA" (SPACE 2508). RELOCATE 29 FIRE SPRINKLER HEADS, REF: B00-01195 FEE SUMMARY Plan Check: $54.11 Calc Valuation: $3,000.00 Permit: $83.25 Claimed Valuation: $3,000.00' Other: $0.00 Total: $137.36 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 / 2446-48 (61Do) N\ -f Cw DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following dedaradons: ❑ t have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the labor Code, for the performance of the work for which this permit Is issued. ❑ t have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ^My works s' compensa on Insurance carder and policy number are: �(This'section need not be completed if the pennit is valued at one hundred dollars ($100) or less.) - ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, anda e that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisions. A /- ( -Applicant Slgnature:_,a= --- `WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Prof, sions C27, and my license is In full force and effeei:,Lir c -�� �-�,7, - +(o - Class 0 17 i Contr ors Signature:��-zF-- CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031 .5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption, Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Cade: The Contractors License Law does not apply to an owner of property who builds or Improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for safe. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): it DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth Into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thlrty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _.............._..._W........................._.........................---.......................---........................................................................................._----..........._-............-_._-... 2 Does or will the applicant or present or future building occupant need to file a registration farm for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic Leet of compressed gas at standard temperature and pressure). ................ .-................................................................................... .........................."....................................... ....----........----�........................................................................................................................................................................ 3 Does or will theappplicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes 11No Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire apartment of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ......................................................................................... ............................................................................................................................................................. ............-.......................... ..... ......... ......... ............. 4 !f an RMPP Is presentiy required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑Yes ❑ No ........................................................................................................................................................................ •........................................................................................................................ 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this a plicatlon aPgermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes ❑ NO (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ---...i6......................................................................._...................................._..........................................................--••--........................................................................_..._..__.................._................_ e Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (it'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Coda). ..............__._...__..._.—._....................... __..................... _— ......................... -- --- .. .._............................................... ........__.............. _ .._.. 7 If apermit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (If yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature �f Legal Owners) Date cl AAndlOOE4Aith6dzed•Appllcant -7.— _ - T rD ��� CODE 1. INSPECTION TYPE 2M I=863 CODE t INSPECTION TYPE INTIVAL$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Well 212 Final Fire Prevention Lu -Z-1-C.X) W 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy 711 PROJECT ADDRESS: 3333 BRISTOL ST UNIT: 2 5_,u OWNER'S NAME: C J SEGERSTROM ADDRESS: 3 315 FAIRVIEW RD iS C.M., CA 92626 ARCHIENGINEER: REG.NO.: ADDRESS: UNIT: PERMITTEE: THE STONE COMPANY (619)660-1333 ADDRESS: 2990 JAMACHA RD EL CAJON CA 92019 LICENSED CONTRACTOR DECLARATION: I hereby affirm that I am licensed under prov' ions of Chapter 9 (commencing with Section 7040) of Division 3 of the Business and Professions Code, and my license is i fuRO�W,Ap if CITY LIC. TATE LIC-: 632054 C Dale: Signature WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have c ' ate onsent to self -insure or a certificate of Workers' Compensation Insurance or a certified copy thereof (Section 3800, Lab, POLICY NO.: CN 961-200 EXP. DATE: 02/15/95 COMPANY: INDUSTRIAL INDE ❑ Certified copy is hereby furnished. EX Certified copy is filed with ci uil Div' Date: Appllcanl: EXEMPTION FROM WORKERS' COMPENSATION DECLARATION: (71% section nee of be completed if the permit is for one hundred ($100) or less). I certify that in the performance of the work for which this permit is issued, shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of Cahfomra. Dale: Signature: NOTICE: It, after making this declaration. you should become subject to the Workers' Compensation provisions of the Labor Code, ydu must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Section 3097, Cry, C) LENDER: ADDRESS: OWNER BUILDER DECLARATION: i hereby affirm that I am eKempt from the Contractors' State License Law for the following reason {Section 7031.5 Business and Professional Code: Any city of county which requires a permit to construct, alter, improve, demolish, or repair any structure. prior to its issuance, also requires the applicant for such permit to file a signed statement that he/she is licensed pursuant 10 the provisions of the Contractors' State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Cade) or that he/she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than live hundred dollars (5500). I, as owner of the property or my employees with wages as their sole compensation, will do the work, and the ❑ structure is not intended or offered for sale (Section 7044, Business and Professional Code: The Contractors' State License Law does not apply to an owner at a properly who builds or improves thereon, and who does such work himself/herself or through his or her own employees. provided that such improvements are not intended or offered for sale. If, however the building or f improvement is sold within one year of completion, the owner will have the burden of proving helshe did not build or improve for the purpose of sale(. I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Section 7044, Business ❑ and Prolessions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon and who contracts for such projects with a contractor(s) license pursuam to the Contractors' State License Law). I am aware that proof of their Worker's Compensation insurance should be provided to me. ❑ I am exempt under Section: B. 8 P. C, for this reason: Date: Owner I do hereby cerUly that I am aware of and understand the requirements of California,Health and Safety Code Sections 25505, 25533, and 25534 and that I or any future building occupant will/will not (circle one) need to comply with said state codes and the requirements for a permit lot construction or modification from the Air Quality Management District. Residential construction applications are exempt from these provisions. Hate: Applicant: hereby certify that I have read this application and state that the above inlo s rrect. I agree to comply with all city and county ordinances and stale laws relating I wilding construction and hereby autho ' pr lives his city to enter upon the above-mentioned property I ins tea Our s, Date Signature: Driver's License or Social Secunly a: 1641-46 White—Building; Green—Code Eniorcement: Canary—Applicant; Pink—Revenue; Goldenrod—Assessor CITY OF COSTA MESA - BUILDING PERMIT PERM NO: B 06$474 PERMIT NO; B 068474 PLAN CHECK NO; N GOVT; N SUPP: N CONSTRUCTION TYPE: I FR PERMIT TYPE; STR PURPOSE: ALT JOB DESCRIPTION : DEMOLITION IN PREPARATION FOR STORE T,I, SQ FT: 3,000 CLAIM VALUE: 3,000.00 CALL -VALUE; 3,000.00 GROUP OCC: B-2 / COMMENTS: "LOUIS VUITTON" STORE T.I. iE 9E aE iE -1F iE aF �F ]E ->F iE -►E iE iF �iE �E dE iE aF � iE iE iE �E aE-If 1E iF �E aE aE aE ->E �1E �1F �F �F iE �F aF dE �E �lE iE aE iE iF iE iF �1E iE iE -� iF iF aF �lE 9E �1E �E �iE aE'lF aF �lE �F �E it 9F �lE -1F aF �E iE 4E dF �1F iE �E Z O N I N G R E Q U I R E M E N T S S E T B A C K S ------------- MAIN BUILDING ---------- --------- ACCESSORY BUILDING--------- FRNT: FT IN REAR; FT IN FRNT: FT IN REAR; FT IN LEFT; FT IN RGHT: FT IN LEFT: FT IN RGHT; FT IN PARKING RE • PROV: PARCEL; 00000000 ZNE: REF NO: PLANNING N TES> D E V E L O P M E N T S E R V I C E S R E Q U I R E M E N -T S s - ZONING APPROVED BY DATE: BUILDING APPROVED BY ; DATE: APPLICATION ISSUED BY: Sc�Ps DATE: � I� 3E`Z la �E * iF iF * BE * jE 1E jE eE iE iF iF iE iF 9E it jF iE iE !E iF iF �F iF * iE'1E ->r �E 3E �F * iE iF iE iE * iE E�3F'�E iE iF !F'lE �E 9E iF 1E � iE !F !E'lE !E iE ft iE * dE iE iF �t iE iE iE iF iF * � jE � 1E iE iE iE 9F * 141E �F iE 9E * iE iE �E +E � �'JE iF �E'!E iF dE 9E 3F iF iF iE iE iF �E 1E iE iE iE iE iE iE iE it iE iE iE iF iF iF iE LEGALIZATION:N F E E S U M M A R Y STRUCTURAL SEGMENT:Y BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT 54.00 SMIP/NON—AES PLAN ,63 ISSUE FEE BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE TOTALS ---- > 54,63 0.00 0,00 54.63 54.63 ,00 REVENUE DIVISION TOTALS--> COLLECTED: 54.63 OVER/SHORT: 00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK 54,00 , 63 iE iE iE iF ii- � iE iE 1F iE � * !F iF !E �lE !F 9E'lE iE iF iF �lE �1F'1E'lE iE'}E iE iE !F iF iF � iF � iF frt iF iE 3F iF iF iE iE � * jE iE � ii iF iF iE iF iE iE 1F �E �F !E iF'lE iE'1F 1E iE iE iE jE iE iE iE 9F 9E iE aE iF iE I N D I V I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST SFC 3000 DEMOLISH BY VALUE COMMERCIAL NOZONE 1.00 3,000,00 END OF FEES fit 00165939-00165940 TOT 54.63 DATE: 08/15144 TIME: 13:39 CONSTRUCTION AND PLANNING APPROVALS Permit # _ Date Inspector POOL a'SPA APPROVALS Permit # Date Inspector 1. Temporary Electrical Service or Poli 52. Pool & Equipment Location _ 2. Soil Pipe-Undrgrnd. - 53. Steel Reinforcement 3. f4ctrical Conduit Utility-Undrgrnd,},. 54. Forms 4. Electrical Conctuit,,Uodrgrnd. i 55. Electrical Bonding -' `' �.=teel Reinforcez�( - 56. Rough Plumbing & Pressure Test J G•-Zilectrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE 7. •Footings ' f - 58. Electrical Conduit-Undrgrnd. $. -Foundation - 59. Gas Pipe, Cl Undrgrnd., Test 9. Water Pipe-Undrgrnd. 60. Backwash Lines, P -Trap, 0 Undrgrnd. t 10. Structural Floor System - 61. APPROVAL TO DECK 11. Property Sewer Line,& HcrstseConneclion 62. Backwash & Receptor -Final , 12. Sewer Cap 63, Heater & Vent -Final 13. Roof Drains r 64. Plumbing System - Final 14_ Rough Plumbing - 65. Electrical -Final 15. Rough Electric$I-Conduit 66. Solar Systern-Final 16. Rough Electric Wiring 67. Fencing & Access Approval l'a7' hough Wiring Sign 68. APPROVED FOR PLASTERING "I.8 -Rough Electrical -T Sar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT `yn j 5? %_Permit 20. RoQh Fjctoiy Fireplace i >' r',APPRCT�1lAt 2 ,'D ct - t uM�t u o 1. a �S, in r ..`.. } - .j a J , -�0. Underground Hydra 22. DuctB, Ventilating- - I .� r r ; ` ' 71. Product_Ni ing C1gS ❑-Qil 23.' -Gas Pipe -Rough & Test J - -72. Underground Flusl ; 24, -Roaf Framing-,-73. -Undergrnd'Storaq(;;-Tahk ©Gas C7 Oil 25. Rood` Sheathing - 74. 'Overhead Hydra J 26. T-9 F, Ceiling (Structural) & Monocoat * - '� ^: ' 75., -'Pry Chemical I -+ 27. --'Fra me and Flashing; j 76.' tJry Standpipe �ua -28. Lathing i; Siding.- _j �q W 77. FIXED SYSTEM#FiNAL' 1 '29. lnsulatiad - ' ; 78.:--IFIRE PREV. FINAiL x 30. Drywall Nailing ^: ' i " HEALTH DEPT. REQUIREMENT .31. Plaster 1 r wr�Coaf ,, - _79.' F I NA L I N�P�CTION , 32. E€ectricaEPower #Meter Final i 80. FOOD CERTIFICATE ISSUED ._33. Finaj'Electric; < } i ( i, T�[ote's; - 4. FinaiHeating=& Air Conditioning:: 35. jinal'Gas Pipe' -Test $6. -'Rodd or -Canopy _ 7 _ r 37. FinaltFactory Firep#ace' 1 i 38. Final,Plumbing 39. Water Service -Final ' ,40. Gas Servic6e-Fin' al •i,. 7 ; '41. Solar Donnestic-Final 42. Backflow'-Preventer, a ' 43. Backflow Irrigation Y _ 44. Landscape Irrigation System ,, y -. 45. Sound Attenuation' - r` 46. Handicap.Reg.4lations 47..FINAL STRUCTURE & BUIC•DING IL I 48, .F,lNAL PLANNING: I •49. Electric Release to Edison` " 50. Gas Release to Southern California Gas Co �- -51. CERTIFICATE OF OCCUPANCY No. Date = The Stone Company General Contractors, Inc. 2990 Jamacha Road Suite 220 EI Cajon, CA 92019 Phone 619-660-1333 Fax 619-660-1499 Lie. #632054 State c .alifornia County of San Diego Subscribed and sworn to before me on August 1.5,1994, August 15,1994 TO WHOM IT MAY CONCERN Let it be known that Shiel Gaylor, being an official representative of The Stone Company has my permission to obtain any and all papers ad permits concerning Louie Vuitton Luggage being built at South Coast Plaza, Costa Mesa, CA. Thank you, 0 /0 1 �91 Clare Fronczek Project Engineer FQic �1 ". '. ' • LISA A. t020YA U : COMM.#1015007 (7 _ NOTARY PUBuC-CAUFORNIA [/7 V SAN DIEGO COUNTY n MY COMMISSION EXPIRES JANUARY 20,1998 CITY OF COSTA MESA DEVELOPMENT SERVICES(BUILDING SAFETY RECOA;D PACKAGE FOR: STREET ADDRESS r WORK DONE <IB3"ng Permit ' lel C Icate of Occupancy Electrical Release Form ❑ Gas Release Form C sanitation Fixture Form F!' Plumbing Permit # 6� R ---Mechanical Permit 'L!3�Electrical Permit # IQ 1{Z Reinspection Permit #. Health Department Approval Roofing Certification Insulation Certification Dry Chemical System Certification Flame Spread Certification Fire Sprinkler Certification Soils Certification ❑ Special Inspection CeTttification IJ Other: All Required Documents Included/16 e/ Clerk O.K. to Approve C.O. lnsoector O.K. to Release C.O. Building Official CMF 144630 City of Costa Mesa Development Services Deportment Building Safety Division CERTIFICATE OF OCCUPANCY No. 002643 P. O. Box 1200 Costa Mesa, California The Building located at 3333 Bristol Street, Space 2508 has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group B-2 Qccupancy. Use of Building Retail Legal Description 412-501-02 (See reverse side for Metes and Bounds) Building Permit No, A 34569 Electrical Permit No.F.30827,E3042 Plumbing Permit No.P 31662 Mechanical Permit No. M 31673 Number of apartments and/or guest rooms ISSUED TO: Building Official William T. Howard C. J. Spoerstmm & Sons 3315 Fairview toad by Mafia Nk+aa. C`A g7E•S2h - A-- - Date Saah4areYxx+r ?1. 19PA This Certificate of OccUpancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. CMF 1015-46 rev. 1/83 White - Owner; Canary - Numerical File; Pink - Bldg. Permit File I Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations. CITY OF COSTA MESA CONS UCTIO PER T PERMIT O. 8g TRACT NO. LOT NO. UNIT NO. ,� �3� ' $ IrJ �A See Project!lddress d I TYPE OF CONSTRUCTION NEW ADD ALTERATION REPAIR �plican t's Mallin AZ, ss j r �' W�ij Owner's Name `10 �rrWQ f • Ph/o/na.12l2 37( Address ry • !" • i�C/ ( -7 Arch/Enteens, No, �—(180'3 r• P ,- Address Contractor's Name one Address (mailing) City License No. LICENSED CONTRACTOR DECLARATION 1 hereby affirm that I am licensed under provisions of Charter 9 (commencing with section 7000) of Division 3 of the Business and Professions Code, and my license is in full force d effect. LiCense-class, p en Date '19f_X 5Z Signature WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self -insure or a Certificate -)f Workers' Compensation Insurance, or a certifle o th f (Section Policy Lab. 4MO Policy No. ///�------A,lY�• Company rtified copy is hereby furnished. Cer ' ietl c e with the city B py is f I g Date Applicant����� EXEMPTION FROM WORKERS' COMPENSATION DECLARATION (This section need not be Completed if the permit is for one hundred ($100) or less). i 1 certify that in the performance of the work for which this permit is issued I ll shanot employ any person in any manner so as to become subject to the Workers' Compensation Laws of California. Date Signature -NOTICE: If, after making this declaration, you should become subject to the Workers' Compensation provisions Of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that thei•e.ls a construction lending agency for the performance of the work for which this permit Is issued (Section 3097 Civ. C.) Lender's Name kYJ Lender's Address OWNER BUILDER DECLARATION ' I hereby affirm that tam exempt from the Contractor's License Law for the following reason (Sedtion-7031.5 Business and Professional Code: Any city or county which requires a permit to Construct, after, improve, demolish or repair any structure, prior lWiits'Issuance„also requires the applicant for such permit to file a signed statement that he/she Is licensed pursuant to the provisions of the Contractor's Lrtense Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he/she is exempt +herefrom and the basis for the alleged exemptlon. Any violation of Section 031:5 by any applicant for a permit subjects the applicant to a civil enalty of not more than five hundred dollars ($500), ❑ 1, as owner of the property or my employees with wages as their sole compensation, will do the work, and the structure is not Intended or offered for sale (Section 7044, Business and Professional Code: The Contractor's License Law does not apply to an owner of a property who builds or Improves thereon, and who does such work hlmsetf/hersetf or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or Improvement Is sold within one year of com- pletion, the owner will have the burden o1 proving he/she did not build or Im- rova for the purpose of sale). I, as owner of the property, am exclusively Contracting with licensed con- tractors to construct the project (Section 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a con- tractor(s) license pursuant to the Contractor's License Law), I am aware that proof of their Worker's Compensation insurance should be provided to me. ❑ 1 am exempt under Section B. a P. C. for this reason Date Owner •I hereby certify that l have read this appl information Is correct, t agree to comply wI and state lawsrelat, to building cons C sentatives of this sty to e t upo t e inspection purp / Signature o and state that the above city and county ordinances and hereby authorize repre- ve-mentioned property for ❑ CONVERSION ❑ DEMOLISH ❑ OTHER DESCRIPTION OF WORK/USE OF BLDG. TYPE PERMIT LJ GRADING LJ.FOUNOATION La STRUCTURAL TENANT ❑ ELECTRICAL ❑ PLUMBING ❑ MECHANICAL ❑ OTHER PROJECT DESCRIPTION SO. ,+ FT.,OCCUPANCY CONSTRUCTION TYPE eft VALUATION S�.DOb—J2a— ZONE GRADfNGCU.YDS. ACRES Remarks: Reinspection Fee $15 Boiler , Duct - Under Ground Duct - Structural Duct - Ventilating Exhaust System ❑ Multiple ❑ Firepl/Fact. Bit. ICBO # Heating System & Ducting ❑ 0-100,000 BTU ❑ 100•oo0 BTI Reinspection Fee Drivers License or SS MF 0665-46, rev. 10/84 White - Building, Canary - Applicant; pink - Accounting; Goldenrod - Assessor $15 Issue Fee MECHANICAL Hood or Type 1 ❑ Canopy Type II ❑ Refrigeration System ❑o-too,00o BTU 01100,000BT System Repair/Alteration Fire Dampers Registers $ 3 FEES Issue Fee $ 3 A.P. # C-1 _CZQ .— S Main Building: E T Front B Rear A C Right K S Left Ping, Ref. # Planning Notes: I Automatic Washer Construction Pale Sub. Cooking Unit' Dishwasher Dryers gGas ❑Electric Fan F.A.U. Fixtures Device Boxes Outlets Switches Garbage Disposal Generator ❑0-5 KW 135-15 KV1 Reinspection Fee 1 $15 DEVELOPMENT SERVI Zoning Approved By— Building Approved By Application Issued By - 6781 18/05/67 Accessory Building: �” to Req.lProvided toot) to tt .� Z i" ELECTRICAL EM 718,70 TL Zone C Transformer ❑ 15-50 KW ❑ 50 + KW Meter ❑up to 100 amps Meter ❑over.100 amps Sub Panel Motors ❑o-1 HP ❑1 h - 8 Inc. Solar 09 -15 HP Ell 6-15+ Microwave Pole Light Range Sign Standing Sections Trash Compactor Issue Fee SU AR OF FEES PLUMBING FEES Bar Sink Showers Backflow Preventer Service Sink Backflow Irrigation Sewer Cap Bathtubs Sewer Connection Clarifiers Solar Collectors Dishwasher Solar Piping Drinking Fountains Solar Tank Floor Drains Swimming Pool w/Spa Floor Sinks Urinal Gas Service Outlets Water Closet Interceptors Water Heater Kitchen Sink Water Service Lavatories Auto -Wash P—Trap �� Laundry Trays Roof Drains r Reinspection Fee $15 Boiler , Duct - Under Ground Duct - Structural Duct - Ventilating Exhaust System ❑ Multiple ❑ Firepl/Fact. Bit. ICBO # Heating System & Ducting ❑ 0-100,000 BTU ❑ 100•oo0 BTI Reinspection Fee Drivers License or SS MF 0665-46, rev. 10/84 White - Building, Canary - Applicant; pink - Accounting; Goldenrod - Assessor $15 Issue Fee MECHANICAL Hood or Type 1 ❑ Canopy Type II ❑ Refrigeration System ❑o-too,00o BTU 01100,000BT System Repair/Alteration Fire Dampers Registers $ 3 FEES Issue Fee $ 3 A.P. # C-1 _CZQ .— S Main Building: E T Front B Rear A C Right K S Left Ping, Ref. # Planning Notes: I Automatic Washer Construction Pale Sub. Cooking Unit' Dishwasher Dryers gGas ❑Electric Fan F.A.U. Fixtures Device Boxes Outlets Switches Garbage Disposal Generator ❑0-5 KW 135-15 KV1 Reinspection Fee 1 $15 DEVELOPMENT SERVI Zoning Approved By— Building Approved By Application Issued By - 6781 18/05/67 Accessory Building: �” to Req.lProvided toot) to tt .� Z i" ELECTRICAL EM 718,70 TL Zone C Transformer ❑ 15-50 KW ❑ 50 + KW Meter ❑up to 100 amps Meter ❑over.100 amps Sub Panel Motors ❑o-1 HP ❑1 h - 8 Inc. Solar 09 -15 HP Ell 6-15+ Microwave Pole Light Range Sign Standing Sections Trash Compactor Issue Fee PLAN CHECK 25% $ Z O N I N G R E O M T S FEES SU AR OF FEES BUILDING PERMIT $ 0 SMTP PLAN CHECK $ ffg PERMIT PLUMBING $ ISSUANCE PLAN CHECK 25% $ ENERGY P.0 ELECTRICAL $ GRADING PLAN CHECK 50°% $ MICROFILM MECHANICAL $ TOTAL FEE PLAN CHECK 25% $ Z O N I N G R E O M T S FEES CONSTRUCTION AND PLANNING APPROVALS Permit # Date Inspector POOL & SPA APPROVALS Permit # Date Inspector 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. 54. Forms 4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6• Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE 7, Footings 58. Electrical Conduit-Undrgrnd. 8. Foundation 59. Gas Pipe, ❑ Undrgrnd., Test 9. Water Pipe-Undrgrnd. 60. Backwash Lines, P -Trap, ❑ Undrgrnd. 10. Structural Floor System 61. APPROVAL TO DECK 11. Property Sewer Line & House Connection 62. Backwash & Receptor -Final 12, Sewer Cap 63. Heater & Vent -Final 13. Roof Drains 64, Plumbing System - Final 14. Rough Plumbing 65. Electrical -Final 15. Rough Electrical -Conduit 66. Solar System -Final 16. Rough Electric Wiring 67. Fencing & Access Approval 17. Rough Wiring Sign 68. APPROVED FOR PLASTERING 18. Rough Electrical -T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit # 20. Rough Factory Fireplace 21. Ducts, in Structure 70. Underground Hydro 22. Ducts, Ventilating 71. Product Piping ❑ Gas ❑ Oil 23. Gas Pipe -Rough & Test 72. Underground Flush 24, hoof Framing 73. Undergrnd. Storage Tank ❑ Gas ❑ Oil 25. Roof Sheathing 74. Overhead Hydro - 26. T -Bar Ceiling (Structural) & Monocoat 75. Dry Chemical 27. Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding 77. FIXED SYSTEM FINAL" 29. Insulation 78. FIRE PREV. FINAL 30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat 79. FINAL INSPECTION 32. Electrical Power Meter -Final 80. FOOD CERTIFICATE ISSUED 33. Final Electric Notes: 34. Final Heating & Air Conditioning t 35. Final Gas Pipe -Test 36. Hood or Canopy 37. Final Factory Fireplace 38. Final Plumbing t. 39. Water Service -Final r 40. Gas Service -Final 1 1 '41, Solar Domestic -Final 1 - 42. Backflow Preventer �` • r 43. Backflow Irrigation - 1 '44. Landscape Irrigation System •.1 .y . 45. Sound Attenuation _ •r 46. Handicap Regulations'• • { 47. FINAL STRUCTURE & BUILDING 48. Special Requirements Completed 49. Electric Release to Edison 50. Gas Release to Southern California Gas Co 7 51. CERTIFICATE OF OCCUPANCY No. Date - CERTIFICATE OF COMPLIANCE PAYMENT OF SCHOOL FACILITY FEES NEWPORT -MESA UNIFIED SCHOOL DISTRICT � t Developer/Applicant:T. N / yin Address: __- J ii.� �� .. `�� R29,Q,, L ri 463`7 13 Telephone Number:._ .20'- — 'ZZ Z D-_. Tract/Parcel and Lot Number(s): l.5 -/P,9 T- s`t%�___� Location of Project: 3�? /���r� ,s'7 -_ 92�� Number of Square Feet of Residential Space x $1.50 Total Number of Square Feet of Commercial and Q _ L/ p V Industrial Space -�v x $0.25 Total The provisions of Government Code Section 53080 are not applicable. This certifies that the above-named Developer/Applicant has paid school facility fees in compliance with Government Code Sections 53080 and 65995. Checks are to be made payable to Newport -Mesa Unified School District. f Business Mvanager Newport -Mesa Unified School District The above representation as to square footage is true. Developer/Applicant agrees that if it is later determined that such representations are not true then this certificate shall automatically terminate and the appropriate City/County shall be notified. Date:�,;? Developer Applicant Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations. - -r - CITY OF COST{ •MESA.- .CONSTBUCTIO�PERMIT r' Project Address 4 FERMI 0,.,/�� TRACT N0. LOT'NO.' UNIT NO, 2214 12/2687 1 5ooI] TYPE OF CONSTRUCTION NEW ADD 'ALTIIEERAj ION ❑CONVERSION ❑ DEMOLISH ❑ OTHER —_ SAW.,( - DESCRIPTION OF WOR KIUSE OF BLDG. �7Rv1EPfA/l,R+ �v� i tom" ! r - ; �� Applicant's Mailing Address Owner's Name Phone Address Arch/Eng. License No. Address + ` A.P..# _ Zone S Main Building: Accessary Building: TYPE OF PERMIT GRADING' FOUNDATION STRUCTURAL ❑ TENANT ❑ ELECTRICAL X PLUMBING ❑ MECHANICAL ❑ OTHER t PROJECT DESCRIPTION' SQ. FT. OCCUPANCY, CONSTRUCTION TYPE VALUATION $ ZONI GRADING CU.YDS. ACRES' � E T Front Z O B A Rear N I I Contractor's Nam PhO 7W !/�� Address (mailing) 11692 rit'�)l UeJl4/�iY City License No. 1'I rd boli : r LICENSED CONTRACTOR DECLARATION Y I hereby affirm that 1 am licensed under provisions of Charter 9 (commencing with section 7000} of Division 3 of the Business and Professions Code, and my license is in full for/e� and fe t, ry License Class 4-^� Date Signature C Right _ ! l K S Left R ,Ping. Ref.# Parking Req,/Provided E _ Remarks: OJTT Planning Notes: __ Q (yl a ( T S, PLUMBING FEES Bar Sink Showers ' ELECTRICAL FEES WORKE ' C MPENSATION CLARATION I hereby affirm that I have a certificate of consent to self -insure or a certificate of Workers' Compensation Insurance, or a certified copy theraof (Section 3soo, Lan, C�f.}r� }�.� C.•� Irf Policy No. �f G0 l�C]a^3 ! Company S05k7m /[f/� Certified copy is hereby furnished. certified co is filed with the cityilding pivisi Backflow Preventer _ Service Sink t Automatic Washer Construction Pole Sub. Transformer ❑ 15-50 KW © -50 + KW , Backflow Irrigation, Sewer Ca P Bathtubs. Sewer Connection i _ Cooking Unit Meter Cup to 100 amps f ' Date Applican EXEMP ON ROM WO RKE RS'qADMPENSATION DECLARATION Clarifiers Solar Collectors Dishwasher Meter ❑over,100amps « {This Section need not be completed if the permit i5 for one hundred ($100) or iessy. ) I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California. Date Signature NOTICE: If, after making this declaration, you should become subject -to the - Dishwasher - - Sa_4ar Piping- Dryers ❑Gas DElectric Sub Panel. Drinking Fountains Solar Tank Fan ' Motors ❑0 VH P ❑.1 %z - B /� I Floor Drains Swimming Pool vv/SpaZ"), — F.A,U, Inc. SOlar ❑9-15 HP ❑"16-15+ - - Floor Sinks t,Urinal f Fixtures Microwave Workers' Compensation provisions of the Labor Code, you, must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY ,r} I hereby affirm that there is a construction lending agency for the performance Gas Service Outlets Water Closet Device Boxes Pole Light of the work for which this permit is issuetl, (Section' 3097 ,a Civ. C.) Lender's Name Interceptors Water Heater t�Ll eCTe.ge_ T d• Outlets ' • Range ` Kitchen Sink - Water Service - - Switches Sign i Lender's Address OWNER BUILDER 13ECLARATION I hereby affirm, that I am exempt from the Contractor's License L.aW for the following reason (Section 7031,5 Business and Professional Code: Any city or county which requires a permit to construct, alter,,Emprove, demolish or repair any structure, prior to its issuance, also requires the applicant for suchGenerator, permit to file a signed statement that he/she is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section'7000) of Division 3 of the Business and Professions Code) or that he/she is exempt - Lavatories Auto -Wash Garbage Disposal Standing Sections P—Trap Laundry Trays 00-5 Generator❑D•5 KW ❑5-15 KW Trash Com actor _ P Roof Drains -+ ' - - therefrom and the basis for the alleged exemption. Any violation of Section ' 7031.5 by any applicant for a permit subjects the applicant to a civil enalty of not more than five hundred dollars ($500). I, as owner of the'+property or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Section 7044, Business and Professional Code: The Contractor's • License Law does not apply to an owner of a property who builds or improves 'thereon, and who does such work himself/herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If,"however, the building or improvement is sold within one year of cam- pletion, the owner, will have the burden of proving he/she did not build or im- prove for the purpose of sale). ❑ I, as'owner of the property, am'exclusively contracting with licensed con- tractors to construct theproject{Section 7044, Business and Professions Code: The Contractor's .License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a con- tract or license pursuant to the Contractor's License Law). I am aware that proof off their worker's Compensation insurance should be piov(ded to me-. ❑ 1 am exemptunder Section B. & P; C.�tor this reason + Reinspection Fee $15 Issue Fee. I Reinspection Fee $15 Issue Fee $ 3 - MECHTNICAL FEES DEVELOPMENT SERVICES REQUIREMENTS: , , Zoning Approved By Date Building Approved By Date - Application Issued By — Date -- - --- - - - Boiler I Hood or Type I ❑ Canopy Type 11 ❑ Duct - Under Ground Duct - Structural Refrigeration System - ❑0-100,000 BTU ❑100,000 BTU Duct - Ventilating , BUILDING PERMIT PLAN CHECK PLUMBING SUMMARY OF FEES $ SMiP $ $ PERMIT i $ ISSUANCE $ 0 Exhaust System ❑ Multiple ❑ System Repair/Alteration Firepl/Fact. Blt. ICBO # Fire Dampers Date Owner ,I hereby certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances Heating S g ystem &Ducting 00-100,000 BTU I] 100,000 BT Registers PLAN CHECK 256 ELECTRICAL - $ `� 0 ENERGY P,C. $ $ GRADING $ ' - i and state laws r lating to building construction and hereby authorize repre- sentatives of s city to a er u on the above-mentioned pr erty for , inspection p ores. -,Signature Dat- •`privers' nse or S5� PLAN CHECK 50% MECHANICAL PLAN CHECK 25% $ MICROFILM $ $ TOTAL FEE $ . 00 $ ~ a Reinspection Fee $15 Issue Fee $ 3 CMF 0865-4b, rev. 10/84 W He ui ng; Canary - licant; Pink - Accounting; Goldenrod • Assessor CONSTRUCTION AND PLANNING APPROVALS Permit # Date Inspector POOL & SPA _ APPROVALS Permit # Date Inspector 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement.: 3. Electrical Conduit Utility-Undrgrnd, 54. Forms 4. Electrical Conduit-Undrgrnd. '55. Electrical Bonding 5, Steel Reinforcement 56. Rough Plumbing & Pressure Test 6. Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE 7. Footings 58. Electrical Conduit-Undrgrnd. 8. Foundation 59. Gas Pipe, ❑ Undrgrnd., Test 9. Water Pipe-Undrgrnd, 60. Backwash Lines, P -Trap, ❑ Undrgrnd. 10. Structural Floor System 61. APPROVAL TO DECK 11, Property Sewer Line & House Connection 62. Backwash & Receptor -Final 12. Sewer Cap 63. Heater & Vent -Final 13. Roof Drains 64. Plumbing System - Final 14. Rough Plumbing ' 65. Electrical -Final 15, Rough Electrical -Conduit 66. Solar System -Final 16. Rough Electric Wiring 67. Fencing & Access Approval 17. Rough Wiring Sign _ 68. APPROVED FOR PLASTERING 18, Rough Electrical -T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit # _ 20. Rough Factory Fireplace 21. Ducts, in Structure 70. Underground Hydro 22. Ducts, Ventilating 71. Product Piping ❑ Gas ❑ Oil 23. Gas Pipe -Rough & Test 72. Underground Flush 24, Roof Framing 73. Undergrnd. Storage Tank ❑ Gas ❑ Oil 25. Roof Sheathing 74. Overhead Hydro 26. T -Bar Ceiling (Structural) & Monocoat 75. Dry Chemical 27. Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding 77. FIXED SYSTEM FINAL 29. Insulation 78. FIRE PREV. FINAL 30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat 79. FINAL INSPECTION 32. Electrical Power Meter -Final 80. FOOD CERTIFICATE ISSUED 33, Final Electric Notes: 34. Final Heating & Air Conditioning ' 35. Final Gas Pipe -Test ,r 36. Hood or Canopy 37. Final Factory Fireplace f 38. Final Plumbing r r, 39. Water Service -Final 40. Gas Service -Final r 41. Solar Domestic -Final ' l 42. Backflow Preventer 43. Backflow Irrigation i✓ir,- , 44. Landscape Irrigation System r, 45. Sound Attenuation 46.- Handicap Regulations i 47. FINAL STRUCTURE & BUILDING = 48. Special Requirements Completed °. 49. Electric Release to Edison 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY No. Date LTO1 / /I/ T OA v l - Applicant to fill In all spaces -except those within heavy border lines and sign all appropriate declarations. CITY, OF COSTA MESA O TRUC ION PERMIT C Project Address ee 2-.7tb -7-3TRACT PER/q NO 3/& NO. LOT NO. UNIT NO. TYPE QF CONNEW ADD ALTERATION ❑ CONVERSION ❑ DEMOLISH ❑ OTHER REPAIR ( pplicant's Mailing Address J��1 �_ Owner's Name Phone DESCRIPTION OF WORK/USE OF BLDG. Fan Address F.A.U. inc. Solar ❑9.15 HP 11116-15+ Fixtures TYPE OF PERMIT GRADING 0 FOUNDATION STRUCTURAL ❑ TENANT ❑ ELECTRICAL 11PLUMBING AMECHANICAL 1:1 OTHER Arch/Eng. License No. Address .1 ntractor's Nam C �o f C- hone ) �le Q1P,��f Address (mailing) //lf6:-W ma .9�..� Yle/ PROJECT DESCRIPTION SQ. FT. OCCUPANCY Switches Sign CONSTRUCTION TYPE VALUATION $ Generator 00.5 KW 05-15 KW City License NO. f 72 -Q�! LICENSED CONTRACTOR DECLARATION ZONE GRADING CU. YDS. ACRES Remarks: $ SMIP I hereby affirm that I am licensed under provisions of Charter 9 (commencing with section 7000) of Division 3 of the Business and Professions Code, and - ' PERMIT my license is In full t rce and effect. Liceiass 20 Llcc No.�L���Z nse - Date �� 9 2 Signature ,.• y _ PLUMBING PLUMBING FEES Bar Sink Showers $ WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self -Insure or a certificate BackfkowPreventer Service Sink GRADING f Workers' Compensation Insurance, or a certified copy thereof (Section 800, Lab. ) 9 p 8ackfiow Irrigation Sewer Cap MICROFILM L� Policy ND.& 'V �� Company �+- �'w,rL[- Certified copy is hereby furnished. Bathtubs Sewer Connection FEE Cer)ifieci copy is filed with the city Buildinglvlslon Date Applicant 7, rL^A�-- EXEMPTION FROM WORKERS' CONAPENSATION OECRATION (This section need not be completed if the permit is for one hundred (5100) or less). I certify that in the performance of the work for which this permit is Issued I shall not employ any person 1n any manner so as to become subject to the Workers' Compensation Laws of California. Clarifiers Solar Collectors �1e, Dishwasher - Solar Piping Drinking Fountains Solar Tank ' Floor Drains Swimming Pool w/Spa Date Signature NOTICE: If, after making this declaration, -you should become subject to the Floor Sinks Urinal Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit Shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there Is a construction lending agency for the performance Gas Service Outlets , Water Closet •r Interceptors Water Heater of the work for which this permit is Issued (Section 3097 Civ, C.) Lender's Name Kitchen Sink - Water Service 4 - Lender's -Address - OWNER BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5 Business and Professional Code: Any city or county which requires a permit to construct, alter; Improve, demolish or repair any Structure, prior to Its Issuance, also requires the applicant for such permit to file a signed statement that he/she Is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000), of Division 3 of the Business and Professions Code) or that he/she is exempt "ierefrom and the basis for the alleged exemption. Any violation of Section )31.5 by any applicant for a permit subjects the applicant to a civil malty of not more than five hundred dollars ($500). IDI, a5 owner of the property or my employees with wages as their Sole compensation, will do the work, and the structure Is not Intended or offered for sale (Section 7044, Business and Professional Code: The Contractor's License Law does not apply t0 an owner of a property who builds or Improves thereon, and who does such work,himself/herself or through his or her own employees, provided that such Improvements are not Intended or offered for ' sale. If, however, the building or improvement is sold within One year of com- pletion, the owner will have the burden of proving he/she did not build Or Im- prove for the purpose of sale). ❑ 1, as owner of the property, am exclusively contracting with licensed con- tractors to construct the project{Section 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a con- Lavatories Auto -Wash ' P -Trap Laundry Trays Roof Drains + , Reinspection Fee $15 Issue Fee S S MECHANICAL FEES Boiler + Hood Or Type I ❑ yp Canopy Type II ❑ Duct - Under Ground Duct - Structural Refrigeration System ' ❑0-100,000 BTU ❑ 100,000 BTU Duct - Ventilating Exhaust System ❑ Multiple ❑ System Repair/Alteration tractor(s) license pursuant to the Contractor's License Law). 1 am aware that proof of their Worker's Compensation Insurance should be provided• to me. ❑ 1 am exempt under Section B. & P, C. for this reason Firepl/Fact. Bit. ICBG # Fire Dampers Date Owner Heating System & Ducting Registers I hereby certify that I have read this application and state that the above 00-100,000 BTU 0100,0008 _ information Is correct, I agree to comply with all city and county ordlnances , and state laws relating to building construction, and hereby authorize repre- SentativeS of this city to enter upon the above-mentiOnrd properly for inspection perp es Z Signature Dace Drivers' license or 55 Reinspection Fee S15 Issue Fee !sem %� CMF 0865.46, rev. 10/84 White - Building; Canary - Applicant: pink - Accounting; Goldenrod - Assessor A. P. # S Main Buildi E T Front ARear C Right K S Left Ping. Ref. Planning Notes: 2279 12/29/67 26025 TL Zone Accessory Building: Parking Req./Provided ELECTRICAL Automatic Washer,' Construction Pole Sub. ' Transformer ❑ 15-50 KW ❑ 50 + KW' Cooking Unit Meter El up to 100 amps Dishwasher. Meter Oover 100amps Dryers ❑Gas ❑Electric Sub Panel Fan Motors00-1 HP[]1i4-8 F.A.U. inc. Solar ❑9.15 HP 11116-15+ Fixtures Microwave Device Boxes Pale Light Outlets Range Switches Sign Garbage Disposal Standing Sections Generator 00.5 KW 05-15 KW Trash Compactor Z O N I N G R E Q M T S FEES Reinspection Fee $15 Issue Fee $ 3 DEVELOPMENT SERVICES REQUIREMENTS: ' Zoning Approved By Date Building Approved By Date Application Issued By Dat SUMMARY OF FEES BUILDING PERMIT $ SMIP S PLAN CHECK $ PERMIT PLUMBING g ISSUANCE S PLAN CHECK 25% $ ENERGY P.C. $ ELECTRICAL $ GRADING S r PLAN CHECK •50% $ MICROFILM $ MECHANICAL d $TOTAL FEE S PLAN CHECK 25% A �1e, `CONSTRUCTION AND•PLANNING r` APPROVALS Permit # Date` Inspector POOL & SPA. •' APPROVALS Permit # Date Inspector '1 -:-Temporary Electrical -Service or Pole �. . 52. Pool &Equipment Location 2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. 54. Forms 4, Electrical Conduit-Undrgrnd. 55. Electrical Bonding 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6. Electrical LIFER Grnd. 57. APPROVAL TO COVER-GUNITE 17. Footings 58. Electrical Conduit-Undrgrnd. 8_Foundation Ir_ 59, Gas Pipe, ❑ Undrgrnd., Test `,�1f:3?Water Pipe-Undrgrnd. 60. Backwash Lines, P -Trap, ❑ Undrgrnd. x10. Structural Floor System 61. APPROVAL TO DECK , 11. Property Sewer Line & House Connection 62 -Backwash & Receptor -Final ' 12. Sewer Cap 63. Heater & Vent -Final 13. Roof Drains- 64• Plumbing System - Final 14. Rough Plumbing 65. Electrical -Final 15. Rough Electrical -Conduit 66. Solar System -Final 16, Rough Electric Wiring 67, Fencing & Access Approval 17. Rough lViring Sign 68. APPROVED FOR PLASTERING 18. Rough(Electrical-T Bar Ceiling s 69. POOUSPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning �1? FIRE DEPT. REQUIREMENT APPROVALS Permit #' ' ! 20. Rough Factory Fireplace `'21. Ducts, in Structure 70. Underground Hydro 22. Ducts, Ventilating 71. Product Piping ❑ Gas ❑ Oil 23. Gas Pipe -Rough & Test 72. Underground Flush 24. Roof Framing 73. Undergrnd. Storage Tank ❑ Gas ❑ Oil - �• 25. Roof Sheathing 74, Overhead Hydro 26. T -Bar Ceiling (Structural) & Monocoat 75. Dry Chemical 27. Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding 77. FIXED SYSTEM FINAL 29. Insulation 78. FIRE PREV. FINAL 30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat 79: FINAL INSPECTION 32. Electrical Power Meter -Final - 80. FOOD CERTIFICATE ISSUED 4 33. Final Electric Notes: 34. Final Heating & Air Conditioning 1 ,.�� Low) ` 35. Final Gas Pipe -Test 36. Hood or Canopy 37. Final Factory Fireplace 38. Final Plumbing t- 39." Water Service -Final Y 40. Gas Service -Final T G r 41 • Solar Domestic -Final 1 r t •.42' Backflow Preventer °�- 43. Backflow Irrigation X44. Landscape Irrigation System „= 45. Sound Attenuation • 46: Handicap Regulations - }• '47. FINAL STRUCTURE & BUILDING 48. Special Requirements Completed 49. Electric Release to Edison I 50, Gas Release to Southern California Gas Co r 51. CERTIFICATE OF OCCUPANCY No. Date 11 Cf Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations. CITY OF COSTA ESA CON IJCTION PER PFRMiT NO. TRACT NO. LOT NO. iIIVIT Nn _ Project Address �{.. 'Applicant's Nlailin Address -C• Owner's Name11 one Address Arch/Eng. License No. Address Contractor's Name Phone lNum MA Address (mailing) City License No. d& 111YINA LICENSED CONTRACTOR DEC ARATION I hereby affirm that I am licensed under provisions of Charter 9 (Commencing with section 7000) of Division 3 of the Business and Professions Code, and my license is in f or a and effect. Licans ss e Date 2wWrInSignature WOR KE 5' COM NSATION DEC TION I hereby affirm that I have a certificat consent to self -insure or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Section 3600, Lab. C.) Policy No. Company 8 Certified copy is hereby furnished. Certified copy Is filed with the city Building Division. Date Applicant EXEMPTION FROM WORKERS' COMPENSATION DECLARATION {This section need net be completed If the permit is fpr one hundred ($100) or toss). I certify that In the performance of thewor r hlc his permit is Issued, I shall o employ person In any, n s come subject to the Work n Laws of CaII(O Date Signature NDTIC . If, after m king this tleclarat you should become subject to the Workers' Compensation provisions of Labor Code, you must forthwith comply with Such provisions or th permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY 1 hereby affirm that there Is a construction lending agency for the performance of the work for which this permit Is issued (Section 3097 Clv. C.) Lender's Name Lender's -Address OWNER BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5 Business and Professional Code: Any city or county which requires a permit t0 construct, alter, improve, demolish or repair any structure, prior to its Issuance, also requires the applicant for such permit to file a signed statement that he/She is licensed pursuant t0 the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000).of Division 3 of the Business and Professions Code) or that he/she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil enalty of not more than live hundred dollars'($500). I, as owner of the property or my employees with wages as thelr sole compensation, will do the work, and the structure Is not Intended proffered for sale (Section 7044, Business and Professional Code: The Contractor's License Law does not apply to an owner of a property who builds or Improves thereon, and who' does such work himself/herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement IS Sold within one year of Com- ptetlon, the owner will have the burden of proving he/she did not build or Im- rOve for the purpose of sale). I, as owner of the property, am exclusively contracting with licensed Con- tractors to construct the project(Section 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a con- tractors) license pursuant to the Contractor's License Law). I am aware that proof of their Worker's Compensation insurance should be provided to me. ❑ I am exempt under Section B. h P. C. for this reason Date Owner I hereby certify that I have read this application and state that the above information '-s correc I agree o Comply with all city and county ordinances and state law elan to b jl in construction, and hereby authorize repro sentatives of L n r Pon the above-mentioned property fo inspection purp Signature at Drivers' Licen 55 & 3d TYPE OF CONSTRUCTION NEW LJ ADD 0 ALTERATION U REPAIR CONVERSION DEMOLISH OTHER A.P. # - DESCRIPTION OF WOOF BLDG. S Main Building: E TYPE OF PERMIT GRADING LJ FOUNDATION LJ STRUCTURAL T Front ❑ TENANT ELECTRICAL ❑ PLUMBING ❑ MECHANICAL I B ❑ OTHER PROJECT DESCRIPTION CON STRUCTION TY ZONE Remarks: Rear A SQ. FT. OCCUPANCY C Right K VALUATION S g I Left GRADING CU. YDS, ACRES Ping. Ref. # Planning Notes: FEES • 8048 10/23/87 Zona Accessory Building: Parking Req./Provided 71-70 ' T L, Z O N 1 N G R E Q M T S Bar Sink Showers ELECTRICAL FEES Backflow Preventer Service Sink Automatic Washer Construction Pole Sub. Transformer ❑ 15.50 KW ❑ 50 + KW Backflow irrigation Sewer Cap - Bathtubs Sewer Connection Cooking Unit I Meter p to 100 amps Clarifiers Solar Collectors Dishwasher Meter ❑over 100 amps Dishwasher Solar Piping Dryers ❑Gas ❑Electric Sub Panel D Drinking Fountains Solar Tank Fan Motors 00.1 NP 01'r4 - 8 Floorr rreinsf ,a Swimming Pool w/Spa F.A.U.lnc.Solar 09-15 HP El 16.15+ Floor SinksL2 Urinal Fixtures ; Microwave Gas Serviced Outlets Water Closet Device Boxes Pole Light Interceptors: Water Heater Outlets Range Kitchen Sink Water Service Switches Sign _ (7 Lavatories',; Auto -Wash Garbage Disposal Standing Sections Laundry Trays Generator 110-5 KW 135-15 KW Trash Compactor Roof.Drains 1 Reinspection Fea $15 Issue Fee $ 3 Reinspection Fee $15 Issue Fee $ 3 MECHANICAL FEES DEVELOPMENT SERVICES REQUIREMENTS: Zoning Approvad By Date Building Approved By Date Application Issued By n Dat Boiler Hood or Type I ❑ Canopy Type It 11 Duct -Under Ground Duct - Structural Refrigeration System 00-100,0100BTU ❑100,000 BTU Duct - Ventilating BUILDING PERMIT $ PLAN CHECK $ PLUMBING $ PLAN CHECK 25%' $ ELECTRICAL $ PLAN CHECK 50%. $ MECHANICAL $ PLAN CHECK 25% $ SUMMARY OF FEES SMIP $ PERMIT ISSUANCE $ ENERGY P:C. $ GRADING $ MICROFILM $ TOTAL FEE $ D Exhaust System ❑ Multiple ❑ System Repair/Alteration Firepl/Fact. Bit. ICBO # Fire Dampers Heating System & Ducting ❑0.100,000 BTU 01100,000 BT Registers Reinspection Fee $15 Issue Fee $ 3 7F 0865-46, rev. 0/84 t; pink - Accounting; Goldenrod - Assessor CONSTRUCTION AND PLANNING .APPROVALS Permit # Date Inspector .4 POOL & SPA -' APPROVALS Permit Date Inspector 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement a 3. Electrical Conduit Utility•Undrgrnd. 54. Forms 4. Electrical Conduit-Undrgrnd. 55..Eiectrical Bonding ' 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6- Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE 7. Footings 58. Electrical Conduit-Undrgrnd. B. Foundation 59. Gas Pipe, ❑ Undrgrnd., Test 9. Water Pipe-Undrgrnd. 60. Backwash Lines, P -Trap, ©Undrgrnd. 10. Structural Floor System 61. APPROVAL TO DECK ; 11. Property Sewer Line & House Connection 62. Backwash & Receptor -Final 12. Sewer Cap 63. Heater & Vent -Final 13. Roof Drains 64. Plumbing System - Final 14. Rough Plumbing 65. Electrical -Final 15. Rough Electrical -Conduit 66. Solar System -Final 16. Rough Electric Wiring 47. Fencing & Access Approval 17. Rough Wiring Sign 68. APPROVED FOR PLASTERING 18. Rough Electrical -T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit # 20. Rough Factory Fireplace 21. Ducts, in Structure 70. Underground Hydro 22. Ducts, Ventilating 71, Product Piping ❑ Gas ❑ Oil 23. Gas Pipe -Rough & Test 72. Underground Flush 24. Roof Framing 73. Undergrnd. Storage Tank 13Gas ❑ Oil 25, Roof Sheathing 74. Overhead Hydro 26. T -Bar Ceiling (Structural), & Monocoat 75. Dry Chemical 27. Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding 77. FIXED SYSTEM FINAL 29. Insulation 78. FIRE PREY. FINAL , 30. Drywall Nailing HEALTH DEPT. REQUIREMENT ' 31. Plaster Brown Coat 79. FINAL INSPECTION 32. Electrical Power Meter -Final 0. FOOD CERTIFICATE ISSUED 33. Final Electric tes: 34. Final Heating & Air Conditioning 35. Final Gas Pipe -Test - 36. Hood or Canopy 37.. Final Factory Fireplace 38. Final Plumbing , I 39. Water Service -Final 40. Gas Service -Final I 1 -41. Solar Domestic -Final 42. Backflow Preventer 43. Backflow Irrigation I 44. Landscape Irrigation System 45. Sound Attenuation l 46. Handicap Regulations 47 -FINAL STRUCTURE & BUILDING I 48, Special Requirements Completed 49. Electric Release to Edison , 50. Gas Release to Southern California Gas Co ; 51. CERTIFICATE OF OCCUPANCY No. Date P Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations. CITY OF COSTA MESA CONSTRUCTION PERMIT..�¢ PERM T NO TRACT NO. LOT NO. UNIT NO Project Address _ _Cna �L� 5T ["Rn `ZSW Applicant's,Maili g Address Owner's Name_ �� .._1DAJ �D Phone Address .(.� �C' IST�L nnr ZROCEE 2 'SCAR Arch/Eng, License Nc�'�� 2�t78�L. Address ^ Contractor's Nam Phone5-02I Address (mailing) I5 U) • , _ B Q *kI o C� City License No, r- o'n I LICENSED CONTRACTOR DECLARATION I hereby affirm that I am licensed under provisions of Charter 9 (commencing with section 7000) of Division 3 of the Business and Professions Code, and my license is in tl force and effect. `� Q Licens lass L- n e N -Q. — L Date Signature WORKERS' COMPENSATION DECL TION I hereby affirm that I have a certiflcat o consent to self -insure or a certificate f Workers' Compensation Insurance r a certified copy thereof (Section 800, Lab. C.) Pohcy No. Company 8 Certified copy is hereby furnished. Certified copy is filed with the city Building Division. Date Applicant EXEMPTION FROM WORKERS' COMPENSATION DECLARATION (This section need not be completed if the permit is for one hundred ($100) or less). I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any m ne o as t ec me subject to the WorkerF jC©�periga�on [Jaws of Califor Date 1 ! T' i — Signature NOTICE! If, after making this declaratiolf.JyOu should become subject to the Workers' Compensation provisions of tty Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Section 3097 Civ. C.) Lender's Name Lender's Address - OWNER BUILDER DECLARATION I hereby affirm that I arp exempt from the Contractor's License Law for the following reason (Sectiori 7031.5 Business and Professional Code: Any city or county which requires a permit to construct, alter, improve, demolish or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he/she is licensed pursuant to the provisions of . the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he/she is exempt )erefrom and the basis for the alleged exemption. Any violation of Section )31.5 by any applicant for a permit subjects the applicant to a civil enalty of not more than five hundred dollars ($500). d 1, as owner of the property or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Section 7044, Business and Professional Code: The Contractor's License Law does not apply to an owner of a property who builds or improves thereon, and who does such work himself/herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of com- pletion, the owner will have the burden of proving he/She did not build or im- rove for the purpose of sale). 1, as owner of the property, am exclusively contracting with licensed con- tractors to construct the project (Section 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a con- tractor(s) license pursuant to the Contractor's License Law). I am aware that proof of their Worker's Compensation insurance should be provided to me. ❑ 1 am exempt under Saction B. & P. C. for this reason Date _ Owner I hereby certify that I have read this application and state that the above information is correct. I agree to comply with all city, and county ordinances and state laws r acing to building construction, and hereby authorize repre- sentatives th s ci y t e er upon the above-mentioned property for inspection p 2 Signature Drivers' L n or SS -IF TYPE OF CONSTRUCTION NEW ADD ALTERATION LJ REPAIR ❑ CONVERSION ❑ DEMOLISH ❑ OTHER A.P. - DESCRIPTION OF WOR.X1USE OF BLDG. S Main Buildi TYPE OF PERMIT �Y GRADING FOUNDATION 1:1 STRUCTURAL T Front 13 TENANT & ELECTRICAL ❑ PLUMBING ❑ MECHANICAL B Rear ❑ OTHER A C Right PROJECT DESCRIPTION SQ. FT. OCCUPANCY K CONSTRUCTION TYPE VALUATION $ S Left ZONE GRADING CU. YDS. ACRES Ping -,Ref, 94` Remarks:'Ba4 FIEZAA "BCj5SI Planning Notes: Bar -Sink Backflow Preventer Backflow Irrigation Bathtubs Clarifiers Dishwasher Drinking Fountains Floor Drains Floor Sinks Gas Service Interceptors Kitchen Sink Lavatories _ P—Trap Roof Drains Outlets Showers Service Sink Sewer Cap Sewer Connection Solar Collectors Solar Piping Solar Tank Swimming Pool w/Spa Urinal Water Closet Water Heater Water Service Auto -Wash Laundry Trays FEES I I Reinspection Fee I $151 I - Issue Fee I $ s Boiler Duct - Under Ground Duct - Structural Duct - Ventilating Exhaust System ❑ Multiple ❑ Firepi/Fact. Bit. ICBO # Heating System & Ducting ❑o-100,000 BTU ❑ 100,000 BT Reinspection Fee 1 $15 IF 0865-46, rev. 10/84 White - Building; Canary - Applicant; Pink - Accounting; Goldenrod - Assessor I>lk Hood or Type I ❑ Canopy Typell ❑ Refrigeration System 00-100,000 BTU E1100,000BT System Repair/Alteration Fire Dampers Registers Issue Fee Automatic Washer Construction Pole Sub. Cooking Unit Dishwasher Dryers ❑Gas ❑Electric Fan F,A,U. Fixtures Device Boxes 7592 10/19/87 Accessory Building: Parking Req -/Provided ELECTRICAL . Outlets Switches Garbage Disposal Generator ❑0-5 KW ❑5-15 KW EES I Reinspection Fee I $15 F Zone Transformer ❑ 15-50 KW O 50 + KW Meter EJ up to 100 amps Meter N<Zr 10o amps Suh Pa'nel Motors 1:10-1 HP ❑ 1 Y, B yx Inc. Solar E) 9-15 HP Ell 6,15+ Microwave Pole Light Range Sign Standing Sections Trash Compactor Issue Fee DEVELOPMENT SERVICES REQUIREMENTS: Zoning Approved By Date Building Approved By A Date Application Issued By— - Date )5.50 TL N N G R E Q M T S FEES - $ 3 1— SUMMARY OF FEES BUILDING PERMIT $ SMIP PLAN CHECK $ PERMIT PLUMBING $ ISSUANCE PLAN CHECK 25% $ ENERGY P.C. ELECTRICAL $ GRADING PLAN CHECK 50% $ MICROFILM MECHANICAL $ TOTAL FEE PLAN CHECK 25% $ $ 3 )5.50 TL N N G R E Q M T S FEES - $ 3 1— ILCONSTRUCTiON AMD PLANNING c APPROVALS Permit # Date Inspector POOL &'SPA APPROVALS Permit # Date Inspector 1'.'Temporary Electrical Service or Pole 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd. 53. ,Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. 54. Forms 4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding , 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6• Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE 7. Footings 58. Electrical Conduit-Undrgrnd. 8. Foundation �' p, 59. Gas Pipe,,❑ Undrgrnd., Test 9. Water Pipe-Undrgrnd --.� 60. Backwash Lines, P -Trap,• ❑ ,Undrgrnd. 10. Structural Floor System 61. APPROVAL TO DECK 11. Property Sewer Line & House Connection 62. Backwash & Receptor -Final 12. Sewer Cap 63. Heater & Vent -Final ,13. Roof Drains 64. 'Plumbing System - Final 14. Rough Plumbing 65. Electrical -Final 15. Rough Electrical -Conduit 66. Solar System -Final 16. Rough Electric Wiring 67. Fencing & Access Approval t 17. Rough Wiring Sign 68. APPROVED FOR PLASTERING 18. Rough Electrical -T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL. 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit # _ 20. Rough Factory Fireplace 21. Ducts, in Structure 70. Underground Hydro 22. Ducts, Ventilating 71. Product Piping ❑ Gas ❑ Oil 23" Gas Pipe -Rough & Test 72. Underground Flush 24. Roof Framing 73. Undergrnd, Storage TankyO Gas ❑ Oil 25. Roof Sheathing 74. Overhead Hydro 26. T -Bar Ceiling (Structural) & Monocoat 75. Dry Chemical _ 27. Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding 77. FIXED SYSTEM FINAL, 29. Insulation 78. FIRE PREY. FINAL �• 30. Drywall Nailing HEALTH DEPT: REQUIREMENT r. 31. Plaster Brown Coat 79. FINAL INSPECTION 32. Electrical Power Meter -Final 80. FOOD CERTIFICATE ISSUED 33. Final Electric 7 Notes: F'? 34. Final Heating & Air Conditioning 35. Final Gas Pipe -Test 36. Hood or Canopy 37. Final Factory Fireplace `. 38. Final Plumbing 39: Water Service -Final 40. Gas Service -Final 41. Solar Domestic -Final - '42. Backflow Preventer r '43. Backflow Irrigation 44. ;Landscape Irrigation System' L ' 45. Sound Attenuation _ w 1 46. aHandicap Regulations 47, FINAL STRUCTURE & BUILDING 48:. Special Requirements Completed 49. -Electric Release to Edison 4' 50. Gas Release to Southern California Gas Co `? 51. CERTIFICATE OF OCCUPANCY No. Date ' Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations. CITY OF COSTA MESA CONSTRI TION PERMIT P IT NO. TRACT NO. LOT NO. UNIT NO. - ProjecMddress S ` Applicant's Mailing Address; LP7W) A4 Owner's Name Address S 1 L Arch/Eng. License No. Address !1 Contractor's Name� �: ��`P one �,.-�I, Address (mailing) Tl�� � pf�Ysdl� ST fit ASL%/4W qm. City License No. __ C1082_. J LICENSED CONTRACTOR DECL RATION I hereby affirm that 1 am licensed under provisions of Charter 9 (commencing with section 7000) of Division 3 of the Business and, Professions Code, and my license is in full fo a aneffect. L cense144 Ci s Ice�t o Date Signature WORKS S' COMPENSATION DECLARATION I hereby affirm that 1 have a certificate of consent to self -insure or a certificate -- of Workers' Compensation Insurance, or a certi ie c py the eof (Section -3B00, Lab. C.) L{ Policy No, r Company Certifie4 copy is hereby furnished. Certif ed cop Is d with the city Build Div' n. Date11 /M Applicant EXEION F OM WORKERS' COMPENSATION DECLARATIO ' (This section need not be completed if the permit is for one hundred 100) or \\ less). I certify that in the performance of the work for which this permit Is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California. Date Signature [� NOTICE: If, atter making this declaration, you should become subject to.the y\\} Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is issued (Section 3097 Cly. C.) Lender's Name _ Lender's Address OWNER BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License taw for the following reason (Section 7031.5 Business and Professional Code: Any city or county which requires a permit to construct, alter, improve, demolish or repair any structure,, prior to its Issuance, also requires the applicant for such permit to file a signed statement that he/she is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Cade) or that he/she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 1031.5 by any applicant for a permit subjects the applicant to a civil renalty of not more than five hundred dollars ($500), 0 1, as owner of the property or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Section 7044, Business and Professional Code: The Contractor's License Law does not apply to an owner of a property who builds or Improves thereon, and who does such work himself/herself or through his or her own employees, provided that such improvements are not Intended or offered for safe. If, however, the building or improvement Is sold within one year of com- pletion, the owner will have the burden of proving he/she did not build or im- prove for the purpose of sale). ❑ I, as owner of the property, am exclusively contracting with licensed con- tractors to construct the project (Section 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or, improves thereon, and who contracts for such projects with a con- tractor(s) license pursuant to the Contractor's License Law). I am aware that proof of their Worker's Compensation insurance should be provided to me. L7 4 am exempt under Section B. & P. C. for this reason Date Owner 1 hereby certify that I have read this application and state that the above information is correct._I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize repre. sentatives of this city t ent upon the above-mentioned prop rly t inspection purposes. Signature 'Date o 7 -Drivers' License or SS # CMF 0865-46, rev. 10/84 .*YPE OF CONSTRUCTION, LJ NEW ADD ALTERATION, REPAIR [:]-CONVERSION ❑ DEMOLISH ❑ OTH - DESCRI TION OF RK/USE O BLD — _ A P # _ S Main Building: TYPE 00 PE RMIF LJ GRADING FOUi,DATIo SYR TURAL T Front TENANT ❑ ELECTRICAL ❑PLUMBING ECHANICAL 'B Rear' ❑ OTHER i A C Right ,.PROJECT DESCRIPTION SQ. FT, OCCUPANCY K CONSTRUCTION TYPE VALUATION $ g Left ZONE GRADING CU. YDS. ACR s Ping. Ref.# Remarks: , 61-3 Planning Notes: T t PLUMBING FEES 1.117 12/05/8'7 63.OG- TL Zone Accessory Building: Z O N I N G R Parking Req./Provided E Q M T S Bar Sink Showers .: ELECTRICAL - FEES Backflow P�eventer Service SinkAutomatic Washer Construction Pole'Sub. Transformer •❑ 15-50 KW -0 50 f KW Backflow Irrigation Sewer Capes Bathtubs Sewer Connection Cooking Unit Meter Oup to 100 amps , Clarifiers Solar Collectors Dishwasher Meter Dover 100 amps Dishwasher Solar Piping Dryers ❑Gas ❑Electric Sub Panel Drinking Fountains Solar Tank Fan Motors ❑O -t HP ❑ 1 r � - B � Floor Drains Swimming Pool w/Spa F.A.U. Inc. Solar ❑05 HP ❑16-15+ Floor Sinks Urinal Fixtures Microwave Gas Service Outlets Water Closet Device Boxes Pole Light Interceptors Water Heater Outlets Range t Kitchen Sink Water Service Switches Sign Lavatories Auto -Wash Garbage Disposal Standing Sections I P—Trap Laundry Trays Generator ❑0-5 KW ❑5-15 KW Trash Compactor Roof Drains i Reinspection Fee $15 Issue Fee $ 3 t Reinspection Fee $15 Issue'Fee $ 3 MECHANICAL FEES Boiler Hood or Type I ❑ Canopy Type I I ❑ DEVELOPMENT SERVICES Zoning Approved By Building Approved By Application Issued By REQUIREMENTS: Date Date at Duct - Under Ground Duct - Structural Refrigeration System - 00-100,000 BTU ❑ 100,000 BTU Duct - Ventilating BUILDING PERMIT PLAN CHECK PLUMBING PLAN CHECK 25% ELECTRICAL PLAN CHECK -50% MECHANICAL PLAN CHECK 25% SyyuuMMAR�YJOJ,E $ , s��-J $ ;$ $ $e $ •$ $ FEES �������•�. ' '-' . SMIP - $J__T�2SL_ PERMIT. ISSUANCE $ P.C. $ ' GRADING. $ ' MICROFILM $ TOTAL FEE $ . Exhaust System ❑ Multiple ❑ System Repair/Alteration Firepl/f=act. Bit. ICBO # Fire Dampers i Heating System & Ducting 0o-100,000 BTU ❑loo,000BT RegistersENERGY Reinspection Fee ' $15 Issue Fee $ 3, - AppNcant; Pink -Accounting; Goldenrod -Assessor CONSTRUCTION AND PLANNING APPROVALS Permit # Date Inspector POOL & SPA APPROVALS Permit # Date Inspector 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. 54. Forms 4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6. Electrical LIFER Grnd. 57. APPROVAL TO COVER-GUNITE 7. Footings t 58. Electrical Conduit-Undrgrnd. 8. Foundation 59. Gas Pipe, ❑ Undrgrnd., Test 9. Water Pipe-Undrgrnd:' . 60. Backwash Lines, P-Trap, ❑ Undrgrnd. 10. Structural Floor System 61. APPROVAL TO DECK 11, Property Sewer Line & House Connection 62. Backwash & Receptor-Final 12. Sewer Cap 63. Heater & Vent-Final 13. Roof Drains 64. Plumbing System - Final 14. Rough Plumbing 65. Electrical-Final 15. Rough Electrical-Conduit 66. Solar System-Final 16. Rough Electric Wiring 67. Fencing & Access Approval 17.'Rough Wiring Sign 68. APPROVED FOR PLASTERING 18. Rough Electrical-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit # _ 20, Rough Factory Fireplace 21. Ducts, in Structure 70. Underground Hydro 22. Ducts, Ventilating 71. Product Piping ❑ Gas ❑ Oil, 23. Gas Pipe-Rough & Test 72. Underground Flush 24. Roof Framing 73. Undergrnd. Storage Tank ❑ Gas ❑ Oil 25. Roof Sheathing y: 74. Overhead Hydro r AA# C1 26. T-Bar Ceiling (Structural) & Monocoat 75. Dry Chemical 27. Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding 77. FIXED SYSTEM FINAL,. d' 29. Insulation 78, FIRE PREY. FINAL z-j- Yr 30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31, Plaster Brown Coat 79. FINAL INSPECTION ; 32. Electrical Power Meter-Final 80. FOOD CERTIFICATE ISSUED 33. Final Electric Notes: 34. Final Heating & Air Conditioning r� 35. Final Gas Pipe-Test ` 36. Hood or Canopy 37. Final Factory Fireplace 38. Final Plumbing 39. Water Service-Final 40. Gas Service-Final 41, Solar Domestic-Final 42. Backflow Preventer " 43. Backflow Irrigation 44. Landscape Irrigation System 45. Sound Attenuation 46. Handicap Regulations 47. FINAL STRUCTURE & BUILDING 48. Special Requirements Completed 49, Electric Release to Edison 50. Gas Release to Southern California Gas Ca 51. CERTIFICATE OF OCCUPANCY No. Date PC# 2895-94 A CITY OF COSTA MESA XEVELOPMENTSERVICESIBUILDING SAFETY RECORD PACKAGE FOR: 3333 BRISTOL STREET UNIT 2508 PARCEL #412-501-07 B-2 STREET ADDRESS RETAIL STORE "LOUIS VUITTON" WORK DONE XXI Building Permit # B68669 X® Certificate of Occupancy ❑ Electrical Release Form ❑ Gas Release Form E Sanitation Fixture Form ❑ Plumbing Permit # XZK1 Mechanical Permit #—M .9DAQ-- X5D Electrical Permit #E6905I ❑ Reinspection Permit # ❑ Health Department Approval ❑ Roofing Certification ❑ Insulation Certification ❑ Dry Chemical System Certification ❑ Flame Spread Certification El Fire Sprinkler Certification G Soils Certification ❑ Special Inspection Certification XXI Other: F69142 All Required Documents Included +Clerk O.K. to Approve C.O. 0 Inspector O.K. to Release C.O. BUllding Offlciat cmF 1046-30 City of Costa Mesa Development Services, Division of Building and Safety CERTIFICATE OF OCCUPANCY pursuant ta s Building u lSection adopted by the City of CosMesa cerfe�that the time oftits uancee the building sstructueher in below described was inspected and approve-d for:occupancy-as=follaws:� /,�C�`` Building Address 3333 BRISTOLKREET UNIT;, 2508 r1 Bldg. Permit No. B68665 Use RETAIL STORE Group B'2 Type ok6nstr' action I-FR F�irl hone "� L `�' Use Zone C1--S ��� � I nr, ! iIL % V� Ti••- l� U`l,}E{ �'i`r,• l rr �'! r,- ,t Ohl Owner of Building C.J: SEGERSTROM- ^ - Telnant "LOIIISI WITTON" Address 33155, HAIRVIEW ROAD,- COSTA--MESA;--CA 92626 Byj BUILDING OFFICIAL- tOC�p�C-IN %aa- �� � � , �� ('� l r Date`s Jq REQUIRED TO BE POSTED?IN`A CONSPICOUS PLACE 0 PROJECT ADDRESS: 3333 BRISTOL ST UNI CITY OF COSTA MESA - BUILDING PERMIT d OWNER'S NAME: C J SEGERSTROM (� ADDRESS: 3315 FAIRVIEW RD �b PERMIT NO: B 068665 PLAN CHECK NO: 02895-94 A v C,M „ CA 92626 ' ARCHfENGINEER: BRAND + ALLEN ARCH REG.NO.: 0 2 0 2 9 0 ADDRESS: 900 NORTHPOINT ST UNIT: 400 S,F, CA 94109 PERMITTEE: THE STONE COMPANY (619)660-1333 ADDRESS: 2990 JAMACHA RD EL CAJON CA 92019 LICENSED CONTRACTOR DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7%) o! Division 3 of the Business and Prole i s C d and4haa' liea is ' II f ce and effect. CITY LIC.' TATE LIC.: � � 2 � � 4 EXP-. ate; � _ Signature: - R COMPE ATION ECLARATION: I horeby alSirm theo f"ate of consent to self insure or a certificate of Workers' Kimpensation t1Vnce9,6,1ce[tif�e6®py thereof (Section 3800. Lab. 0-8/31/94 POLICY NO.: INDUSTRIAL INDE EXP. DATE: COMPANY: ;lied opy is h by furnished. Certified copy is tiled it ui1 ' g Division. Da Applicant: EXEMPTION FROM ORNERS' OMPENSAiIOH DECLARATION: (This se ne of be completed if the permit is for one hundred (5700) or less}. I certify that in the performance of the work lot which this permit is i ued, shall not employ any person in any manner so as to become Subject to the Workers' Compensation Laws of California. Date: Signature: NOTICE: V. alter making this declaration, you should become subject to the Workers' Compensation provisions of the Labor Code. you must forthwith comply with such provisions or this permit shag be deemed revoked. CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Section 3097, Civ. C). LENDER: ADDRESS: OWNER BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractors' State License Law for the following reason (Section 7031.5 Business and Professional Code: Any city of county which requires a permit to construct, alter, improve, demolish, or repair any structure. prior to its issuance. also requires the applicant for such permit to file a signed statement that he/she is licensed pursuant to the provisions of the Contractors' State License Law {Chapter 9 (commencing with Section 7006) of Division 3 o1 the Business and Professions Code) or that he/she is exempt therefrom and the basis for the apeged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty at not more than five hundred dollars ($500). I, as owner o1 the property or my employees with wages as their sole compensation, will do the work, and the ❑ structure is not intended or offered for sate (Section 7044, Business and Professional Code: The Contractors' State License Law does not apply 10 an owner of a property who builds or improves thereon, and who does such work himself/herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however the building or improvement is sold within one year of completion, the owner will have the burden of proving he/she did not build or improve for the purpose of sale). I, as owner of the property. am exclusively contracting with licensed ccntractors to construct the project (Section 7044, Business ❑ and Professions Code, The Contractors' State License Law does not apply to an owner of property who builds or improves thereon and who contracts for such projects with a contractor(s) license pursuant to the Contractors' State License Law). I am aware that proof of their Worker's Compensation insurance should be provided to me. ❑ t am exempt under Section: B. 8 P. C. for this reason. CONSTRUCTION TYPE; I FR PERMIT TYPE: STR PURPOSE: ALT JOB DESCRIPTION ; 2379SF 2ND FL & MEZZANINE STORE T.I. SQ FT: 3,379 CLAIM VALUE; 100,000,00 CALC-VALUE: 42,495,50 GROUP OCC: B-2 / COMMENTS: "LOUIS VUITTON" STORE T.I. ' Z O N I N G R E Q U I R E M E N T S S E T B A C K S ------------- MAIN BUILDING ---------- --------- ACCESSORY BUILDING--------- FRNT; FT IN REAR: FT IN FRNT; FT IN REAR: FT IN LEFT; FT IN RGHT: FT IN LEFT; FT IN RGHT: FT IN PARKING RES: PROV: PARCEL; 00000000 ZNE; C1 -S REF NO: PLANNING NOTES> TENANT IMPROVEMENTS FOR A 2,300 SQ,FT, RETAIL STORE (LOUIS > VUITTON). D E V E L O P M E N T S E R V I C E S R E Q U I R E M E N T S ZONING APPROVED BY _ DATE; C1T�. BUILDING APPROVED BY DATE; APPLICATION ISSUED BY:DATE; OZ 14! * 1 �E �F iE !F i4 � i(�t � if iE if it iE iF * iE'lE iE � iE iE � #t• * 1F !(* jE � if if �t if � 1t jt iE it iE 9E iF it i(• iE iE 3E i4 iE * �E 1E � * }F �t iF �(- iE iE ie• iF jF #F � iE iE iE it- iE iE i(• iE iE +e � LEGALIZATION;N F E E S U M M A R Y STRUCTURAL SEGMENT:Y BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT 369,00 EQU-ALT COMM, SPRINKLLR SYS -ALTER 2379 EQU-ALT COMM. AIR GOND -ALTER SMIP/NON-RES ALTER BY VALUE PLAN 59.96 NOZONE 8.92 END OF FEES ISSUE FEE BUILDING -DIV-> PERMIT ISSUE PLAN -CHECK TOTAL PAID DUE TOTALS ---- > 377,92 0.00 59.96 437.88 437,88 ,00 REVENUE DIVISION TOTALS —> COLLECTED; 377,92; OVER/SHORT: ,00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN -CHECK 369.00 8,92 i! iE i@ � � iE � iF � � iE * 9f � iE it if• iE'� iE iE �E iE iF iE � iE * * jt iE it iE it iN'rF !F � * it iF iE fit• iE iE iF iF iE iE ii iF jE 1E iE * iE � aE � it 9(-'lt iE �E iE iE iF � it � 3t 9t 9E * � * it �E iF I N D I V I D U A L F E E B R E A K D O W N TYPE Date: Owner. SFC I do hereby certify that I am aware of and understand the requirements of CaMornia,Heallh and Safety Code Sections 25505, 25533, and SFC 25534 and that I or any future building occupant willlwill not (circle one) need to comply with said state codes and the requirements for a SFC permit for construction or moditicalion from the Air Duality Management District. Residential construction applications are exempt tram SFC these provisions. Date: Applicant: I hereby certify that I have read this application and state that the above infor do 's co ct. i agree to comply with all city and county n nd state laws relalmg to building construction and hereby aulhori e s of this city to enter upon the above-mentioned property for p :[ion purpo s. zd_ elolle' rivers Lic use or Soli- sit l 4: ;\ 1841-46 White-9uilomg: Green—Code Enforcement: Canary—Applicant: Pink—Revenue: Goldenrod—Assessor QTY D E S C R I P T I O N 2379 STO-INT, ALTER TYPE I II F,R, -AVER 2379 EQU-ALT COMM, SPRINKLLR SYS -ALTER 2379 EQU-ALT COMM. AIR GOND -ALTER 8000 ALTER BY VALUE COMMERCIAL NOZONE END OF FEES UNIT COST TOTAL COST 13.48 32,068.92 .33 785,07 ,69 1,641,51 1.00 8,000,00' / V Di 90166834-00166835 T��T 377.92 DATE: 08/29/94 TIME: 14:13 CONSTRUCTION AND PLANNING • APPROVALS Permit # r Date Inspector POOL &SPA APPROVALS Permit # _ Date ' Inspector 1. Temporary Electrical Servicg•o`r Pole ,.� 52. Pool &Equipment Location 2. Soil Pipe-Undrgrnd. �'-' - 53. Steel Reinforcement 3, Electrical Conduit utility-Undrgrnd. _ 54. Forms 4. Electrical Conduit•Undrgrnd. 55. Electrical Bonding •r' . 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6. Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE 7. Footings 58. Electrical Conduit•Undrgrnd. 8. Foundation f 59, Gas Pipe, ❑ Undrgrnd., Test f 9. Water Pipe-Undrgrnd. 60. Backwash trines, P•Trap, © Undrgrnd• , 10. Structural Floor System , '. : i,;=�d 61. APPROVAL TO DECK 11. Property Sewer Line & R�usetbnnection d 62. Backwash & Receptor-Final >r. 12. Sewer Cap ( 63. Heater & Vent-Final 13. Roof Drains 64. Plumbing System - Final 14. Rough Plumbing 65. Electrical-Final 1 15. Rough Electrical-Conduit , 66. Solar System-Final 16, Rough Electric-Wiring 67. Fencing & Access Approval 17. Rough Wiring Sign 66. APPROVED FOR PLASTERING 1B.. Rough Electrical-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit # 20, Rough Factory Fireplace 21. Ducts, in Structure 70. Underground Hydro 22. Ducts, Ventilating 71. Product Piping 0 Gas © Oil 23. Gas Pipe-Rough & Test , 72. Underground Flush 24• Roof Framing 73.. Undergrnd. Storage Tank © Gas © Oil 25. Roof Sheathing 74. Overhead Hydro 26._ T-Bar Ceiling (Structural) &,Monocoat 27. Frame and Flashing 28, Lathing & Siding f • 75. Dry Chemical 76. Dry Standpipe 77.' FIXED SYSTEM FINAL 29. Insulation 78.* FIRE PREY. FINAL 30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat 79.' FINAL INSPECTION 32, Electrical Power Meter•Final �� .80. FOOD CERT1FI'CATE ISSUED 33. Final Electric " ' Notes: 34. Final Heating & Air Conditioning} - - ,i �? 35. Final Gas Pipe-Test 36. Hood or Canopy ; 37• Fin4l Factory Fireplace l 38. Final Plumbing 39. Water Service-Final 40. Gas Service-Final 41. Solar Domestic-Final } 42, -Backflow Preventer { 43. Backflow Irrigation 44. Landscape irrigation System 45. Sound Attenuation 46. Handicap Regulations 47. FINAL STRUCTURE & BUILDING 46. FINAL PLANNING 49. Electric Release to E6son 50. Gas Release to Southern California Gas Co F. 51. CERTIFICATE OF OCCUPANCY No, Date - _ ,_ PROJECT -ADDRESS- 3333 B R I S TOL S T UNIT: 2508 OWNER'S NAME: C J SEGERSTROM ADDRESS* 3 315 FAIRVIEW RD C.M _ CA 92626 ARCH(ENGINEER: REG.NO.: ADDRESS: BRAND + ALLEN ARCH C2 0 900 NORTHPOINT ST 400 PERMITTEE: S . F , CA 94109 ADDRESS: LEISURE AIRE HEATING & AI (714)630-9485 3160 LA PALMA AVE A ANAHEIM CA 92806 LICENSED CONTRACTOR DECLARATION: I hereby atfirm that I am licensed under provisions of Chapter 9 (commencing with Section 700D) of Division 3 of the Business and Professions Code. and my license is in full force and effect. c �J3613{A1 STATE LIC.: 424 92 C 20 EXP; 07/95 rate:-- W09— NER$' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to sell -insure or a certificate of Workers' Compensation Insurance. or a certified copy thereof (Section 3800, Lab. C). POLICY ND.: P C 9 9 6 9 9 6 EXP. DATE: 01 / 01 / 9 5 COMPANY: REPUBLIC Ir:N�DEM ❑ Certified copy is hereby furnished. u q Certifiedopy file with the city Building Division. Date: Q Applicant: J EMPTION FROM WORKERS' COMPENSATION DECLARATION: (This section need not be completed if the permit is for one hundred (S1DO) or less). I certify that in the performance of the work for which this permit is issued. I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California. Date:.._ _ Signature: NOTICE: If, after making this declaration. you Should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Section 3097, Civ. C), LENDER: ADDRESS: OWNER BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractors' State License Law for the following reason (Section 7031.5 Business and Professional Code: Any city of county which requires a permit to construe;, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he/she is licensed pursuant to the provisions of the Conuactor8' State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he/she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (5500►. 1. as owner of the property or MY empployees with wages as their sole compensation, will do the work, and the El structure is not intended or offered for sale (Section 7044, Business and Professional Code: The Contractors' State License Law does not apply to an owner of a property who builds or improves thereon• and who does such work himselflherself or through his or her own employees. provided that such improvements are not intended or offered for sale. If, however the building or improvement is sold within one year Of completion, the owner will have the burden of proving he/she did not build or improve for the purpose of sale). 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Section 7044, Business Eland Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or Improves thereon and who contracts for such projects with a contractor{s) license pursuant to the Contractors' State License Law). I am aware that proof of Iheir Worker's Compensation insurance should be provided to me. ❑ I am exempt under Section: B. S P. C. for this reason: Date: Owner: I do hereby certify that 1 am aware of and understand the requirements of California Health and Safety Code Sections 25505, 25533, and 25534 and that I or any future building occupant will/will not (circle one) need to comply with said state codes and the requirements for a permit for construction or modification from the Air Ouality Management District. Residential construction applications are exempt from these provisions. Date: Applicant: I hereby certify that I have read this application and a above information is Cor t. I agree ;o compty with all city and county ordinan s and state laws relating to building Cons tr coon and here authorize represent es this city td enter upon the above- tioned pr rly r inspection ppuiposes. pate: `I Signature: 's license or Social Security 1641.46 While—Building: Green—Coda Enforcement: Canary—Applicant; Pink—Revenue; Goldenrod—Assessor CITY OF COSTA MESA — BUILDING PERMIT PERMIT NO: M 069040 PLAN CHECK NO; N CONSTRUCTION TYPE: I FR PERMIT TYPE; MEC JOB DESCRIPTION ; 2379SF 2ND FL & MEZZANINE STORE T.I. CLAIM VALUE; CALC—VALUE: PERM NO: M 069040 GOVT: N SUPP: N PURPOSE: ALT SQ FT; GROUP OCC; B-2 / COMMENTS: REF: 8--68665 Z O N I N G S S£ T H A C K R E Q U I P. E M E N T S ------------ MAIN BUILDING ----------- ---------- ACCESSORY BUILDING--------- FRNT; FT IN REAR; FT IN FRNT: FT IN REAR; FT IN LEFT; FT IN RGHT; FT IN LEFT: FT IN RGHT; FT IN PARKING REQ; PROV; PARCEL: 00000000 ZNE: REF NO; PLANNING NOTES> iF#i(-•1F###3EiEiliFiE�t*!E#iFiF 9tiFiF�#ia###itiFiFiEit•#iFiE##iEiF*##iF*#iEiE#iF#iE#iE*#ie it it•#it�##3F#iF##iF��aF�tE#9EiEiF#iE D E V E L O P M E N T S E R V I C E S R E Q U I R E M E N T S ZONING APPROVED BY DATE; UILDING APPROVED BY ; DATE; `APPLICATION ISSUED BY: DATE; iM,'-�� iE # iE iE 1F # iE'1(• iH it # dF iF # iF 9k'}E 3E iE iE * * iE # ie iF 1F iE iE # iF it it it 9h # * # � iF �E * �E iE iF 3F # iF # i6 iE * it # # iF # 3E iE'lE iE i(- iE # # # # � # , * ir• it• iF �E # i(• LEGALIZATION;N F E E S -U M_M,A R Y STRUCTURAL SEGMENT;N BLDG PMT PLUMBING ELECTRIC- MECHANIC FIRE SMTP/RES GRADING PERMIT 22 50 PLAN ISSUE FEE BUILDING—DIV—> TOTALS ---- > 25% SMIP /NON --RES 15.00 PERMIT ISSUE PLAN—CHECK - TOTAL PAID DUE 22,50 15.00 0,00 37,50 37,50 ,00 REVENUE DIVISION TOTALS--> COLLECTED';, 37,50 VER/SHORT; 00 BLDG PMT PLUMBING ELECTRIC MECHANIC !'—FIRE FIRE SMIP/TOT GRADING PLAN --CHECK 37,50 # # iE # !P #'1F'1F'1F ')(# # # # # 1}I. # # iE ii• �E iF iE'ir '� jE # if iF iE'1E'rE # # ![# # �E if �F �F �E �F iE iF'lE iE it iE if iE iF iE i(- iE # # �F # # # # iF it• # # i(• -# # � # iF #'iE# # it• i(aE I N D I V I D U A L F' £ E /,D R E A K D O W N TYPE QTY D E S C R I P T I O N, UNIT COST TOTAL COST MEC 1 REPAIR/ALT COOLING UNIT/SYS W/CNTLS 9.00 9,00 MEC 1 REPAIR/ALT HEATING UNIT/SYS W/CNTLS 9.00 9.00 MEC 1 VENTILATION FAN CONN-TO'SINGLE DUCT 4.50 4,50 END OF FEES 01 00168622-00163622 TOT 37.5E DATE: 09/29/74 TME: 11:41 CONSTRUCTION AND PLANNING APPROVALS Permit # Date Inspector POOL & SPA APPROVALS Permit # Date Inspector 1, Temporary Electrical Service or Pole 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement 3. Electrical Conduit Utility-Uridrgrnd. 54. Forms 4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding 5. Stee! Reinforcement 56. Rough Plumbing & Pressure Test 6- Electrical LIFER Grnd. 57. APPROVAL TO COVER-GUNITE 7, Footings 58. Electrical Conduit-Undrgrnd. 8. Foundation r 59. Gas Pipe, C3 Undrgrnd„ Test 9. Water Pipe-Undrgrnd, 60. Backwash Lines, P -Trap, ❑ Undrgmd. 10.4otructural Floor System 61. APPROVAL TO DECK 11 y Property Sewer Line & House Connection 62. Backwash & Receptor -Final 12, Sewer Cap 63. Heater & Vent -Final 13. Roof Drains 64. Plumbing System • Final 14. Rough Plumbing 65. Electrical -Final 15. Rough Electrical -Conduit 66. Solar System -Final 16. Rough Electric Wiring 67. Fencing & Access Approval 17, Rough Wiring Sign 68. APPROVED FOR PLASTERING 18, Rough Electrical -T Bar Ceiling 69, POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit # 20, Rough Factory Fireplace _ 21, Ducts, in Structure 70, Underground Hydro 22. Ducts, Ventilating 71. Product Piping ❑ Gas J Oii 23. Gas Pipe -Rough & Test 72. Underground Flush 24. Roof Framing 73, Undergrnd. Storage Tank O Gas 0 Oil 25, Hoot' Sheathing 74. Overhead Hydro 26. T -Sar Ceiling (Structural) & Monocoat 75. Dry Chemica€ 27. Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding 77. FIXED SYSTEM FINAL 29. Insulation 78, FIRE PREV. FINAL 30, Drywall Nailing HEALTH DEPT. REQUIREMENT 31, Plaster Brown Coat 79. FINAL INSPECTION 32. Electrical Power Meter -Final 80. FOOD CERTIFICATE ISSUED 33. Final Electric Notes: 34, Final Heating &Air Conditioning 35. Final Gas Pipe -Test cM- 36. Hood or Canopy 37. Final Factory Fireplace 38. Final Plumbing la --1 q 39. Water Service -Final 40. Gas Service -Final ; 41. Solar Domestic -Final 42. Backflow Preventer 43. Backflow Irrigation 44. Landscape Irrigation System 45. Sound Attenuation i 46, Handicap Regulations 47. FINAL STRUCTURE & BUILDING I 48, FINAL PLANNING 49, Electric Release to Edison 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY No. Date ' PRO.(ECT'ADDRESS: OWNER'$NAME: 3333 BRISTOL ST ADDRESS: C.J. SEGERSTROM & SONS 3315 FAIRVIEW RD C.M „ CA 92626 UNIT: 2508 ARCHIENGINEER; ( 714 ) 5 4 6— 0 1 1 0 REG.NO.: ADDRESS: $RAND -I- ALLEN ARCH C2WiT:90 900 NORTHPOINT ST 400 PERMITTEE: S. F. CA 94109 ADDRESS: ALERT FIRE PROTECTION INC (714)993-2822 4740 BRYSON ST 1.r ria a7rn7 LICENSED CONTRACT DECcRAn3r�r"M I hereby affirm that I am licensed under provisiods of hepter 9 (commencing with Section 7000) of OMsion 3 of the Business and Professions Code, and my license is in full force and effect. CITY LIC.: STATE LIC.: C u: Date:-/ 00_2$ 316324 C `16 EXPP03/95 0 ��_ Signature: WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to set sure or a certificate of Workers' Compensation Insurance. or a certified copy thereof (Section 3800, Lab. Q. POLICY NO.: NWC — 2 4 6 5 5 2— 0 1 EXP. OATS: 10/01/95 COMPANY: GOT�D pN AC F ❑ Certified copy is`hereby furnis�ed. Z,? Certified copy is filed with the city Building Division. J� n a Date: " "'!_ Applicant: ,'�" 1/ EXEMPTION FROM WORKERS' COMPENSATION DECLARATION: (This secton need not be completed if the permit is for one hundred (5100) or less►. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California. Date: Signature: NOTICE: It, after making this declaration, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Section 3097. Civ. C), LENDER: ADDRESS: OWNER BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractors' State License Law for the following reason (Section 7031.5 Business and Professional Code: Any city of county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance. also requires the applicant for such permit to file a signed statement that he/she is licensed pursuant to the provisions of the Contractors' State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Prolessions Code) or that he/she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500►. 1, as owner of the property or my employees with wages as their sole compensation, will do the work, and the ❑ structure is not intended or offered for sale (Section 7044, Business and Professional Code: The Contractors' State License Law does not apply to an owner of a property who builds or improves thereon, and who does such work himself/herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however the building or improvement is sold within one year of completion, the owner will have the burden of proving he/she did not build or improve for the purpose of sale). I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Section 7044, Business F-1andProfessions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon and who contracts for such projects with a contractors) license pursuant to the Contractors- State License Law). I am aware that proof of their Worker's Compensation insurance should be provided to me. ❑ I am exempt under Section; B. & P. C. for this reason: Date: owner: I do hereby certify that I am aware of and understand the requirements of California Health and Safety Code Sections 25505, 25533, and 25534 and that 1 or any future building occupant will/will not (circle one) need to comply with said state codes and the requirements for a permit for construction or modification Item the Air Ouality Management District. Residential construction applications are exempt from these provisions. Datu: Applicant' I hereby certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. Date: /`r �j r Signature, W Driver's License or Social Security k: 164146 While— Building: Green—Code Enforcement: Canary—Applicant: Pink—Revenue; Goldenrod—Assessor CITY OF COSTA MESA – BUILDING PERMIT PERMIT NO: F 069142 PLAN CHECK NO: 03630-94 L CONSTRUCTION TYPE; IFR SP PERMIT TYPE; FIR JOB DESCRIPTION ; FIRE SPRINKLER SYSTEM FOR TENANT IMP, CLAIM VALUE; 2,000.00 CALC--VALUE; DORM Atf1- r 11�U9d". GOVT; N SUPP; N PURPOSE; OTH SQ FT: GROUP OCC; B-2 / COMMENTS: "LOUIS VUITTON" STORE T.I. / RE; B68665 #iF#i[-iFiEiE##iEiFis;E#####TETE###iE�Fit•#iric#iFlF##iFiEiE-iE###TETE#FiF###*it•#iF##3F'k#ia#3riF#3EiE•###1EiF3EiEir•?riF#iE#�iC Z O N I N G S E T B A C K S R E Q U I R E M E N T S ---------------- MAIN BUILDING ---------- ---------- ACCESSORY BUILDING--------- FRNT; FT IN REAR; FT IN FRNT; FT IN REAR; FT IN LEFT: FT IN RGHT; FT IN LEFT: FT IN RGHT; FT IN PARKING REQ; PROV: PARCEL; 41250102 7NE; REF NO: PLANNING MOTES> D E V E L O P M E N T S E R V I C E S R E Q U I R E M E N T S ZONING APPROVED BY , DATE; BUILDING APPROVED BY : 1i DATE; APPLICATION ISSUED BY: 4^t L— DATE-/L/L��� yt�SFyE lE �E # # i(• # # # iE 3E �F iE iF # iE iF aE iE WJE �E �E gF iE- # iE iE iE it- iE iE iE 9E'lf- iE # if iE 3F # yE iF iE i(� aF it- iE iE'rE # # iE 3E 9F �it3F # # # iE !F 1E # }F �E # # iF 3'r 7E iF iF'lE iE aE # fF �C'iE # # LEGALIZATION:N F E E S U M M A R Y STRUCTURAL SEGMENT:N BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMTP/RES GRADING PERMIT 45,00 65% SHIP/NON–RES PLAN 29,25 ISSUE FEE BUILDING–DIV–> PERMIT ISSUE PLAN–CHECK TOTAL PAID DUE TOTALS ---- > 45,00 0,00 29,25 74,25/ 74,,25 ,00 REVENUE DIVISION TOTALS--> COLLECTED: 45,00`/OVER/SHORT: ,00 BLDG AMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN–CHECK 45.00 I N D I V I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST FIR 45 FIRE EQUIP FEE (FROM BLDG VAL TABLE) 1,00 END OF FEES 01 00169037-00169837 T O T GATE; :0/06/94 TIME; 15133 45,00 [i,/ 415r 90 CONSTRUCTION AND PLANNING ' APPROVALS Permit # Data Inspector POOL & SPA APPROVALS Permit ' Date Inspector 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd, 53. Steel Reinforcement 3. Electrical Conduit Uti€ity-Undrgrnd. 54. Forms 4. Electrical Conduit-Undrgrnd, 55. Electrical Bonding 5, Steel Reinforcement 56. Rough Plumbing & Pressure Test ' 6. Electrical LIFER Grnd. 57. APPROVAL TO COVER-GUNITE f 7. Footings 58. Electrical Conduit-Undrgrnd, 8. Foundation 59. Gas Pipe, 0 Undrgrnd., Test 9. Water Pipe-Undrgrnd, 64. Backwash Lines, P-Trap, El Undrgrnd, 10, Structural Moor System 61, APPROVAL TO DECK 11. Property Sewer Line & House Connection 62. Backwash & Receptor-Final 12. Sewer Cap 63. Heater & Vent-Final 13. Roof Drains 64, Plumbing System - Final 14. Rough Plumbing 65. Eiectrical-Final 15. hough Electrical-Conduit 66. Solar System-Final 16- Rough Electric Wiring 67. Fencing & Access Approval l 17. Rough Wiring Sign 68. APPROVED FOR PLASTERING 18, Rough Electrical-T Bar Ceiling 69. POOLlSPA SYSTEMS FINAL 19. Rough Keating & Air Conditioning FIRE DEPT. REOUIREMENT APPROVALS Permit 20. Rough Factory Fireplace 21. Ducts, in Structure 70. Underground Hydro 22. Ducts, Ventilating 71. Product Piping G Gas 0 OiI 23, Gas Wipe-Rough & Test 72. Underground Flush 24. Roof Framing 73. Undergrnd, Storage Tank D Gas 0 Oil 25. Roof Sheathing 74. Overhead 26. T-Bar Ceiling (Structural) & Monocoat 75, Dry Chemical i 27. Frame and Flashing 76. Dry Standpipe 28, Lathing & Siding 77. FIXED SYSTEM FILIAL 29. Insulation 78. FIRE PREV. FINAL 30, Drywall Nailing HEALTH DEPT, REQUIREMENT 31. Plaster Brown Coat 79. FINAL INSPECTION 32. Electrical Posner Meter-Final 80. FOOD CERTIFICATE 15SUED 33. Final Electric Notes: 34. Final Heating & Air Conditioning 35. Final Gas Pipe-Test 36. Hood or Canopy 37, Final Factory Fireplace 38, Final Plumbing 39. Water Service-Final 40. Gas Service-Final 41. Solar Domestic-Final , i 42. Backflow Pfeventer 43, Backflow Irrigation 44. Landscape Irrigation System 45, Sound Attenuation 46. Handicap Reguiations I 47. FINAL STRUCTURE & BUILDING 48. FINAL PLANNING 49. Electric Release to Edison 50. Gas Release to Southern California Gas Ca 51. CERTIFICATE OF OCCUPANCY No. Date PRNECAADDRESS: 3333 BRISTOL ST UNIT: 2508 .OWNER'S NAME: C J SEGERSTROM ADDRESS: 3315 FAIRVIEW RD C.M., CA 92626 ARCHIENGINEER: BRAND + ALLEN ARCH REG.NO.: 0 2 0 2 9 0 ADDRESS: 900 NORTHPOINT ST UNIT: 400 S,F, CA 94109 PERMITTEE: TARGET ELECTRIC (310)926-8658 ADDRESS: 15401 SHOEMAKER AVENUE 200 NORWALK CA 90650 LICENSED CONTRACTOR DECLARATION: Ihereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 70001 of Division 3 of the Business and Prill eSSLons Code. and my license is in lull force and effect. CITY LIC: STATE LIC.: 615 6 Ci CLASS: �Cr�1-0 EXP: Date: 9 e 9 Signatur" �� r`' "WORXERS' COMPEN ATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure or a certificate of Workers' Compensation qwali 011c4rtll on thereof (Section 3800. Lab. a.8 /31/95 POLICY ND.: CENTRAL CITY EXP. DATE: COMPANY: V r0 Certified copy is hereby furnished. C] Certified cop is filed with the city Building Division. Date:X29Applicam:;� ' EXEMPTION FROM DRXERS' COMPENSATION DECLARATIOW (Tis section need not be completed if the permit is for one hundred (5100) or less), I certify [hat in the performance of the work far which this permit is issued. I shall not employ any person in any manner so as to become Subject to the Workers' Compensation Laws of California. Date: Signature: NOTICE: II, after making this declaration. you should become subject to the Workers' Compensation provisions of the Labor Code. you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Section 3097. Civ, Q. LENDER: ADDRESS: OWNER BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractors' State License Law for the following reason (Section 7031.5 Business and Professional Code: Any city o1 county which requires a permit to construct, alter, improve, demolish, or repair any structure. prior to its issuance, also requires the applicant lot such permit to file a signed statement that he/she is licensed pursuant to the provisions of the Contractors' State License Law (Chapter 9 {commencing with Section 7000) of Division 3 of the Business and Professions Code) or that hPlshe is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (5500). i, as owner of the property or my employees with wages as their sole compensation, will do the work, and the © structure is not intended or offered for sale (Section 7044, Business and Professional Code: The Contractors' State License Law does not appy on to an owner at a property who builds or improves there. and who does such work himself/herself or through his or her own employees. provided that such improvements are not intended or offered for sale. 11, however the building or improvement is sold within one year of completion. the miner All have the burden of proving he/she did not build or improve ter the purpose of sale). I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Section 7044, Business © and Professions Code: The Contractors' State License Law does not appy to an owner of property who builds or improves thereon and who contracts for such pro{ect9 with a contractor(s) license pursuant to the Contractors' State License Law). I am aware that proof of their Worker's Compensation insurance should be provided to me. 0 1 am exempt under Section: B. S P. C. for this reason: Date: Owner I do hereby certify that I am aware of and understand the requirements of California Heatlh and Safety Code Sections 25505, 25533, and 25534 and that I or any future building occupant will/will not (circle one) need to campy with said state codes and the requirements for a permit for construction or modification from the Air Duality Management District. Residential Construction applications are exempt from these provisions. Dale: Applicant: I hereby Certily that I have read this application and state that the above information is correct. I agree to comply with ail City and county ordinances and state laws relating to building construction an hereby authorize representatives of this city to enter upon the above-mentioned Property I rispeclion urposes. are: Driver's icense a Social Security p; 1641-46 While—Building; Green—Code Enforcement: Canary—Applicant; Pink—Revenue; Goldenrod—Assessor CITY OF COSTA MESA -- BUILDING PERMIT PERMIT NO: E 069051 PLAN CHECK NO; N CONSTRUCTION TYPE: I FR PERMIT TYPE; ELE JOB DESCRIPTION : 2379SF 2ND FL & MEZZANINE STORE T,I, CLAIM VALUE; CALC—VALUE; PERM NO; E 069051 GOVT; N SUPP; N PURPOSE; ALT SQ FT: GROUP OCC; B-2 / COMMENTS: "LOUIS VUITTON" STORE T.T. REF;B68665 Z O N I N G R E Q U I R E M E N T S S E T B A C K S ------------ MAIN BUILDING ---------- --------- ACCESSORY BUILDING---------- FRNT: FT IN REAR; FT IN FRNT: FT IN REAR; FT IN LEFT; FT IN RGHT; FT IN LEFT; FT IN RGHT: FT IN PARKING RE • PROV: PARCEL; 00000000 ZNE: REF NO; PLANNING N TES> > iFit######iEiC'##iE#iF#iE9EjEieiE##iF�3FiEiiieiEjr•#iE�9EiE#�E#�t-3EiF�iF##iEiFiE�it#iE�ieiF#iE*9tiF#####�#it itiaic#EiElE9tjt� D E V E L O P M E N T S ESR V I C E S R E Q U I R E M E N T S ZONING APPROVED rf BY DATE; BUILDING APPROVED BY DATE: APPLICATION ISSUED BY; DATE; iF 9E # if iE !f iE � # #'Jf i6 iF'14'Jf if # T'F in it # � # it in ' . iF it it if ir• #'Jf # # iF # # # # !F if # iE it # * 3t 1f � iE i4 # iF � # ik !P # 1E iE tt iE +E ie # iF ft 'rt # 1F ia'}F # # iE iP iE * iE # #F it•'lt iE # iF !E # # �E 9E # # #'1tF # iF at #'1r• iF is iE � �E �E * iE #'f it sr # !F iE iE ik # if iE iF it �E � # i4'lf ie # LEGALIZATION:N F E E S U M M A R Y STRUCTURAL SEGMENT;N BLDG PMT PLUiB NG ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT 129,35 50% SMIP/NON—RES ALAN ISSUE FEE 15,00 BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE TOTALS----> 129,35 15.00 0,00 144.35 144,35 ,00 REVENUE DIVISION TOTALS--> COLLECTED; 144,35 OVER/SHORT: ,00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK 144.35 Ir- iP ir� iF 1F # iIiE if- 9E 9F it iF jF �E it• iE # # iF # iE• # # aE• iE if # # 9F # # # iE # ff i41F # iF iF YF iw # iF 9(' iE # # iE # jF iE * 9t # if i(• ir. iF �E �E of �E ik # # # # # iE'!t• # iE iF # # #f• I N D I V I D U A U F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST ELE 20 FIXTURES, LIGHTING 1 ST 20 EA, ,75 15,00 ELE 133 FIXTURES, LIGHTING ADDITIONAL EA. ,45 59.85 ELE 8 RECEPT/OUTLET 1 ST 20 EA, ,75 6,00 ELE 2 RECEPT/SWITCH 1 ST 20 EA, ,75 1,50 ELE 1 SUB—PANEL 11,00 11.00 ELE 2 MOTOR/POWR APPARATUS 0.0 — 1,0 HP 3.00 6,00 ELE 2 SIGN/ OUTLINE LIGHT SYS ON 1 BR CIRC 15,00 30,00 END OF FEES 01 00168650-00168450 TOT 144.35 DATE; 09/29/94 T1hE; 14:12 CONSTRtJCTION AND PLANI1ftNG APPROVALS Permit # Date Inspector POOL & SPA APPROVALS Permit # Date Inspector 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location 2. Soil Pipe�Undrgrnd. 53. Steel Reinforcement 3. Electrica€ Conduit Utility-Undrgrnd. 54, Forms 4. Electrical Conduit-Undrgrnd. 55, Electrical Bonding 5. Steal Reinforcement 56. Rough Plumbing & Pressure Test 6. Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE 7. Footings 58. Electrical Conduit-Undrgrnd. 8. Foundation 59. Gas Pipe, © Undrgrnd., Test 9. Water Pipe-Undrgrnd, 60. Backwash Lines, P•Trap, 13 Undrgrnd. 10. Structural Floor System 61. APPROVAL TO DECK 11. Property Sewer Line & House Connection 62. Backwash & Receptor -Final 12, Sewer Cap 63. Heater & Vent -Final 13. Roof Drains 64. Plumbing System - Final 14. Rough Plumbing 65. Electrical -Final 15. Rough Electrical -Conduit 16. Rough Electric Wiring 17. Rough Wiring Sign �! T�f67. 2(jc 66. Solar System -Final Fencing & Access Approval 68. APPROVED FOR PLASTERING 18, Rough Electrica€•T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT, REQUIREMENT APPROVALS Permit # 20. Rough Factory Fireplace 21. Ducts, in Structure 70. Underground Hydro 22, Ducts, Ventilating 71. Product Piping C Gas O Oil 23, Gas Pipe -Rough & Test 72, Underground Flush 24. Root Framing 73, Undergrnd. Storage Tank © Gas ❑ Oil 25. Roof Sheathing 74. Overhead Hydro 26. T -Bar Ceiling (Structural) & Monocoat 75, Dry Chemical 27. Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding 77, FIXED SYSTEM FINAL 29. Insulation 78. FIRE PREY. FINAL 30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Plaster Brawn Coat 79. FINAL INSPECTION 32. Electrical Power Meter -Final 80. FOOD CERTIFICATE ISSUED 33. Final Electric 34. Final Pleating & Air Conditioning Notes: 35. Final Gas Pipe -Test 36. Hood or Canopy 37. Final Factory Fireplace 38. Final Plumbing 39. Water Service -Final 40, Gas Service -Final 41, Solar Domestic -Final 42. Backflow Preventer 43. Backflow Irrigation 44. Landscape Irrigation System 45, Sound Attenuation 46. Handicap Regulations 47. FINAL STRUCTURE & BUILDING 48. FINAL PLANNING 49. Electric Release to Edison 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY No. Date CI: Y OF COSTA Ml.'/A Development Services, Division of Building and Safety CERTIFICATE OF OCCUPANCY This certificate is issued pursuant to the reiluiremerits of the Uniform Building Code, Section 308 adopted by the City of Costa Mesa certifies that at the time of its issuance the buildingstructur`e herein below described was inspected and approved for occupancy as follows: 3333 Bristol St. , Ste ` 12 1-3 BC07--00190 Building Address Bldg, Permit Number Use Sales/Merchandise (2,500 s.f.) Group Type of Construction MI -FR Fire Zone X X X X X X Use Zone P D C Owner of Building South Coast Plaza Tenant INTERMIX _ Address 3315 Fairview RD., Costa, --Mesa, CA 92626• i _.--- BUILDING OFFICIAL-Khanh Q. Nguyen, C.$.O. By Date 02/nl /OR/ REQUIRED TO BE POSTED IN A CONSPICUOUS PLACE CITY OF COSTA MESA o`" Esq BUILDING DIVISION COPI * 77 FAIR DRIVE, COSTA MESA, CA 92626 - (714) 754-5273 - Fax (714) 754-4856 • www.ci.costa mesa.cams 4 FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BC10-00207 PERMIT TYPE: B_COMBO STATUS: FINALED Sub Type: COM—ALT DATE ISSUED: 06/18/2010 ISSUED BY: KJB JOB ADDRESS:Ca3,33 21213"BRISTO�ST'CM2 Suite/Unit: 1213 APM 41250107 L-"—Zoning:PDC, , Vicinity: SPACE 1213 Primary Occ: Const Type: I-A SQ. FT: 2500 Valuation: $145,000.00 SCOPE OF WORK: 2,500 SF INTERIOR TI FOR "INTERMIX", SPACE 1213. WORK TO INCLUDE NEW PARTITION WALLS, CEILING, FINISHES, INSTALL NEW FIRE WALL AT OLD STOCK ROOM LOCATION, RELOCATE STOCK ROOM, RELOCATE DUCTING, ADD/RELOCATE 38, LIGHT FIXTS, 14 OUTLETS, 5 SWITCHES, 1 SVC MOP SINK: OWNER: SOUTH COAST PLAZA Address: 3315 FAIRVIEW RD Unit: Phone: City/State/Zip: COSTA MESA, CA APPLICANT: CRANDALL, GRANT Address: Unit: Phone: 978-762-8744 City/State/zZip: CONTRACTOR: STEVEN KIRSCH CONSTRUCTION.'' License No. 880649 ?hone: 978-762-8744 Address: 100 CONIFER HILL DRUnit: STE 306 Cell: City/State: DANVERS, MA ZipCode 01923 ARCHITECT: PAUL J BUFFING, AIA License No.C4264 PHONE: 949-660-8062 ENGINEER: License No. PHONE: COMBINATION PERMIT FEE SUMMARY Building Plan Check: $202.44 Building Fees: $1,245.75 Electrical Fees: $79.54 - Mechanical Fees: $37.20 Plumbing Fees: $33.30 SMIP Residential: $0.00 SMIP Commercial: $30.45, Bldg Std Admin Fund $6.00• TOTAL FEES: $1,666.03 'Refer to fee receipts for all fees paid for project HOURS FOR CONSTRUCTION ACTIVITY: EFFECTIVE 3/1812010 - PER CMMC Sec. 13-279 Monday thru Friday - 7:00 am thru 7:00 pm. Saturdays -9:00 am thru 6:00 pm. Prohibited all hours - Sundays and the following Federal holidays: New Years Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day and Christmas Day NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE k. INSPECTION TYK DATE INTMAL5 CODE11 INSPECTION TYPE DATE INTMALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Fina$ Re -Roof 210 Final Electrical 201 Fina{ 6locktRetaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final 80ding/Occupancy A WORKERS' COMPENSAt}Tlait LARATION: I hereby affirm under penaljo�f-Oerjaty.oiite of the following declarations: ❑ I have and will maintain a certificate of consent to self -insure for workers' compensation, as providoed for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: (This Section need not be completed rf the permd fs valued atone hundred dollars {3700) or less.) Policy Number: ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisions. Applicant's Signature Date WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL_ FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic. # Class # Contractor's Signature Date CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Dale OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason {Sec- 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature 3057-46 (31D7) Dale Owner ID verified by driver b license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Date Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? []Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No S. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Goverment Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if "yes". the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If 'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature of Legal Owner(s) Andlor Authorized Applicant Dale Date CITYIOF COSTA MESA o BUILDING DIVISION } 77 FAIR DRIVE, COSTA MESA, CA 92626 - (714) 754-5273 - Fax (714) 754-4856 • www.ci.costa-mesa.ca.us FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: SB07-00112 PERMIT TYPE B_SIGN \STATUS: -ISSUED DATE' ISSU ED: 11/09/2007 ISSUED BY: SOK JOB ADDRESS: 3333 1213 BRISTOL ST CM �' 1213 Vicinity: iSuitelUni#r '[ / SO. FT: 0 'Valuation: $2,20 SCOPE OF WORK: INSTALL-7-S.F. ILLUMINATED, CHANNEL LETTER SIGN FOR "INTERMIX" N.E fl OWNER: SOUTH COAST PLAZA Address: Unit:COSTA MESA CA PHONE: City/State/Zip: 3315 FAIRVIEW ROAD APPLICANT: RICK TILTON Address: 11661 SEABOARD Cl Unit: PHONE: 714-891-5682 'City/StatelzZip: STANTON, CA CONTRACTOR: 6%eAe BLWV,.E S' k License No. .12345 Address: Unit: PHONE: City/State: ZipCode: _ CELL: - ARCHITECT: License'No. PHONE:,, + ENGINEER: License No. PHONE: SIGN PERMIT FEE SUMMARY PLAN CHECK FEE: $54.11 HOURLY PC FEE: $0.00 PERMIT FEE: $83.25 ELECTRICAL FEE: $48.10 SMIP FEE: $0.50. OTHER: $0.00 INSPECTION: $0.00 TOTAL FEE: $137.86 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION, INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE 0, INSPECTION TYPE DATE INTMALS CODER IH PE TIQW TYP DATE INTMAL5 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Root 210 Final Electrical! 201 Final Block/Retaining Wall 212 Final Fire Prevention r 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign, 222 Final Site ti '204. - .Final Demolition 250 Final Building/Occupancy WORKERS' COMPENSATION DECLARATIC. I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code. for the performance of the work for which this permit is issued. 55;have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy Less J Owne?ID verifieV by d. s Ik. 4_ ❑ Yes [] No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized permit, and that no building structure, scaffolding, falsework, or demolition �Aigehantling thereof, will be more than thirty-six (36) feel high. (Chap. 3.2, Grp 2 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would ❑ I certify that in the performance o he work for which &s permit is require a permit from the Division of Industrial Safety, as noted above, unless issued, I shall not employ any person in any manner so as to become subject such person has a permit to do such work from the division. to the workers' compensation laws of California, and agree that if i should become subject to the workers' compensation provisions of Section 3700 of Applicant's Signature Date the Labor fAWe. I feAhwiitr comply with these prov'slon &I Ston of Industrial Safety Permit Number: RDOUS MATERIALS AND EMISSIONS CERTIFICATION: WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE 1. Will the applicant or present or future building occupant need to file and IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL certify a Business Plan for emergency response to release or threatened PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS release of a hazardous material? ❑ Yes ❑ No ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my li ase-islin,futl force and effect. _ r CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property. or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature 3057-46 (3/07) Dale (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will theapplicantor present or future -building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Ouality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be fumished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (1f 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If 'yes-, attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this applicalion and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. egal Owner ] An r'Auttlartzed App_Rc nt Io CITY OF COSTA MESA BUILDING DIVISION 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 - Fax (714) 754-4856 • www.ci.costa-mesa. s �. FOR INSPECTIONS CALL: (714) 754-5626 VF07-00272 FIRE SUPRESSION PERMIT Job Address: 3333 BRISTOL ST 208 Status: ISSUED Suite: 1213 210 Final Electrical Applied: 09/118t2007 Final Block/Retaining Wall ! Final Fire Prevention 202 Final Factory Fire Place Vicinity: SUITE 1213 INTERMIX'.F Z =` - , 203 `_, Issued: 09/28/2007 Parcel Nunmber: 41250107 /4', , �} '= ---.; Zoning PDG' -PDC Final Building/Occupancy Applicant: SHEILA,L'OONEY Address: 5200 E HUNTER AV SUITE.Bs •'C" err Phone: ;a;:, �•-:'F ANAHEIM, CAJ 4'' Zip: .J14-993-2822 92807 Owner: SOUTH COAS7rPLAZA _ s _ :; =;• : ,.;i ' _' Address,1rI. ? COSTA MESA CA t Phone: , p: - 3315 FAIRVIEW ROAD r Zi92626_,;_, - `.iV 1. t. • i'tq / _ Contractor: ALERT FIRE PROTECTION INC —" Address: 5200 E HUNTER�AV SUITE B --Phone: 714=993-2822,-__ ANAHEIM, CA Zip: 92807 4' License: 316324 . ; SCOPE OF PERMIT _ - . ADD 8 OVERHEAD SPRINKLERS AND RELOCATE 29 IN SPACE 1213 FOR INTERMIX", REF.: BC07-00190 e .'.;;, >>•�t. `FEE'SUMMARY :r Plan Check: $90.51 ' r. } �'�: t, , ;Calc Valuation: $6,500.00 Permit: $139.25'- Claimed Valuation: $6,500.00 Other: $0.00 - � t - ., Total: $229.76 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE I• INSPECTION TYPE DATE INTITIALS CODE / INSPECnON TYPE 0_AT� INn IALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical — 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: - - ❑ 1 have and will maintain a certificate of consent to self4sure for workers' compensation, as- provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued.. , . - XI have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. M�yrfampenation Insurance carrier and policy number are: /v/�• "� Carrier: G' (This section n€ed not be completed if the permil is valubd atone hundred dollars ($100) or less.) Policy Number. 15- WA, 06, ❑ I certify that in the performance of the work for which this permit is issued. I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subjeql to the wc)fkers' compensation provisions of Section 3700 of the Labor Cof, , shall forthwith co ply with these provisions. Applicant's Signature 0 Date WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic. # 31&3 l Class # `P Z/ - Contractor's Signature We CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Hale OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. It, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ .I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and' Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature Date 3057-46 (3107) Omer ID verified by driver's .1. ❑ Yes ❑ No Driver's License No. Expires: Verification 'of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth'. into' which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Division of Industrial Safety Permit Number: Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to fife and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure), 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If 'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under -penalty of perjury the information given above is correct. Fagree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions - Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. AiGgAture of Le I Owners Date -Z -o And/or Authorized Applicant Date ��nl-�.Y:�>i''.r.�.'.-._„e'er .— �.�,e _ ,,,���.�,;,:`^c�•fs�-'11•'tf,+,�..�- � r...F. .r�,..a-..,r..- .,rt.,i� ,.._. CT Y OF COSTA MF -.A Development Services, Division of Building and Safety CERTIFICATE OF OCCUPANCY This certificate is issued pursuant to the requirements of the Uniform Building Code, Section 308 adopted by the City of Costa Mesa certifies thatat the time of its issuance the building structure hereinbelow described was inspected and approved for occupancy as follows 3333 Bristol St. Ste 1212- B06-01655 Building Address Bldg. Permit Number Use Clothing Retail`, (5,200 s.f) w Rt`�. bRLY PdC Group Ty, pe of Construction XPUR Use Zone Owner of Building South. Coast plaza Tenant HUGO BOSS Address 3315 Fairview'Rd:, Costa Mesa, CA By BUILDING OFFICIAL-Khanh,Q..Nguyen, C.B.Q. Date 9262 110T REQUIRED TO BE POSTED IN A CONSPICOUS PLACE = I - x (714) 754-5273 • Fax (714) 754-4856 . www.cl.costa-mesa.SOFILDING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST SCOPE OF PERMIT _ I Status: ISSUED Suite: 1212 , ' "' -' �`�� '--,",Applied: 10/03/2006 Vicinity: 1212 Pian Check: Issued: 10/03/2006 Primary Oce: M Display/Safe Merchandise Type of Construction: f -FR Permit: Parcel Number: 41250107 Zoning: PDC SMTP Res: Applicant: WATSON,-BUSTY SMIP Com: Address: Other: $0.00 Phone: 714-662-7933 ISSUED BY: Zip:_ Owner: SOUTH COAST PLAZA " Total: Address COSTA MESA CA Phone:' _ 3315 FAIRVIEW ROAD Zip: 92626 '+ SETBACKS MAIN STRUCTURE Contractor: WATSON,CONSTRUCTION INC.: Rear 0-0 ' Left ' •_ '0- 0 Right 0- 0 , .. ACCESSORY Address:, 1260 LOGAN AVE Rear. 0- 0 L"eft Q- 0 ;.. ,,-; ;Right 0-0,, ; PARKING UNIT 6002 Phone: 714-662-7933` COSTA MESA, CAS - i Zip: 92626 License: 705797 % Arch : GEORGE ENESEY Eng:. Address: WESTGROUP DESIGNS Address: IRVINE,CA Phone: 949-250-0880; - Phone: ; 1350 REYNOLDSAV STE 101 -• - Zip: 92614 License:. C27058-- " License: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California stat es d related regulations. (Ord. No. 92-26, § 1, 12-21.92) EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days, or if work Is s su pended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must compri th all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will res.lt in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446-46 (6100) SCOPE OF PERMIT _ INTERIOR 5200SF STORE IMPROVEMENTS FOR "HUGO BOSS" IN SPACE 1212 ' FEE SUMMARY Pian Check: $283.43 Calc Valuation: $234,000.00 Permit: $1,744.15 - -` j � - \ Claim Valuation: ,. $234,000.00 SMTP Res: $0.00 SMIP Com: $49.14 Other: $0.00 Inspection..$0.00 Total: $2,076.72 PLANNING-& ZONING SETBACKS MAIN STRUCTURE Front 0- 0 Rear 0-0 ' Left ' •_ '0- 0 Right 0- 0 , .. ACCESSORY Front 0- 0 Rear. 0- 0 L"eft Q- 0 ;.. ,,-; ;Right 0-0,, ; PARKING Existing: 0 Required: 0 Proposed: 0 \ !, - NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California stat es d related regulations. (Ord. No. 92-26, § 1, 12-21.92) EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days, or if work Is s su pended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must compri th all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will res.lt in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446-46 (6100) DECLARATiOMS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. _�My workers' compensation Insurance carrier and policy number are: Carried �:,.�.. Boli Nu �y !c�yoyc� (This section need not be comple d 1f the permit Is valued at one hundred dollars ($100) or less.) ❑ I certify that in the ormance of the work f�hhlch this permit is issued, I shall not employ any person in any manner so as ro become subject to the workers' compensation law o California, and agree I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, 1 shall forthwlth comply with these ro isio ! Applicant Signe r r -Date WARNING"FAILURE TO SECURE WORK $' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUB,]ECT AN EMPLOYER TO CRIMIK L PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I her affirm that I am licensed under�ovislons o apter 9 (commencing with Section 7000) of Division 3.of the Business and Professions Code, and my license is in full "force and effac ki�c. # '� Class # s P3 Cor tr� e s Slgnat`ure: Date: 3 QT . 34oe CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is Issued. (Sec. 3097, Civil Code). Landers Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty Of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors license Law does not apply to an owner of property who builds or Improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. It, however, the building or improvement is sold within one year Of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. Cl Yes ❑ No Driver's license No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in Connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, Califomia Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .............i..._......................................................................... ..................................................................................................................................................... .......---........................ .. 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ......................................................................................................................•-•............................ _........................................ _...................... ......,,................................................................................. ......................................... .............................. 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ... ........................ ............................................. ,........-...............-----.......................... ......................................... ..............."I ............ 11.........11................- ............. .........-....................................... ................................... 4 11 en RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No _...................__.................................................................... ... ....._................................. _.__...........................-----1_111..._.___ .. _ .11­_.1.1111 Does or will the applicant or present or future building occupant require for the work which is the subject of thisa plication aggermh for such construction Or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? E Yes LJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). Y 6 Witl any part of the fecilit to be constructed under this permit be within 1000 feet from the outer boundaries Of a school? Yes ❑ No (If "yes". the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ...............................................................................................................•.............................................................................................................................................................-----•--.................................... 7 Ifs permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject Of this application, have all of the disclosures prescribed by Califomia Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ................................................................................................................................................................................................................................................................................................................................................................... ................... 8 (If "yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions, Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of pedury that I have read this application and state that the information given is torr ct. I agree to comply with al state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the abo a -d scribed property for in a tion purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Si LegalOwner(s) Date kM6ZZ � A 4 Z %. . IL, nd/Or'Authorized Applicant ' Date CODE t. INSPECnQN W UN 1NMALS CODE! INSPEcnoRTYPjNTIT1AL5 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final BlocklRetaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Buiiding/06cupancy CITY OF•COSTA•MESA ° BUILDING DIVISION D. r 77 FAIR DRIVE, COSTA MESA, CA 92$26 (734) 754-5273 •Fax (714) 754-4856 www.costame3aca.gov FOR INSPECTIONS CALL: (714) 754626 PERMIT NUMBER: BX13-00065 PERMIT TYPE B_MISC STATUS: APPROVED APN: 41250107 DATE ISSUED: 02/26/2013 Zoning: PDC, ISSUED BY: JOB ADDRESS: 3333 1212 BRISTOL,ST C.M ­Suite/Unit: 1212 Vicinity: HUGO BOSS ENTRY ✓ Primary Occ: Const Type: 77 /;. 5Q. FT: 19 ;,"Valuation: - $11,200.00 SCOPE OF WORK: INSTALLATION'OF A,19 SF�F,RONi ENTRY LED LIT SIGN FOR "HUGO BOSS", SPACE 1212. kit -%70- Ci�fAt w000nt.Al nC OC nAAIT.I+LJAI 1 �\InTlO C.!_`GA AITCn IIKITII A/"!`CCC TnniAlGlA IIJf`_ I IIJiTICI IC flCnVlnCn GnG OWNER: SOUTH COAST PLAZA ",�`: i Address: 3315 FAIRVIEW RD Unit: City/State: COSTA MESA;,CA -;'� Zip Code:92626 Phone: Cell: TOTAL FEES $123.60 HOURS FOR CONSTRUCTION ACTIVITY: EFFECTIVE 3!1812010 - PER CMMC Sec. 13-279 Monday thru Friday - 7:00 am thru 7:00 pm. Saturdays -9:00 am thru 6:00 pm. Prohibited all h urs - Sundays and the following Federal Holidays: New Years Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day and Christmas Day NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE /. rxsPECTIOM TYPE 1616 APPLICANT: REICH, JEFF, _. `,-Address: Unit: City/State: = r:w '" Zip Code: Phone: 818-764-19091 _. Final Factory Fire Place CONTRACTOR: MALL SIGNS AND SERVICE - Final Sign License No.811074 Final Demolition Address: 12439 MAGNOLIA BLVDUnit:SUITE 113 City/State: N HOLLYWOOD, CA _ , Zip Code: 91607 -* Phone 818-7647.1909 ARCHITECT: License No. Phone, ENGINEER: License No. Phone FEE SUMMARY Building Plan Check: i t� ' , „-$29.15' Building Permit: mss;' ` �, ` 44.85 - $44.85- Electrical Electrical Permit: `� , , = " $48.10 SMTP Residential $0.00 SMIP Commercial = - . $0,50. Bldg Std Admin Fund $1.00. Cell: TOTAL FEES $123.60 HOURS FOR CONSTRUCTION ACTIVITY: EFFECTIVE 3!1812010 - PER CMMC Sec. 13-279 Monday thru Friday - 7:00 am thru 7:00 pm. Saturdays -9:00 am thru 6:00 pm. Prohibited all h urs - Sundays and the following Federal Holidays: New Years Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day and Christmas Day NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE /. rxsPECTIOM TYPE 1616 Fixed System Final Fire Prevention 1266 Pool Spa Final 200 Final Re -Roof 201 Final Block/Retaining Wall 202 Final Factory Fire Place 203 Final Sign 204 Final Demolition i TTIL CODE/ INSPECTION TYPE 206 Final Mechanical 208 Final Plumbing 210 Final Electrical 212 Final Fire Prevention 220 Final Planning Approval 222 Final Site 250 Final Building/Occupancy DATE rNTMALS H 29_,I 5 Ha aP WORKERS' COMPENSATION DECLARATIL Owner ID verified by o s license. ❑ Yes ❑ No I h b fr d 1 f ore y a tmi un or vena ly o pequry one of the following declarations... •- Drivers License No. Expires: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' Verification of Ownership by (type of document, i.e. - property tax bill or deed): compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. ave and will maintain workers' compensation insurance, as required by '96ction 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: -- s —utv 9 (Carrier: (This sediun need not be cumpfeted amt pwnil is vak ed Blom lumvred dadars (5100) orhm&) Policy.Number: OZ 1 S � C) � ` ❑ 1 certify that in the performance of the work for which this permit is issued. I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Califomia, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisions. -(�. _ Z -z6 13 plk;aM Signature '^ Data — WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. J X1074 aClasCq5 s # 2-26-13 _Cos Signature �Oatt t— - CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to Construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractors) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature 3857-48 (3187) Date DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Appkeant's Signature Date Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4, If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If "yes', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If 'fres", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that i have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature of Legal Owner s) Date n r A o Applidanl L_ Date (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesaRLOCTRICAL PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Suite No 1212 Vicinity: 1212 Parcel Nunmber: 41250107 Applicant: STEVE STALONE Address: _ SCOPE OF PERMIT ,Phone: 714-744-2845 - Zip f` Owner: SO11.1T4C6AST PLAZA FEE SUMMARY Address Quantity Quantity COSTA MESA CAS Phone: Temp Dist System ! Lighting 3315 FAIRVIEW ROAD Zip: 92626 $0.00 _ Busway /100 ft $0.00 0 -'%- $0.00 Contractor: CAREY, SIGN GRAPHICS 0 New Res (1-2 units) $0.00 ` 0 Misc Electrical Equipment $0.00 Address 28716 L/U"ESTAR $0.00 I 0 Transformers up to 1 kvalkw $0.00 Phone: 714-630-8414 $0.00 i .......:........up to 10 kvalkw $0.00 0 ANAHEIM CA Zip: 92806 .................up to 50 kvalkw $0.00 License: 376085 . ISSUED BY: status: ISSUED Applied: 12!2212006 Issued: 12122!2006 COMMENTS I SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2448-46 (6100) _ SCOPE OF PERMIT '1306-02168 SUITE 12.12 HUGO BOSS ILLUMINATED STORE SIGN n•. FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 ; Temp Dist System ! Lighting $0.00 0 Temp service test $0.00 _ Busway /100 ft $0.00 0 'Res: a/c package $0.00 Standing Section $0.00 0 New Res (1-2 units) $0.00 ` 0 Misc Electrical Equipment $0.00 0 New Res (3+units) $0.00 I 0 Transformers up to 1 kvalkw $0.00 0 Pool ! Spa $0.00 0 _ .......:........up to 10 kvalkw $0.00 0 Lighting Fixts 3 $0.00 -"0- = .................up to 50 kvalkw $0.00 0 Recept Outlets $0.00 0 .................up to 100 kvaAkw $0.00 0 Switches $0.00 0 ..................over 100 kvalkw $0.00 0 Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0 , Res Appi $0.00 0 Low Volt Wiring System ! Ckt $0.00 0 Service to 200a $0.00 0 Misc. Conduit $0.00 0 Service to 1000a $0.00 0 Misc. Conductor $0.00 0 Service over 1000a \ 40.00 0 Circus ( gen or ride) $0.00 0 Motors to 1 hp, '\\$0,00 0 Circus (mech ride or lights) $0.00 0 Motors to 10hp, < $0.00 0 ., Christmas Tree Stand $0.00 - 0, Motors to 50hp: ' $0.00, i `' ' 0' Fireworks Stand $0.00 0 Motors to 100hp, . ,-,so ' 00 '0 Other Electrical Fee $0.00 Motors over 100hp $0.00, 0 Communication drops $0.00, 0 ,. Investigation Fee $0.00 Sub panel to 200a $0,00. 0: Plan Check Fee $0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits _ •,x$24.60 , , 1-- - Temp Pwr Pole \ $0.00' . - "o ' ' TOTAL CALCULATED FEES $48.10 Intermed Pole COMMENTS I SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2448-46 (6100) C C Adlhk DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the fallowing declarations: ❑ ave and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain rkers' oompensatian insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. Mywo o ens Insur A6 carrier and policy number are: Ca or: �� __ Number,ilIs ► _ is section need not be corrpldfed if the permit is valued atone hundred dollars ($100) or cess.) ❑ 1 certify that in the performance of 1 e work for which this permit is Issued, I shall not employ any person in any manner so as to become subject to the workers' FA atian laws of Califomi d a that it I should become subject to the workerS_G nsatlon provisions of SecU n 37 of the Labor Code, I shall forthwith kh these ps isi tRETOLARS {5100,0001, IN ADDITION TO THE COST OF COMAFIJSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE R CODE, INTEREST, AND ATTORNEY'S FEES. LICENS ONTRACTORS DECLARATION: I h e r t I am licensed under proyWoRs of Chapter 9 (commencing with Section 7000) of Dlvisio sin essions Coda, and my license is in full and effect. Lic. # s Contractors e: z CONSTRUCTION LENDING AGENCY: S hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Landers Name: Lenders Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, after, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than live hundred dollars ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL: DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Coda: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for safe. It, however, the building or improvement is sold within one year of completion, the ownar-builder will have the burden of proving that he or she did not build or Improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sao, 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a coniractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i,e. - property tax bill or dead): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet In depth into which a person Is required to descend, will be made in Connection with work authorized by this permit, and that no building structure, scaffolding, latsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, L will not employ anyone to do work which would require a permit from the Division of Industrial Safety. as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of Compressed gas at standard temperature and pressure). _-.._......._....................................._.._:.._.....................................__._.^............-...................................-........................................... ........... ......... _.. 2 Does ar will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑Yos ❑-No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant Hoed to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. _ .._ _ .................. __... _ _......... ---.................. _........-... .............................. __..................................... 4 If an RMPP Is presently required, has Section 25534 of the California Health and Solely Code boon fully complied with? ❑Yos ❑ NO ................................................_......_ __.._......................... ._ __............................—.....------................—...._..----......................................... - --........ �. 5 Does or will the applicant or present or future building Occupant require lot the work which is the subject of this a plication a ermit for such Construction or modification from the South Coast Air Qupllty Management District or from any other air pollution control district or agency7 Yes U No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-rosidential building permits). 6 Will any part of the facility to pe constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If yes', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). _ -. ............ --—.._...._.......-..... _._...... --- _ _- ............. ...... -_.._....... _._....................... 7 It a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No _....��..............._.......—..._......... —. _.._...-...................__....._.... _ _._........... ...................... 8 (11 yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy of allow occupancy of any building authorized by this permit until final inspection. Signature Ot Legal Owners) Dale An ed App!5 CODE 3. INSPECTION TYPE QM IffTMA S CODE 0 INSPECTION TYPE Qin, INTIMAL 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 RcW Site f 204 Final Demoiition 250 Final BuildingfOccupancy Job Address: 3333. BRISTOL ST Status: ISSUED Suite: 1212 Applied: 12122/2006 Vicinity: Issued: 1 212 212 006 Primary Occ: M Display/Sale Merchandise Type of Construction: I -FR Parcel Number: 41250107 Zoning: PDC Applicant! STEVE STALONE Address: Phone: 714-744-2845 Zip: ISSUED BY: Owner: SOUTH COAST. PLAZA Address COSTA MESA CA Phone: 3315 FA1RViEW ROAD-_" Zip: 92626 Contractor. .,�CAREY�SIGN GRAPHICS Address:,-'• 2871 BLUE STAR Phone: 714-630-8414 ANAHEIM CA, - zip,: 9280161,,, License: 376085 Arch �/ %, ` Eng: Address: Address: Phone: Phone: Zip: -License: �. License: .� SCOPE OF PERMIT B06-01442 HUGO BOSSSUITI 1212 ILLUMINATED WALL SIGN. FEE SUMMARY Plan Check: . $41.05 '' « Calc Valuation: $1,720.00 Permit:. $63.15 Claim Valuation: $1,720.00 SMIP Res: $0.00 SMIP Com: $0.50 Other: $0.00 Inspection: $0.00 Total: ', $104.70 PLANNING & ZONING SETBACKS';�; AIN STRUCTURE Front \0- 0 Rear: ; 0- 0 . Left 0-0 . Right 0-0 , ACCESSORY Front. 0 0 \` ., Rear 0-0 Left 0-0 Right 0-0 PARKING— Existin :' 0 , '"Required: 0 Proposed: o NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. !NSPFCTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all 'equired Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. 8 R INSPECTIONS CALL: (714) 754-5626 1 i (8x00} DkumAnoms WORKERS' COMPENSATION DECLARATION. I hereby affirm under penalty of perjury one of the following declarations: 1361 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the ork for which this permit is issued. bd il!maintain wo ars'compensation insurance, as required by section 3700,911the Labor Code, for the performance Of the work tar which this permit IS issued. y woomponsate Insu� a carrier and policy number are: icy N�umbv l_�r (This section need not be completed if the permit is valued atone hundred dollars ($100) or loss.) - ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in anymanner so as to become subject to the workers' compensation laws of Califomia agree that if I should become subject to the workers' compensatia rev n.5 Section 700 of a Labor Code, I shall forthwith comply with these visions. / phi gna Data: br ARNING: FAILOSECE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL S1J JECT AN EMPLOYER TO CRIMINAL PE TIES AND CIVIL FINES UP TO ONE HUNDRED LARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 37060F THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereb an un r ' • r s of Chapter 9 (commencing with Section 7000) of Division Business a Pr f s Code, and my license is in full fo an a ec . rc. $ ass Co te: G CONSTRUCTION LENDING AGENCY: ❑ - I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature:. Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that i am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any City or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its issuance. also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption, Any violation of Section 7031.5 by any applicant for a permit subjects the applicant 10 a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sate. (1, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractors) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drlver'S license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, t.e. - property tax bill or deed). DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I heraby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsawork, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title B, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: _ , . _ __ Date: r Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need 10 file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume o1 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present of future building occupant need to file a registration form for acutely hazardous materials? (Section 25533 of the California Health and Safety Code. with some exceptions, requires registration with the Costa Mesa Fire L one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a vi compressed gas at standard temperature and pressure). -- ................................... --.................................................................................................... _...................... ----.................................... ......................................... ........... ....... _........ 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention P ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preps Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 ff an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully Complied with? ❑ Ye pP p ...............................•-- ............ _...... ..._.............---...................._-........---................... ...............�........................... ............................. 5 floes or will thea applicant or resent or future building occupant require for the work which is the subject of this a plication a from the South Coast Air Quality Management District or from any other air pollution control district or agency? a Yes (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for nal .................................................................................... ............................................................ ............................... .................................. ...... ............................................... . fi WIII any part of the facility lobe constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yi (if 'fires", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). -- ..........._................................... .............................................. ..................................................................................... .......___........••-•--......................... _........._., 7 If a permit from the South Coast Air Ouslity Management District or other air pollution control district or agency is required application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ----.................................._........................................................._................................---......po"l l u'li.............................1*ca._..............................._.............................................. ....., 8 (If'jres ;attach certificate of compliance from the appropriate air pollution control officarJ. CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is Correct. I agree to com regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE. OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I cerlity under penalty of perl'ury that 4 have read this applieai correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of above-describad property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit Signature Of Legal Owner(s) An r Authorized Ap i t CODE ii. INSPECTION TYPE INTITAL$ CODE i IN5PECT10NTYPE 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Fina! Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy Job Address: 3333 BRISTOL ST Status: ISSUED Suite: 1212 Applied: 11/16/2006 Vicinity: Issued: 12107/2006 Parcel Nunmber. Zoning: ISSUED 13Y: Applicant: SHEILA LOONEY Address: , Phone: 714-993-2822 Zip. Owner: /SOUTHCOAST PLAZA Address COSTA MESA CA Phone: 3315 FAIRVIEWROAD Zip: 92626 Contractor: ALERT FIRE PROTECTION INC Address:. 5200,E•HUNTER AV ' V�' SUITE B" Phone:, 714-993-2822 ANAHEIM, CA Zip: 92807 License: 316324 . SCOPE OF PERMIT -RELOCATE 47 SPRINKLER HEADS AND 9 NEW SPRINKLERS FOR "HUGO BOSS" STORE TI, RE:1306=01655 J r r FEE SUMMARY Plan Check:' $99.61 Calc Valuation: $8,000.00 Permit: $153.25 _�' �' '�,"r �` -'461 'Claimed Valuation: 'sa,aoo.00; Other: $0.00 Total: $252.86 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 W6.46 (6/00) DECLARAVONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will malotain a certificate of consent to self-insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the / work for which this permit Is issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued.' My workers' core ti Insuran carrier and policy number are: /���� �� ' 1 Cartier. _ t 60 Policy Number: /y ('This section need not Be completed if the permi is valued at one hundred dollars ($100) or less.) ❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Califomia n agree at if I shoul become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisions. Applicant Signature: Data: . 2- �--7 _- —U „ WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLA L AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSME) DOLL.ARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, D AGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR OODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: hereby affirm that I am licensed under pro 's€ons of Chapter 8 (commencing with Section 7000) of Division 3 of the Buslnand Professions Code, and my license is In full force and effect. Lic. N Class q (P Contractor's Signature: [late: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: — _ Data: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Profession$ Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).); ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building of Improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Cade: The contractOrs License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: �! Date: Owner ID verified by drivers license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby rerlify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: - — -- — Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 1 Will the applicant or present or future building occupant need to file and certify a Business Pian for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume o1 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ....................................... re-....ildi......................................................................................._................................................---......t'a-ria"I.—...__..........,.......................................................................,.. 2 Does or will the applic=ant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mese Fire Department by each business which at any one time has on hared a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 65 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). w _ _.............................. ...... ---..._..__............................. __.... __............. ---.............. ... ........_...................... ........................ _...................... ................. ........................... _._..._............ 3 Goes or coil! the aappplicant Or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes 13NO (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ....................................................................................................................................................................... .......................cfi� ............................................................. 4 If an RMPP is presently required, hoe Section 25534 of the Califomia Health and Safety Code been fully complied with? ❑ Yes �] fJo ................................................... .................................__ .........................._.................................................... .................................................................. _._............................................................... .. 5 Does or will the applicant Or present or future building occupant require for the work which is the subject of this a plication aermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes f No (Section 65850.2 of the California Government Code requires that the requested Information be furnished on applications for non-residential building permits). _ _............ ... .....----._....................:..............._...........-......... .............----........................... . _ ............... _....__ _ ....... ..__........................_.._........................._.__.....-----..................... 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ NO (If 'yes", the facility must meet the requirement Of Sections 25534 and 42303 of the California Health and Safety Code). ......................................_..... _.......... ... .................... ..._...................................... ....................................... ... _... __....................................................... ..._—........................ ............................. ........... 7 if a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No .................................................. ---.......................................................... ......................... •................................ __...................................................................................... ......,......................... _.................................................... yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the Information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to core y with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described props r ins pe on purpose I agree not to Occup Ilow occupancy of any building authorized by this permit until final ' spection. Signature Of ego Owner(s) /21 2Z D� And/Or Authorized Applicant Date CODE f. INSPECTIONTYPE RM INTMAL,5 CODE INSPE�TIQ({TYPE . Qdg INTRIA1� 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 206 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention t J o —07 ckl_ 202 Final Factory Fire Place 220' Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.cl.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT Job Address: 3333 BRISTOL ST Suite No 1212 Vicinity: SUITE 1212 HUGO BOSS Parcel Nunmber: 41250107 Applicant: SCHELIN, KEVIN Address: 136 E GARRY SANTA ANA, CA Owner: SOUTH COAST PLAZA Address COSTA MESA CA 3315 FAIRVIEW ROAD Phone: 714-556-8591 Zip 92707 ` Phone: Zip: 92626, Contractor:. SMALLCOMB WIRING CORPORATION Address: 136 E GARRY Phone: 4714-556-8591 SANTA ANA, CA Zip: 92707 License: 145961 ISSUED BY: Status: ISSUED Applied: 11/06/2006 Issued: 11/06/2006 SCOPE OF PERMIT, INTERIOR 5200SF STORE IMPROVEMENTS FOR "HUGO BOSS" IN SPACE 1212.1 REF: B06-01655 181 LIGHT FIXTURES, 24 OUTLETS, 14 SWITCHES, 3 SUB PANELS TO 200A COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1. 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 2446.46 (6=) FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 Temp Dist System 1 Lighting $0.00 0 Temp service test $0.00 Busway 1100 ft -= 1$0.00 0 Res. a/c package $0.00 Standing Section $0.00 0 New Res (1-2 units) $0.00 0 - Misc Electrical Equipment t , $0.00 0 New Res (3+units) $0.00 0 Transformers up to 1 kGifkw $0.00 0 Pool / Spa $0.00 0 :..:............up to 10 kva/kw $0.00 0 Lighting Fixts $139.53 181 ................up to 50 kvalkw $0.00 0" Recept Outlets $24.92 24 ..........:...:..up to 100 kvalkw $0.00 0 Switches $15.40 14 .........: '......over 100 kvalkw $0.00 0„ Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0 Res Appl $0.00 0 .Low Volt Wiring System / Ckt $0.00 0 Service to 200a $0.00 0 Misc. Conduit $0.00 ''0 Service to 1000a $0.00 0 Misc. Conductor- $0.00 0 Service over 1000a $0.00 0 Circus (gen or ride) $0.00 0 Motors to 1 hp $0.00 0 Circus (meth ride or lights) $0.00" 0, Motors to 10hp $0,00 0 Christmas Tree Stand = $0.00 , 0 Motors to 50hp $0.00 = 0 Fireworks Stand $0.00 0 Motors to 100hp $0.00 0. Other Electrical Fee $0.00 Motors over 100hp $0.00. 0 Communication drops $0.00 0, Investigation Fee_ $0.00, Sub panel to 200a ,,$91.50 3,-, Plan Check Fees :$0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $0.00 0 Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $294.85 Intermed Pole $0.00 0 COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1. 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 2446.46 (6=) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: . ❑ 1 have and will maintain a Certificate of Consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the _WeKfor which this permit Is Issued. I have and will maintain workers` compensation insurance, as required by section 3700 of the tabor Code, for the performance of the work for which this permit is issued. My ( workers�mprensatlon Insurance carrier and policy number are: CeAldi: 7tf�1f[fir PoiiCA– bar: _ (r►t s section naec'nat a Completed it the permit' valued atone hundred dollars ($ t 00) or less.) ❑ I certify that in the p ' ormance of wo for which this permit is Issued, I shall not employ any person In any manner so as to become subject to the workers' compensation laws f allfamla, gr t t ii I should become subject to the workers' compensation provisions of Sectio 3700 of the Labor Code, I shall forthwith comply with these p signs. Appli®ryt signature: WARNING: FARORE TO SEC E WORKERS' COMPENSATION COVERAGE IS UNLAWFUL. AND SHALL SUB.fECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($i DD,0M, IN ADDITION TOTHE ODST OF COMPENSA nON, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am Ii s oA ons of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Li... fy A Class C, 10 ContractorsSt LIUDere__ fX _ CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, after, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL 00 THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Cade: The Contractors License taw does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sac. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts tot such project with a contractors) license pursuant to the Contractors License Laws.). ❑ I am exempt under see. Business and Professions Code for this reason: Signature: Data: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, 1.0, - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, talsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high, (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Indu$tdal Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 WIII the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ............... ....................... ...... ....................... 1 ................. ..,..--.... _.................................. ............,........................ ............................................................................................................................................................ ...................................... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Coda, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time hes on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic foot of compressed gas at standard temperature and pressure). ...................................................... — .................. .......... -.........................._—_................................ —........................ .....-........... ........................................................................ ----................... ---.._..... _r. ....... ............ 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 it an RMPP is presently required, has Section 25534 of the Califomia Heaflh and Safety Code been fully complied with? ❑Yes [] No — .............. ................... ................................. .._.__.......................... _............................................................................ .._.... ....... .................---.................. ..... ........................ - ..........._ ........ ..... _.._._.... 5 Dass or will the applicant or present or future building occupant require for the work which is the subject of this a plication aPPermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency Yes Il No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ...................................... ........................................................................................_......................................_..............................,e,,,r..........................................._r..........................._.......----......................................- ......................... 6 WIII any part of the facility to be constructed under this permit be within 1000 fest tram the Qatar boundadas of a school? ❑ Yes ❑ No (If yes", the facility must meet the requirement of Sections 25531 and 42303 of the California Health and Safety Code). .........................:...--- ................... ......... ---^^............. --._.... -_....................................................... __.._........................................................ _.... _.... _...................... ...._.r .... _... ................... .-_................ 7 Sf a permit from the South Coast Air Quaiity Management District or other air pollution control district or agency is required for the work which is the subject at this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No . ............................ ....................................................................................._......................................................................................------................................__.............................-...................................................•....................... 6 (If ryes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Data: CERTIFIOATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. J agree to comply with all Oato laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above -d sc 'bed property Isp ion purposes. 1 agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. I to Of Legal Owner(s) Date A�dlOG ut o zed'Appiicant COaE t• ftUJ&J9h_UU 2LU INTrnACODE INSP€CTION Typ QAM KU Ml� 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing Fina 200 Final So -Roof 210 Final Electrical 201 Final BlocklRetaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Sita 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 MECHANICAL PERMIT Job Address: 3333 BRISTOL ST Suite No 1212 Vicinity: Parcel Number: 41250107 Status: ISSUED Applied: 12128/2006 Issued: 12/28/2006 Applicant: SANDERS,BILL ISSUED BY: ' Address: 1140 RED GUM S,T.�!- /,';%.!, Phone: 714-630-3200' ` Quantity, ANAHEIM, CA'--,- Zip: 92806 ' Repair / Alt Absorbtion Unit Owner: S UTH'COAST'PLAZA� ' Address:i " $0.001 0 'COSTA MESA CA-/ Phone: 3315 FAIRVIEW ROAD, Zip: 92626 0 Inst FAU >100 k BTU $0.00 0.. - Contractor; THERM INC .r,-AIAIR i ; Addre'ss:- 1140 RED'GUM ST Phone: 714-630-3200 0 r'V ANAHEIM, CA I Zip: 92806 $54.80 4 • 'License: 102216 • _ $0.00 0 SCOPE OF PERMIT, $0.00 0 " -� ` HUGO BOSS SUITEA212 B06:01655 ; �', J4 ALT DUCT, SYSTEM 4-VAV BOXES 0 Refrig Sys <100 k BTU $0100-=a`=- ' �% FEE SUMMARY $0.00 � 0 Refrig Sys >100 k B7U� ' Quantity Quantity, ISSUE FEE $23.50' ' r rr i' Repair / Alt Absorbtion Unit $0.00 0 Inst FAU <100 k BTU $0.001 0 Repair 1 Alt Refrigeration Unit $0.00 0 Inst FAU >100 k BTU $0.00 0.. - Ventillation System $0.00 0 Repair /Alt Cooling/Heat $54.80 4 Evaporative Cooler $0.00 0 Inst I Rep. Recess WillHtr $0.00 0 " -� Commercial Incinerator $0.00 0 Refrig Sys <100 k BTU $0100-=a`=- ' �% .\ 'Domestic Incinerator $0.00 � 0 Refrig Sys >100 k B7U� $0.00:F= a -" Compressor's-! Absorpti6n Systems Gas Piping - '� '' $a.06 " 4 Up to 3 hp 1100 k BTU $0.00 0 Factory Fireplace' ;. l' $0.00 0 3 To'15 hp'! 500 k BTU $0.00 _0 Hood w1Mech Exhaust, $0.00 0 15 To'30 hp 1,1,000 k BTU, $0.00 '0 VAV Box 1`` $42,60 4 30 To 50 hp /.1,750 k BTU ' " ,"$0.00 0 Vent Fan/ Single Duct $0.00 0 Over 50 hp / Over 1,750 BTU $0.00 0 Appliance,',, $0.00 0 w _ ��� , Boilers Fire Dampers ! $0.00 0 v'' Up to 3 hp ; �i $0.00 0 Smoke Dampers 1_, $0.00 0 ""; �� 3,To 15 hp-, „ .2 J $0.00 0 Inst or Relocate Appl Vent_ Air Handlers ��10000cfm x$0.00 0*� �� $0.00 0-7 r : °"� ` 15 to 30 hp',,: . - i 30 to 50 lip' $0.00 ' $0.00 ; ,0 D Air Handlers > 10000cfm , $0;00,\ -0 „ : Over, 50 hp $0.00' 0 Floor Furnaces ` �� $0.00�.0� - Other Mechanical Fee Floor or Suspend, Heater �, r $0.00-�0� �� - - Investigation'Fee - �, / $0.00 Plan Check Fee-- = i �. -Reinspection Fee ; , -"-$0.00 �/ $0.00 FEES,, TOTAL CALCULATED FEE' $120.90 % `COMMENTS4 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result In the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 244848 (6100) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ LVk1yeand wiii maintain a cari'llicate at Consent to sett-insure I(x workers' compensation, a$ ptovidad foT by section 3700 of the Labor Code, lar the performance of the for which this permit Is Issued. I have and will maintain workers' compensadon insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: •C9[dei:�T]T�L5C3'fo�l�t-_Jf�01�2-0�0 Policy Num r: �'-RA11�1-ESS r '?This section need not be completed if the permit is valued at one hundred dollars ($100) or less.) ❑ 1 cortify that in the performance of the work for which this permit is Issued. I shall not employ any person in any manner so as to became subject to the workers' compensation laws of California, an groe that I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these PMV. €ons, -Applicant Signatur?: _ _l_�- - - Oele:� s " C2 ED f=WARMNG,''FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUEl1ECT AN EMPLOYER PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (9100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR COPE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: 1 hereby odf€rm,ihat.i.a�licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 361- a Business and Professions Code, and my license is in full for '.and effect.�Uc�q O -lass a � 20 y C_ CG.4 . N 1 G ContracfoSignature: A A CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is issued. (Sec. 3097, Civil Code). Lender's Nama: Lender's Address: Signature: Dose: OWNER-BUILDER DECLARATIONS: 1 hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to Its Issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than rive hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for safe (Sec. 71344, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not intended or offered for safe. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a conVactor(s) ticatlse pursuant to the Contractors Uconse Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i-e. - property tax bill or dead): _ DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet In depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec, 341, Title 8, Califomia Administrative Code). ❑ As owner-builder, i will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number. HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I Will the applicant of present or future building occupant need to file and certity a Business Plan for emergency response to release or threatened release of a hazardous malerial? ❑ Yes ❑ No (Section 25505 of the California Health and Safely Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every busirloss which has at any one time during a reported year a quantity of hazardous materials equal t0 or greater than a weight of 500 pounds, or a volume of 55 gatlons, or 200 cubic feet of compressed gas at standard temperature and pressure). __..........................................................................................._...._.. _ _ .............................................................._.._._....................�................ _.................—................_..........--. 2 Does ar will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal 10 or greater than a weight of 5D0 pounds, or a volume of 55 gallons, or 200 cubic feet of comp(assed gas at standard temperature and pressure). —_._................ _.................. _.._—_—__....._.._.__................_..-------..............-.-..-..----- - _ _- r_. — ...................... —_.�-_ .- — ....._... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and tiling with the Fire Department of an RMPP by businesses which are requited to register acutely hazardous materials with the Fire Department, ...........................................----•--...-.............................,,...,-........_............._.......--...................................... _._.- .",................ 4 If an FSMPP Is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? J...", Yes-No .............................................................................................................................................................................................................................................................................................1..........._................................ .......,..................... 5 pass or will the applicant or present or future building occupant require for the work which Is the Subject of this a pfication a ermlt for such construction or modllicatlon from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). .....................................................-..-.........................,.,....................................-•-------.......................................-................................................................................................................................. .. art of the lac€li t0 be constructed under this permit be within 1000 feet from the outer bounder es of a school? 6 will any p ty p ❑Yes No (ti yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Cade). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by Califomia Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (If yeses, attach certificate of oomptianCe from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certity that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and State that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. 92 I slurs O L gal Owners) Date t .v AndlOr Authorized App)jGanni CODE-1. INSPECTION TYPE 2M I=AL P&Q f INSPECTION TYPE �J 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final BlocklRetaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final BuildinglOccupancy — (714) 754-5273 • Fax (714) 754-4856 • www.cl.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 MECHANICAL PERMIT .lob Address: 3333 BRISTOL ST Suite No 1212 Vicinity: Parcel Number: 41250107 Status: ISSUED Applied: 11/06/2006 Issued: 11/06/2006 ISSUED BY: KT15 Applicant: SANDERS, BILL ' FEE SUMMARY Address: 1140 RED GUM ST Quantity Phone., 714-6304200 ISSUE FEE ANAHEIM, CA, Zip: 92806 $0.00 0 Inst FAU X100 k BTU $0,00 Owner. SOUTH'COAST PLAZA, $0.00 ' Address: $0.00 0 Ventillation System $0.00 COSTA MESA CA Phone: $13.70 1 3315 FAIRVIEW ROAD Zip: 92626 Inst I Rep. Recess Wall Htr $0.00 0 - Commercial Incinerator Contractor: THERMALAIR INC Refrig Sys <100 k BTU $0.00 0 Domestic incinerator $0.00 0 Address: 1140 RED GUM ST 0 Compressors I Abaorption Svstems ; Phone; -114-630-3200 i 0 ANAHEIM, CA Zip: 92846 License:`102216 ppb- SCOPE OF PERMIT REF: 01655. INTERIOR 5200SF STORE IMPROVEMENTS FOR "HUGO BOSS" IN SPACE 1212. MECHANICAL TO INCLUDE: 4 VAV BOXES, 1 REPAIR/ALT COOLING HEATING COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work Is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTION$: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result In the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 244&a (OM) ' FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 r y' - Repair/Alt Absorbtion.Unit,' $0.00 0 Inst FAU X100 k BTU $0,00 ' 0 Repair / Alt Refrigeration Unit $0.00 0 , Inst FAU >100 k BTU $0.00 0 Ventillation System $0.00 0 Repair 1 Alt Cooling/Heat $13.70 1 Evaporative Cooler $0.00 0 Inst I Rep. Recess Wall Htr $0.00 0 - Commercial Incinerator $0.00 0 Refrig Sys <100 k BTU $0.00 0 Domestic incinerator $0.00 0 Ref rig Sys >100 k BTU $0.00 0 Compressors I Abaorption Svstems ; Gas Piping $0.00 0 Up to 3 hp 1100 k BTU $0.00 0 Factory Fireplace $0.00 0 3 To 15 hp 1500 k BTU -30 $0.00. 0 Hood w/Mech Exhaust $0.00 0 15 To hp 11,000 k BTU $0.00 0 VAV Box $42.60 4 36 To 5D hp J 1,750 k BTU $0.00 0 Vent Fan 1 Single Dud $0.00 0 Over 50 hp 1 Over 1,750 BTU $0.00 0 Appliance $0.00 0 Boile[ Fire Dampers $0.00 0 Up to 3 hp $0.00 0 Smoke Dampers $0.00 0 3 To 15 hp... $0.00 0 Inst or Refocate Appf Vent $0.00 -0 , , 15 to 30 hp ' ..__ :., : $0.00 0 Air Handlers < 10000cfm $0.00 0 30 to 50 hp $0.00 0 Air Handlers a 10000dm $0.00 0 Over 50 hp $0.00 0 Floor Furnace $D.00 � 0 _ Other Mechanical Fee Floor or Suspend Heater $0.00 0 investigation Fee " , $0.00 Plan Check.Fee "$0,00 ' Reinspection Fee V ', , - / ; ` $0.00 TOTAL CALCULATED FEES $79.80 COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work Is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTION$: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result In the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 244&a (OM) DECLARAVOMS WORKERS' COMPENSATION DECLARATION: hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the perfOmtance of the w rk for which this permit is issued. I have and willmaintain workers' compensation Insurance, a5 required by Section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. My workers' compensation Insurance carrier and policy number are: Cam ar:A\/�L r— Policy Number: (This section need not be complafad ! th©—perm![ is valued of One hundred dollars ($100) or less.) ❑ I certify that in the performance Of the work for which this permit is issued. I shall not employ any person In any manner so as o become subject to the workers' compensation laws of Califomia, and agree that ' hould become subject to the workers' compensation provisions of Sectl G 00 1 the Labor Code, I shall forthwith o (,o comply wlf_ h these grorisionk 1 , Applicant Signature: % 1 t�y _ Date: WARMNG: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE (5100,010), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROMDED FOR IN SECTION 37011 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions ofChapt 9 (commencing with Section 7000) of Division 3 of the Business and PrDfasslons de, and my license is In full force and affect. Lic. p _11% force Class A tContraclot's Signature: 7 1 Data: CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction tending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lenders Address: Signature: _. _ Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a p4mlit to construct, alter, improve, demolish, or repair any structure, prior to Its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption, Any violatlon of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): Q 1, as owner of the property, Or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sate (Sec. 7044, Business and Professions Code; The Contractors license Law does not apply to an owner of property who builds or Improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the build}ng or Improvement is sold within One year of completion, the owner -builder will have the burden of proving that he or she did not build or Improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply 10 an owner of property who builds or Improves thereon, and who Contracts for such project with a contractor(s) license pursuant t0 the Contractors License taws.), ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID vorified by driver's license. ❑ Yes ❑ No Driver's License No. Expires:- Verificatlon of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth Into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, Scaffolding, falsawork, or demolitlon or dismantling thereof, will be more than thirty-six (36) feet high. (Chap, 3.2, Grp 2, Art 2, Sec, 341, Title 8, Califomia Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: _ Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to Or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet o1 compressed gas at standard temperature and pressure). _ �..._ .--- ............._.--llcant ....................._... _�..._..-----.............__................. —.._....._..............................._.— — ._._ .......W...... ........---..._...................... ........_..._..... _............ 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health Snd Safely Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal 10 or greater than a weight of 500 pounds, or a volume of 55 gallons, Or 200 cubic toot of compressed gas at standard temperature and pressure). ——•---..... ---....................... -.—... _............................... ...._ — __ ............_..._............_.._..... — ............ . 3 Does or will the applicant or present or tulure building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ NO (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP Is presently required, he9 Section 25534 of the Califomia Health and Safety Code been fully complied with? ❑Yes ❑ No _—.. ................... _.. .._...................... ......... .�---...................................... .... _.................................................... -....... ,.,,,.,,,.,...................... ,.............. _............ —_........ 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication aermit for such construction or modification from the South Coast Air Ouality Management District or from any other air pollution control district or agency? U Yes No (Section 65650.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the fadBty to be COnstrUCted under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). .............................................. ---.................... —.--- ...... _................ ... __— ----- 7 If a permit from the South Coast Air Ouality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by Callfomle Health and Safety Code Section 42303 been made? ❑ Yes ❑ No . _—_._........�. _..,......._�_..............._..._...........__..—.—--------------- .................._...............................................-............................................... ................_... 8 (If yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty Of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the Information given is correct. I agree to comply with all state taws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-descdbod property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. gnatur0 a al Owners) ate I & Inca And/Or Authorized Applicant j7 ale CODE /• INSPECTION TYPE DbLE NTITIALS CODE 0 INSPECr10N TYPE Qat 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final BuildinglOccupancy (714) 754-5273 • Fax (714) 754-4856 • www.cl.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 PLUMBING PERMIT Job Address: 3333 BRISTOL ST Status: ISSUED Suite No 1212 Applied: 11/13/2006 Issued: 11/13/2006 Vicinity: Parcel Nunmber: 41250107 ' Applicant: RYAN GLOVER ISSUED BY: Address: 2645 E DEMISE AVE r -Phone: 714-637-0202 ORANGE, CA- ,J Zip: 92867 Owner: COAST -PLAZA' /SOUTH Address! COSTA MESA CA!:' Phone: 3315 FAIRVIEW ROAD, ' Zip: 92626 Contractor. GLOVER'PLUMBING AND MECHANICAL Address:,' 2645-E DENISE AVE ' Phone: 714-637-0202 ORANGE, CA Zip: 92867 License: 533148 SCOPE OF PERMIT 5200 SF INTERIOR,TENANT IMPROVEMENTS FOR "HUGO BOSS" IN SPACE 1212. REF.: B06 -01655.E PLUMBING TO INCLUDE: 2 FLOOR DRAINS, 2 P -TRAPS, 1 SEWER CONNECTION, 2 TRAP PRIMERS, 2 WASH BASINS, 2 WATER CLOSETS, 1 WATER PIPING AND 2 INSTA HOTS. FEE SUMMARY AMT CITY f �- -. AMT, '{TY AMT QTY ISSUE FEE $23.50 _ _Laundry Tub f Washer $0.00 , " 0 Sump Pump $0.00 0 Backflow irrigation $0.00 0 '" Landscape Irrigation $0.00 0. Swimming Pool $0.00 0 Backflow Prevernter . $0.00 0 P -Trap $19.60 2 Trap Primer $19.60 2 Bathtub $0.00 0Pressure Regulator $0.00 0 Urinal $0.00 0 Clarifier System $0.00 0 process Piping (per 10 ft) $0.00 - 0 Vacuum Brkr Bkflow(1-4) $0.00 0 Connect (Ice,Soda,etc) :; ' $0.00 0 Receptors $0.00 0 Vacuum Brkr Bkflow(5+) $0.00 0 Dental Units., $0.00 0 Septic Tank $0.00 0 Wash Basin $19.60 2 Dishwasher $0.00 0 Sewer Cap fot•Demo - ' $0.00 0 Wash Basin Set $0.00 0 Drain, Floor, $19.60 2 Sewer Connect S24.65 1 Waste and Vent System $0.00 0 Drain, Rainwater so 00'\' 0 Sewer Private Line $0.00. 0 Water Closet (Toilet) $19.60 2 Drain, Roof � $0.1000 ' 0, : _r .: •Shower $0.00 0 Water Heater 1 vent $0.00 0 Drinking Fountain S0.00-\ ' 0" Sink, bar $0.00 0 Water Piping (Inst or Rep.) $9.80 1 Expansion Tank, .'$0.00 0; Sink, commercial 50.00 0 Water Re -pipe $0.00 0 Gas Earthquake Valve /,$0.00 0 Sink, Floor $0.00 0 Water Service $0.00 0 Gas (1 4 outlets) -SO .00,i -0 Sink, kitchen $0.00 0 Water Softener $0.00 0 Gas (Over 4 outlets), ` 50.00 /"0- ' Sink,`service/mop $0.00 0 OTHER $19.60 Gas Repipe .50.00 `•. 0 . Spa (private) $0.00 0 VIOLATION $0.00 Gas Service ` $0.00 0,„' /, Spa (public) $0.00 0 PLAN CHECK $0.00 Interceptors (Grease, Oil) 'S0.00� 0" t/ REINSPECTION $0.00 0 Interceptors (Sand Auto) TOTAL CALCULATED FEES: $175.55 ---COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all apptical l` a codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 244846 (6100) e WORKERS' COMPENSATION DECLARATION: hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is Issued. L='§ktion i flava and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit Is Issued. My worke p a tionlr/}I/��ur�an�c carrier and policy number are: E"4� r�i 1 L/4�--------- - -- rPolkyNumber; need not be composted if the permit is valued atone hundred dollars ($ f 00) or less.) c ❑ 1 certify that in the performance of the work for which this permit Is Issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, nd agree that if 1 should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, 1 shall forthwith comply with those pr slons. J I z n1 _4pplkoarttSignature:—^--Date;�_r W .-FAILURE TO SECUREWORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUEUECT AN EMPCOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLURE ($100,ODD0 IN ADOMON TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3705 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am Ilce se ndaprovisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business n rofessiens Code, and my license is in full farce and affect-Llc: p � ctorlsSignature: —" CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Data: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its issuance, also requires the applicant lar such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Socllon 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or Improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. It, however, the building or Improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I. as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of properly who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ l am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: VerificBlion of Ownership by (type of document, Le. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, faisework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high, (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 WIA the applicant or present or future building occupant need to file and certity a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 5D0 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ......................„._._......................._................................._..,.ilding ....._........ ................ ..... t'e. _...__.-..................... ..... ........... 2 Does er wifl the applicant or present or future building occupant need to file a registrar€on form for acutely hazardous materials? 0 Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions. requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _T.._.................... ---... ................ ._........ _............................................ .................. --....................... ........................................................ .... _.................._ ........._................. 3 bo"'o"'s or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Soction 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. _..................-------..............-•-----......---_..................................................................-........................................................................................................................................................... —...................... -.---... .—............... 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully compiled with? ❑ Yes ❑ No — ..Does ......... _. _ — .....---........................ _.... —... _................... __....................... 5 or willVthe applicant or present or tuture building occupant.. �.requir...... .e for the work which is the subject of this appllcatlon aermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? W Yes f No (Section 65850.2 of the California Government Code requires that the requested informatlon be furnished on applications for non-residontial building permits). _ _— ..................---................................ ---.......................... _........... ......... .............. _.............. .... ........... ...------........... 6 W€II any part of the facility to t. con_..structed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If yes-, the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency €s required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 boon made? ❑ Yes ❑ No 8 pf "yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above Is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that t have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. net Of Legal Ownor(s) Da1Q , f -"AndfOr Authortzed Applicant r--Dato — - OODE�, INSPECMN TYPE Qej)r INTMA$ WDE INSPECTIQNTYPE R ] $ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pod Spa Final 208 Final Plumbing Ll 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final 8uildinglOccupancy BUILDING PERMIT ,lob Address: 3333 BRISTOL ST Status: ISSUED Suite: 1212 Applied: 08/30/2006 Vicinity: SUITE 1215 HUGO BOSS Issued: 09/19/2006 Primary Occ: M Display/Sale Merchandise Type of Construction: I -FR Parcel Number: 41250107 Zoning: PDC ISSUED BY: Applicant: IMBRAILE, PAT Address: Phone: 714-957-8250 Zip: Owner:SOUTH COAST PLAZA , Address i COSTA MESA CA' Phone: 3315 FAIRVIEW ROAD Zip: 92626 Contractor: DEVELOPMENT SUPPORT SERVICES INC Address: 1515 W ALTON AV SANTA ANA, CA Zip: 92704 Phone: 714-957-8250 License: 748446 Arch : GEORGE ENESEY Eng: Address: WESTGROUP DESIGNS Address: IRVtNE,CA Phone: 949-250-0880 Phone: 1350 REYNOLOSAV STE 101 Zip: 92614 License: C27058 License: SCOPE OF PERMIT `INTERIOR DEMOLITION FOR NON BEARING WALLS TO UNIT 12112, HUGO BOSS, AND CEILING FOR FUTURE TI. CAP THE PLUMBING IN THE BATHROOM THE ELECTRICAL AND REMOVE THE DUCT SYSTEM. i Plan Check: $208:81 'Permit: $321.25 ; SMIP Res:, SMIP Coin: �. , . '$4.20/ Other: '$0.00 ' Inspection: -$0.00 FEE SUMMARY. J Calc Valuation: $20,000.00 Claim,Valuation: $20,000.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2449-46 {tYOOi : • ' w v DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one Of the following declarations: ❑ 1 have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is Issued. 0� I have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued, rimy workers' compen tion Insurance carrier and policy number are: Carrier: C Oare"t701 / _ - _ GP&(ti Number: 0 3 k/��C —ooa19— —(This sBctlon need not be completed it the pormlf is valued at one hundred dollars ($ 100) or fess.) J❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shalt forthwith comply with theserSiTons Applicant Signature:'_ WARNING: FARURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE (5100,000), IN ADDITION To THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am liensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic-#N Class _ 'Contractors Signature- CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there Is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to Its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Lew (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (5500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or Improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. It, however, the building or improvement is sold within one year of comptetion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors Uconse Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Drivor's License No. Expires: Verification of Ownership by (typo of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Pian for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the Califomle Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feel of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or fulure building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ................................ .................................................. ._................. ...................... —........................................................ _.._.-........ ............. ........ ..—......_..... ............................................. 3 Does or will the appplicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? El Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a Qermil for such construction or modification from the South Coast Air Quality ManagOmOnt District or from any other air pollution control district or agency/? Ll Yes j] No (Section 55650.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (it'yee, the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). - - ................ ................ _ __..........._.............,.......................... ..... _ _ — _ .....— ................... -- --.._—.... __.......... ......... _.............. 7 if a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (If yes', attach certificate of compliance from the appropriate air pollution control offlcory. CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the Information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I cenify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not 10 occupy or allow occupancy of any building authorized by this permit until final inspection. UJSignature Of Legal Owner(s) Date O----_ 9- r 9- o K 'AndlOr Authorized Appllcant (-Dwa CODE /. (NSPECTIONTYPE QdT KTITIA CODE INSPECTION TYPE Qdjg (M1,11 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final B1ock/Rotaining Wall 212 Final t=ire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition ! d 250' Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.c€.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 BUILDING PERMIT Job Address: 3333 BRISTOL ST ', rrz ,, c -. Status: ISSUED Suite: 1601 ELECTRIC. Applied: 0211 212 0 0 2 Vicinity: J Issued: 02/1212002 Parcel Number: 41250107 Zoning: PDC PDC Calc Valuation: $8,000.00 Permit: $153.25 Applicant: SIEBERT, PHIL -SMIP Res: $0.00 ISSUED BY: SMIP Com: $1.68 Address: 2377 SO EL CAM INO REAL- Inspection: $0.00 'Total: $254.54�� SUITE 103 - Phone: (949) 361-0111 PLANNING & ZONING SAN CLEMENTE, CA " - Zip: 92672 MAIN STRUCTURE Front 0- 0 Rear 0-0 Left 0-0 Right, -';.0- 0 Owner: SOUTH COAST PLAZA ACCESSORY Front 0-0 Rear - 0-0 Left 0-0 - Right . ; ,G -'O, PARKING Existing; 0 ._Reduired:. 0 Address NOTES: - - COSTA MESA CA Phone: /3315 FAIRVIEW ROAD; Zip: 92628 Contractor. `HORST AND-SIEBERT�� 'Address:: 2377 SO,EL CAMINO REAL SUITE,103-/ Phone:; '(949) 361-0111 SAN CLEMENTE, CA Zip:.. 92672,' License: 622681 Arch Eng: - Address: Address: _Phone: Phone: 'Zip: License: License: NOTICE: The work autherfzed by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or it work Is suspended or abandoned for a period of 180 days. _ INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 44646 t6ro0► OF PERMIT.— ', rrz ,, c -. _� .SCOPE r - -• � DEMOLISH EXISTING T.I. FRAME NEW MALL BULKHEAD AND INSTALL -NEW PAVERS TO LEASE LINE SAFETY OFF ELECTRIC. 'DOONEY AND BOURKE' UNIT 1601. 2,400 SF, J _ FEE SUMMARY,, Plan Check: $99.61 - i Calc Valuation: $8,000.00 Permit: $153.25 -� Claim Valuation:,, $8,000.00 -SMIP Res: $0.00 SMIP Com: $1.68 Other:. $0.00 Inspection: $0.00 'Total: $254.54�� PLANNING & ZONING SETBACKS MAIN STRUCTURE Front 0- 0 Rear 0-0 Left 0-0 Right, -';.0- 0 ACCESSORY Front 0-0 Rear - 0-0 Left 0-0 - Right . ; ,G -'O, PARKING Existing; 0 ._Reduired:. 0 NOTES: - - NOTICE: The work autherfzed by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or it work Is suspended or abandoned for a period of 180 days. _ INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 44646 t6ro0► DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the }� �ork for which this permit is issued. V have and will maintain workers' compensation insurance, as required by section 37th of the Labor Code, for the performance of the work for which this permit is Issued, My workers' a ar.� • co rs Ion Ins a_nte ca aUnumber are: � GG ,._ ._ %Number:. is section need not be completed it the permit is valued at one hundred dollars ($100) or less.) ❑ 1 certify that In the performance of the work f7whicilhis pe It Ls issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Calif is d a ould a subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisi O Z �q�llca'nt-Signature Date:" �' ,� '�� z � WARNING: FAILURE TO SECURE ORKERV COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL RNEs up TO ONE HUNDRED THOUSAND DOLLARE (tel D0,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm thatlam licead under v' ions of C pter 9 (commencing with Section 7000) of Division 3 of the Busin s and Professions Code, and my license Is In full forc and eHect.,Lic..M, - 2-Z Efass q' -"r - Coact&.5-Signature:tem.,-7- , 2�(Z `O CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lenders Address: Signaturo: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, altar, Improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or Improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a coniractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's Ucense No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION. ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, talsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-bullder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or luture building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Pian be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ......... .............. »....................................... .-------- ......................._.............._._............._—....................... ..................... _...................................................................... ---- .... _......... __....... ------ - 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the Calitomia Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic teat of compressed gas at standard temperature and pressure). .........................__......................................................................»......................................... __..................................................................................................................... ........ ............... ».».»-....-1111.......»......... _ .. 3 Does or will the appplicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes [3No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ..............................................»».»..........................._.............................1111..—......_.....................................»»........................................................................................................................................._............................ ......... _. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been tuliy complied with? ❑Yes ❑ No ......................._..__......................._...—.._........................ .--_..... ....--............................................ ..................... ...................................................................... _.............. _.................................... _................... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ».....................................»»»....................................._...._...—_...ithi.....---..._........................._...................................................................................................._......................- $ W III any pari of the facility to be constructed under this permit be within 100D fest from the outer boundaries of a school? ❑ Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ....._....................... _.......... -- -- »»»»1111..».».----....--.._—....................._........---....-----••----..........................................................�.-................ ........ .. 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No .. ............. ............................. »».»».......... .......................... _.._.................... -........................................................................................................................ »....... ..........................»»....1111.--....... _........... —.... attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I cartity that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given Is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for Inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature gal err ) Date OrAuthonz dApplicant�� CODEL INSPECMNTYPE Qdjf, KTITIA CODE It INSPEMO-N- PE RAN INTMAL� 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Ra -Roof 210 Final Electrical 201 Final BlocklRelaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval . 203 Final Sign 222 Final Site .204 ' Final Damolillon 250. Final Building/Occupancy MAL.f " (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT Job Address: 3333 BRISTOL ST Suite No 1423 Vicinity: Parcel Nunmber: 41250107 Status: ISSUED Applied: 09/22/2003 Issued: 09/22/2003 Applicant: SMALLCOMB, KEVIN • _ ISSUED BY: Address: 136 E GARRY J Phone: (714) 556-8591 SANTA ANA; CA _ - Zip: 92707 Owner: /SOUTH COAST'PLAZA Address - COSTA MESA CA Phone: 3315 FAIRVIEW ROAD Zip: 92626 Contractor: SMALLCOMB WIRING CORPORATION Address: 136 E GARRY Phone: '(714)556-8591 SANTA ANA, CA ' ; ' Zip: .9.2707_ ` License: 145961 NOTICE: The work authorized by this permit shall comply with ail applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 2446.46 (6=) --SCOPE OF PERMIT - INTERIOR 1850 SF SALES AREA AND 302,SF STOCK ARE(TOTAL: 2152 SF) STORE TI FOR "ROBERTO CAVALLI"-IN SPACE7 1423./ _ 1 _'i NO PLUMBING TO'BE DONE -WITH THIS TI. ELECTRICAL TO INCLUDE: 192 LIGHT FIXTURES, 32 OUTLETS, 10 SWITCHES AND 1 SUBPANEL TO 200 AMPS. REF: B03-01318 - FEE SUMMARY 7' Quantity Quantity ISSUE FEE $23.50 Temp Dist System / Lighting $0.00 0 Temp sorvice test $0.00 Busway /100 ft - $0.00 0 , Re6.`alc package $0,00 -.,Standing Section $0.00 • „0 New Res (1-2 units) $0.00 0 �., ,'': 'Misc Electrical Equipment $0.00 0 New Res (3wunits) $0.00 0 , s'' Transforrriers up to 1 kvalkw $0.00 0 Pool / Spa, $0.00 0 ; ; .........:.....up to;10 kvalkw $0.00 ' 0 Lighting Fixts $147,56 ;192. ......up to 50 kvalkw $0.00 0 Recept Outlets 32 - .up to 100 kvalkw $0.00 0 Switches /'"$30.76 -$58.50 70 ..................over 100 kvalkw $0.00 0 Non Res Appi $0.00 0 J Low Voltage Equipment $0.00' • 0 Res Appl 66.00 01 Low Volt Wiring System 1 Ckt $0.00 0 Service to 200a $Il.bo 0 Misc. Conduit $0.00 0 Service to 1000a $0.00. •0 _ Misc. Conductor $0.00 0 Service over 1000a $0.00 0- Circus ( gen or ride) ' $0.00 ; 0 Motors to 1hp $0.00. 0 ' ' ` - Circus'(mech ride or lights) $0.00 l-' 0 Motors to 10hp $0.00 0- .. Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 0 Fireworks Stand $0.00 0 Motors to 100hp $0.00 0 - Other Electrical Fee $0,00 Motors over 1 00h $0.00 0 NOTICE: The work authorized by this permit shall comply with ail applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 2446.46 (6=) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: . I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the . ork for which this permit is issued. I have and wilt maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My wors' compensation Insurance carrier and policy number are: Carrier: CA _ Policy Number: (This section not be completed if the permit fs valued at one hundred dollars ($100) or less.) ❑ 1 certify that in the performance of the work f which this permit is issued. I shall not employ any person in any manner so as to become subject to the workers' compensation laws o slifomia, ee at if I should became subject to the workers' compensation provisions of Section 00 of the Labor Code, I shall forthwith comply with these pr ions. •," Applicant Signature: Date: L 6j Ln !.� WARNING: FAILURE TO SECURE WORKERSCOMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,00D), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am lice s d under prov' to of apter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic. tt Class p Contractor's Signature: pate: CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ f, as owner o1 the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not intended or offered for sale. 11, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). - [3 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet In depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION - 1 Will the applicant Or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reponed year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ............................................................................................................................................................................................................................................................................................................................................................................................ 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 o1 the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ....................._............................................................................................................................................................................................................................................................................................................................ 3 boas or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ...........................................................................................................................................................................................................................",......................._............................................................................................. 4 if an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No ........ ....... .............................................................................. ................................................................................................................................................................................. ................................................ ........................ 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application aermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or aganc 7 U Yes 6 No (Section 65850.2 of the California Government Code requires that the requested information be fumished on applications for non-residential building permits). ........ ............................................ _...... ................................. ­--­--- 1.................................................................................................................................................... _........................................................................................ 6 Wil! any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (It "yes', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ................. .­­..................... .............................. _...... ----............................................................................. ..................... -...._............................................... ......................................................................................... ...................... 7 It a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Coda Section 42303 been made? ❑ Yes ❑ No ....................•••------......................................I...._........ ._.................................... _............................................ -................................. --•-•--........................------- 8 (N yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to Comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances ielating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the ab o -described property far i pection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. ig lure 01 Legal Owner(s) Date And/Or Authorized Applicant Date CODE R. ! INWIAL$ CODES INSPECTIONTYPE RALE I S 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Root 210 Final Electrical Hit 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy 71M N CITY OF COSTA MESA BUILDING DIVISION DEVELOPMENT SERVICES DEPARTMENT PERMIT (714) 754-5273 - Fax (714) 754-4856 • www.ci.costa-meM fu%UPRESSION PERMIT .lob Address: 3333 BRISTOL ST Suite: 1423 Vicinity: SPACE 1423 (ROBERTO CAVALLI) Parcel Number: 41250107 Zoning: PDC PDC Applicant: SCOTT SHELTON Address: Phone: 714-779-6012 PERMIT'NUMBER 77 FAIR DRIVE, COSTA MESA, CA 92626 Status: ISSUED Applied: 0912412003 Issued: 10/06/2003 ISSUED BY: We, Zip: Owner:,, SOUTH COAST PLAZA Address, '.. COSTA MESA CA Phone: 3315 FAIRVIEW ROAD Zip: 92626 Contractor: SHELTON FIRE PROTECTION CO INC Address: 4875 E LA PALMA AV SUITE 609 Phone: - 714-779-6012 ANAHEIM, CA Zip: 92807 License: 677631 SCOPE OF PERMIT RELOCATION OF 30 OVERHEAD SPRINKLERS IN CONJUNCTION WITH THE INTERIOR 1850 SF SALES AREA AND 302 $F STOCK AREA (TOTAL: 2152 SF) STORE TI FOR "ROBERTO CAVALLI" IN SPACE 1423. REF: B03-01318 l - FEE SUMMARY Plan Check: $63.21 Calc Valuation: $3,200.00 Permit: $97.25 Claimed Valuation: $3,200.00 Other: $0.00 Total: $160.46 , NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 >446.46 (6=) DECLARATIONS A WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Coda, for the performance of the workrfor which this permit is issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Cade, for the performance of the worts for hick this permit is issued. —My wo c pensatio suranc carrier policy number are: ���� Carrier: l , � // v> PoNi Number (This section need not be completed 1l the p is valued at one hundred dollars ($100) or less.) �� ❑ I certify that to the anc t wo r i s permit is issued, I shall not employ any parson In any manner so as to become subject to the workers' compensatl0s of Cali a, Id become subject to the workers' compensation provisions of Section 370 of the Labor Code, I shall forthwith comply with to Applicant Signature: ' -Date: ZZ WARNING: FAILURE TO SECURE COMPENSATION COV ERA IS UNLAWFUL AND SHALL SU131ECT AN EMPLOYER TO CRIMINAL. PENALTIES D CIVIL FINES UP TO ONE HUNDRED THOUSAND DOt LARE (SIOO,ODD), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby afflrm.that.i_am_ licensed un r a ter 9 (commencing with Section 701X)) of Division 3 of.the Business and fessi ns Code, and my license is in full force and effect. Lic. A Class if j Cont-racto��gnature:. 1 Date: CONSTRUCTION LENDING AGENCY: f ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code), Lenders Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5. Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to Its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not Intended or offered for sate (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or Improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. if, however, the building or Improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of properly who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. © Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type o1 document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more then thirty-six (36) feet high, (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present Or fUlure building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Cade requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .... ................... .............................................................................._................................... ... -................... -..................................................................................... ... _111. ..............................................._ 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 Of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to Or greater than a weight of 500 pounds, or a volume of 55 gallons, Or 200 cubic feet of compressed gas at standard temperature and pressure). ...................................................................................................... -...................... _...................... ---................... —..... ............................................................ ...................----................. .._.....-.....- .............. .. 3 Does or will theapplicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? r_1 Yes ❑ No Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and tiling with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required, has Section 25534 of the California Health and safety Coda been fully complied with? ❑Yes ❑ No .........................................I..............,.,.................................................................................................................................................................................................................................................................................................................... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication aPermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? El Yes L] No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ....................................................................................• ---......................-............................ .................................................................................................................. ......................................................-�-�----111.1......................... 6 wk any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (It "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safely Code). .................................................................................................................1---..................... ...............................------•-•----................................................................... ........_................................. ................................... ................................. 7 If fl permit from the South Coast Air Quality Management District or other air potlution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No .....................................rtjf............................4ja' ,'c"...lio'.....t'h........p'r'...............air,.. o'1'1......................o,"I..ffic"ar')......................... ................................................ .................................................................. ... 8 (If "yes", attach certificate of compliance from the appropriate air, pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF D RATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. i ogre compt ith all d city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa t0 enter upon the p es. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. �inf r(s) to rAnd/Or Authorized Applicant_ CODE ii, INSPECTION TYPE 2&U INTITIAIS CODE 1 INSPEC11ONTYPE 2&U RMDALS 1616 Fixed System Final l=ire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical Blo 201 Final 8locklRetaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.'91fflLDING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Status: ISSUED Suite: 1423 Applied: 08/04/2003 Vicinity: SPACE 1423 (ROBERTO CAVALLI) Issued: 09/0212003 Parcel Number: 41250107 Zoning: PDC PDC Applicant: RON BEGLEY ISSUED BY: J� 1 Address: 1506 RAILROAD ST Phone: 818-232-1118 GLWENDALE; CA%�_ Zip:' MAIN STRUCTURE Front', 0- 0 Rear_ SOUTH COAST PLAZA Right 0.0' i Owner: Address ' COSTA MESA GA Phone: Rear`0- X3315 FAIRVIEW ROAD-,;:. Zip: 92626 / Right.0-.0'„ PARKING Existin 0 Required: Contractor: vBRODSON:CONSTRUCTION % 'Address: 167•NE 39TH STS Phone: -" 305-576-9909 �,`� �� �• �, MIAMI,, FL Zip: % 33137 ,' License: 821395 Arch BARTELUCE ARCHITECTS, PC I,MICHAEL'GATTI ­ Eng: Address: CIO 36 W -25TH ST _ . Address:' . •, ;� �� Phone: —212-691-7200 _ - �� Phone: NEW YORK,.NY f i n Zip: 10010 ` License: C-26233 License`. SCOPE OF PERMIT INTERIOR 1850 SF SALES AREA AND 302 SF STOCK AREA (TOTAL: 2152 SF) STORE TI FOR`ROBERTO CAVALLI" IN SPACE 1423. 'NO PLUMBING TO BE DONE WITH THIS TI., FEE SUMMARY Plan Check: $343.49 Permit:' $2,113.75 SMIP Res: l $0.00 SMIP Com: $63.00 Other•'\ x,$0.00 %In \,$0.00 v,Total:$2,520:24: �, Calc Valuation: �! ! $300,000.00' claim Valuation: $300.000.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work Is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754.5626 PLANNING& ZONING SETBACKS v'\ MAIN STRUCTURE Front', 0- 0 Rear_ 0-011—, Left- 0-0 Right 0.0' i ACCESSORY Front ,-0-,0 �`:' Rear`0- 0 Left 0 " / Right.0-.0'„ PARKING Existin 0 Required: .0 . ( 0. - Proposed: 0 % NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work Is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754.5626 7 DECLARATIONS WORKERS' COMPENSATION DECLARATION: y , ! hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. ❑ t have and win maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy number are: Carrier: - C) C�Ct,,M14 � f^uP,—= �-0. � Policy Number: .O GC rz�'�_S9 (This section need not be comp! red f permit Is valued at one hundred dollars ($100) or lass.) ❑ 1 certify that in the pe nce of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws is, _Ia. end a that Ii I sh become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with thea Applicant Signature: Date: WARNING: FAILURE TO SECURE WORKERS' COMPENSATi RAGE IS UNLAWFUL AND SKALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLL4RE ($100,000), IN ADDrrI0N TO THE PENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS D LARATION: I hereby affirm that I am Ilcan ndef provisions of Ch pt 9 (commencing with Section 000) of Division 3 of the Business and Prof ions Code, and my license is in full force and effect. Lic. K Class N G Contractor's Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there Is a construction fending agency for the performance of the work for which this permit Is Issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Data: OWNER -BUILDER DECLARATIONS: 1 hereby affirm that under penalty of perjury that t am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professlons Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to Its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors license Law (Chapter 9 (commencing with Section 70)0) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a efvil penalty of not more than five hundred dollars (SSW).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). . ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, I.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person Is required to descend, will be made In connection with work authorized by this permit, and that no building structure, scaffolding, faisework, or demolition or dismantling thereof, will be more than thirty-six (38) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Data: Division of industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 WIII the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cable feet of compressed has at standard temperature and pressure). -._ compressed ................_.... _.. __.... _ _.._ __.. ...............-----..__......._..—.-.-....---.... _..._ � . 2 Does or will the applicant or present or future building occupant need to fila a registration form for acutely hazardous materials? ❑Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _..................................._............................................. I ............. -- 11 .................. ..._.-............................. _................................................. _... .... ..................... .......................... ............................ ............................ _.................... __. 3 Does or will theaappplicant or pres#nt or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? 13 Yes ❑ No (Section 25534 of the California Health and Safety Coda provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully compiled with? ❑Yes ❑ No ...._............................................................................................. .................... ......._.._............................ _._.............. ..---.................._._......................................................_-........................ .................................... ...................... _ 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this a plication a grmit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes 8 No (Soctlon 65850.2 of the California Government Code requires that the requested Information be furnished on applications for non-residentlal building permits). ........ .........._..._...................... _..................................................... ..-._........................ .-. W .......................... -.................... .-............... ............................_._..._......._..._...................._....._......................__T._................._.......... 6 WIII any part of the facility to be constructed under this permit be within 1000 foot from the outer boundaries of a school? �] Yea ❑ No (it 'yes*, the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). .............................................................................................................................................................................................................................................................................................................-........................_.................................. 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by Califomia Health and Safety Code Section 42303 been made? ❑ Yes ❑ No .....................................rtif...........................:I'ia,...........................*a.p' .'r'o'.............eir,.p,o.l.............00'i..........off,l.......................................... .......................................................................................................... _... _......................... _.... 8 (if fres", attach certificate of wmpiiance from the appropriate a€r pollution control officer). CERTIFICATE OF COMPLIANCE: I certity that under penalty of perjury the Information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF OMPWANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the infor7enterupon is correct. I agr o mply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to he above -d aroporty for €n action purposes. l4gree not to occupy or allow occupancy of any building authorized by this permit until final inspection: tL Z ature al Owner(s) D to za AndfOr rfzed Applicant ate G9DE I INSPECTION TYPE 2M INTMAI$ 00DE INSPECTION TYPE 2M PITIM 1616 Fixed System Final Fire ention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wali 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Fina! Sign 222 Final Site 204 Final Demolition 250 Final Bullding/Occupancy Q/7 ii (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 MECHANICAL PERMIT Job Address: 3333 BRISTOL ST Status: ISSUED Suite No 1423 Applied: 09/25/2003 Issued: 09/25/2003 Vicinity: SC( Parcel Number: 41250107 ISSUED BY: Applicant: FIGUERORA, CHARLES Address: 7077 ORANGEWOOD AV # 211 Phone: 714-894-7294 GARDEN GROVE Zip: 92841 Owner: SOUTH COAST PLAZA Address: i COSTA MESA CA Phone: 3315 FAIRVIEW ROAD Zip: 92626 Contractor: CONTINENTAL BUILDING CONTROL SYSTEMS Address: 7077 ORANGEWOOD AV # 211 Phone: 714-894-7294 GARDEN GROVE �" , Zip: 92841 License: 750822 SCOPE OF PERMIT INTERIOR 1850 SF, SALES AREA AND 302 SF STOCK AREA (TOTAL: 2152 SF) STORE TI FOR "ROBERTO CAVALLI".IN SPACE 1423. NO PLUMBING TO BE DONE WITH THIS TI. HVAC WORK TO INCLUDE: 2 ZONES FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 Repair 1 Alt Absorbtion Unit $0.00 0 Inst FAU <100 k BTU $0.00 0 Repair 1 Alt Refrigeration Unit $0.00 0 Inst FAU >100 k BTU $0.00 0 Ventillation System $0.00 0 Repair I Alt Cooling/Heat $27.40 2 Evaporative Cooler $0.00 0 Inst! Rep. Recess Wall Htr $0.00 0 Commercial Incinerator MOO 0 Refrig Sys <100 k BTU $0.00 0 Domestic Incinerator $0.00 0 Ref rig Sys >100 k BTU $0.00 0 Compressors / Absorption Systems Gas Piping $0.00 0 Up to 3 hp 1 100k BTU $0.00 0 Factory Fireplace $0.00 0 3 To 15 hp / 500 k BTU $0.00 0 Hood wlMech Exhaust $0.00 0 15 To 30 hp / 1,000 k BTU $0.00 0 VAV Box $0.00 0 30 To 50 hp! 1,750 k BTU $0.00 0 Vent Fan / Single Duct $0.00, 0 Over 50 hp 1 Over 1,750 BTU $0.00 0 Appliance $0.00 �0 Boilers Fire Dampers $0.00 '0 Up to 3 hp $0.00 0 Smoke Dampers $0.00 0 3 To 15 hp $0.00 0 Inst or Relocate Appi Vent $0.00 '0 15 to 30 hp $0.00 0 Air Handlers < 10000cfm $0.00 .0 30 to 50 hp $0.00 0 Air Handlers > 10000cfm ` , $0.00 q Over 50 hp $0.00 0 Floor Furnace $0.00 0 Other Mechanical Fee Floor or Suspend Heater $0.00 -0 Investigation Fee $0.00 Plan Check Fee $0.00 Reinspection Fee $0.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 2446-46 (6100) C � • ;�<-,. j TTL. � - WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the coo r which this permit is issued. have and will maintain workers' compensation Insurance, as required by section 3700 of the tabor Code, for the perlomtiance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed i7 the permit is valued at one hundred dollars ($100) or fess.) ❑ f certify that in the parfortnarlpe of the work for which this permit is issued, I shall not employ any person in any manner so as toRM ome subject to the workers' compensation laws of Cala ia, a agree that if I should become subject to the workers' compensation provislons of Sec} r Coda. I shall forthwith comply with the S. (/f Applicant Signature: , �J� Date: L WARNING: FAILURE TO SECURE WORKERS' COMPENSATION GE IS UNLAWFUL AND SHALL L SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOILARE (SIDD,OOD). IN ADDITION TO THE COST OF92IMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 37M OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed Under p ovislons of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic. # Class M Contractor's Signatur Date: CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lenders Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penAlty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions CO(J@) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a Civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors license Law does not apply to an owner of property who builds or Improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). - ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who Contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner !D verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title B, California Administrative Code). ❑ As owner-builder, I will riot employ anyone to do work which would require a permit from the Division of Industrial Safely, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number. HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or pre or future building Occupant need to file and certify a Business Plan for emergency responso to release or threatened release of a hazardous malarial? ❑ Yes Ll No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons. or 200 cubic feet of compressed gas at standard temperature and pressure). ........................—......................................................_....................._—..................._—......................_.........................................,...................................T_.............---...,_..-.... — 2 hoes or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ........---.._._......................................................_--..._...................... ...... ,-----.................. _.... ...... ................._._.................................. ............. ..___.„__._._................... .......... ....... _-----.. 3 Does or will theaappplicant or present or future brui)ding occupant need to prepare an RMPP (Rlsk Management and Prevention Program for acutely hazardous materials)? ❑ Yes El ;T1 (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ........... California -- ....a ..................No­_­­­_­­____­__ .__...................._.._....... __.—........... 4 If an RMPP is presently required, has Section 25534 of the a..Health and Safety Coda been fully complied with? ❑Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the ...................work which Is the subject of this a plication aPgermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes l..] No (Section 65850.2 of the California Government Code requires that the requested information be lumished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes No (If yes", the faci5ty must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). _...... ... _..........................._...................... —•---.................. ......................................... ---------................................................----.................................. _ -------- .__...... -- - ...................... 7 if a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Cade Section 42303 been made? ❑ Yes ❑ No 8 (If yes", attach certificate of compliance from the appropriate air pollution control Officer). CERTIFICATE OF COMPLIANCE: ! certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and Dryordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. 1 agree to Comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. 112 /1 C a ure al Owner(s) ^ ] An uth ed Applicant Da CODE 0• INSPECTIONTYPE Q&U INTITIA CODE INSPECTION TYPE 1616 Fixed System Final Piro Prevention 205 Final Mechanical 1266 Pool Spa Fina! 206 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final BlocklRetaining Well 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Buildingloccupancy CITY OF COSTA MESA j&.p f BUILDING DIVISION > 77 FAIR DRIVE, COSTA MESA, CA 92626 - (714) 754-5273 - Fax(714)754-4856 - www.ci.costa-mesa.ca.us F FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BC10-00173 PERMIT TYPE: B_COMBO STATUS: ISSUED - Sub Type: COM—ALT DATE ISSUED: 07/23/2010 ISSUED BY: RIVID JOB ADDRESS: 3333 1►249 BRISTLOL SST CMS; 1f APN: 41250107 Zoning:PDC, , Vicinity: SPACE 1249 Const Type: I -A SO. FT: 6723 Suite/Unit: 1249 Primary Occ: Valuation:' 3,000,000.00 SCOPE OF WORK: 6,723 SF INTERIOR TI AND EXTERIOR FACADE AND WALK WAY IMPROVEMENTS FOR "MICROSOFT', SPACE 1249. WORK TO THE MAJOR STRUCTURAL DEMOLITION OF CEILINGS, WALLS AND FLOOR, IMPROVEMENT WORK TO INCLUDE RELOCATION OF PARTITION WALLS IN ORDER TO EXPAND TENANT SPACE, REMOVAL OF NON -LOAD BEARING WALLS TO RECONFIGURE TENANT SPACE; NEW NON -LOAD BEARING WALLS TO CREATE 2 NEW EMPLOYEE RESTROOMS, BREAK AREA, OFFICES, TECH/SERVER ROOMS, JANITORS ROOM, EL CLOSET, STOREAGE AREA, NEW EXIT OPENING TO GRADE, NEW GLASS STORE FRONT, NEW FINISHES AND 2 ALTER/REPAIR CLOOLINGIHEAT, 9 VAV BOX, 2 VENT FANS, 1 FIRE DAMPER, 2 AIR HANDLER TO 10K CFM, 288 LIGHT FIXTS, 174 LIGHT FIXTS, 16 SWITCHES, 1 SVC TO 1000A, 16 MOTORS TO 10 HP, 8 SUB PANELS TO 200A, 1 TRANSFORMER OVER 100 KVA, 1 BKFLW ARV, 1 ICE/COFFEE CONNECT, 2 FLOOR DRAINS, 1 DRINKING FOUNTAIN, 1 EXP TANK, 10 P-TRAP,1 FLOOR SINK, 1 KITCHEN SINK, 1 SVC MOP SINK, 1 TRAP PRIMER, 2 WASH BASINS, 1 WASTENENT, 2 WATER CLOSETS, 1 WATER HEATER, 1 WATER PIPING INST/REP. OWNER: SOUTH COAST PLAZA Phone: APPLICANT: OSBORN, BRYCE Phone: 310.449-5694 Address: 3315 FAIRVIEW RD City/State/Zip: COSTA MESA, CA Address: City/State/zZip: CONTRACTOR: KINNEY CONSTRUCTION SERVICES INC License No. 936863 Phone: 928-779-2820 Address: 120 NORTH BEAVER STREETUnit: Cell: CitylState: FLAGSTAFF, AZ ARCHITECT: ENGINEER: WILLIAM H THORPE License No. License No.S3866 Unit: Unit: : ZipCode 86001 PHONE: PHONE: COMBINATION PERMIT FEE SUMMARY Building Plan Check: $8,390.69 tE:: �Building Fees: $12,908.75Electrical Fees: $.1,003.86 !r '1 i•� l Mechanical Fees: $189.Q n 1 U TF' Plumbing Fees: $317.50- `\ SMIP Residential: $0.00 SMIP Commercial: $630.00 Bldg Std Admin Fund $120.00 TOTAL FEES: $23,560.60 "Refer to foo receipts for all fees gald for project e� �Mymi r I uesan reae eguIations. (Ord. o. 2 , 1. 1 - EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE i, INSPECTION IYpE 9A19 INT91AL CODE t INSPECTION TYPE 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 200 Final Re -Roof 201 Final BlocWRetaining Wall 202 Final Factory Fire Place 203 Final Sign 204 Final Demolition 208 Final Plumbing 210 Final Electrical 212 Final Fire Prevention 220 Final Planning Approval 222 Final Site 250 Final Building/Occupancy DATE INTMAlS a -a3-1 t ) .ze.,, g -a- tr P-13 j jCJt- WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which thit permit is issued. ❑ I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy number are: r �rvLdtat (This seder need not be cwnplefed d the penrw is vakied of one hundred dawrs (S100) orkss-) PIiC tuber. ❑ 1 certify that in the performance of the work for which this permit is issued. I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to tiR�?y ensation provisions of Section 3700 of the Lab e,lshwith these provisions. ___Z0/q Z Q — L09p=V 1011111011W s WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. TS—Mor?3 - ORZC J .! CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5. Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature 3057-06 43/t171 Date Owner ID verified by driver's license. ❑ Yes CENo''� Driver's License No. Expires Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework. or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec, 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Division of Industrial Safety Permit Number: Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and Certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds. or a volume of 55 gallons, or 200 Cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department, 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution Control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be fumished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the Califomia Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (if "yes", attach certificate of compliance from the appropriate air pollution control officer), CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature hate CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. it _-j� • • // yr USE OF BUILDING AND WORK TO BE PERFORMED AUG 17-77ensa001618* ****66.50 APPLIC-4(TION FOR STRUCTURAL PERMIT REC I B DATE RECEIVED D EJE) FERMI A.P. N % BUILDING ADDRESS ti TRACT RACT L4F�7D P / � - VALU$ PEGROUP F• /}9 DAT --/;71 ' 1 Z NO. OF USE OF NEW PLANS BUILDING YARDS APPROVED YARDS APPROVED MAIN BUILDING ACCESSORY BUILDING (FROM C/L STREET) A DISTANCE BET. MAIN SLOGS. L VAR.* DATE COSTA MESA BUILDING -SAFETY DEPARTMENT P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626 For Appl' a t o ill ' Ce 1 Use Ink BUILDING ADDRESS the State of California. "T44G is OWNER L-1 VOgy MAIL t ADDRESS �, �-j � �� PLAZA Chapter 9, and that such licenses are In full force and effect, or I TEL. CITY �L213� NO. +" CONSTRUCTION PERMIT FEE $ LENDER and Professions Code, Division 3, Chapter 9. BRANCH ADDRESS Signature o/p(` �Lj`/ /fid-7_�+lJ—[SZi ARCHITECTL PLAN CHECK �r OR ENGINEER Permittae,i, ADDRESS TAX S $ CONTRACTORf C.aI�jT f(JN ADDRESS 1 1'�]� I �kEPI 1571 i-+ _ T EL . CITY C�T� MP � t GA NO. �;W - I STATECITY LIC. NO. LIC. NO. SIZE .T NO. OF SLDGS.7 OF LOT NOW ON LOT USE OF EXISTING BLDG. GW f TT I N ✓ 1 V 4�� Separate permits are required for electric, plumbing and heating work. USE OF BUILDING AND WORK TO BE PERFORMED AUG 17-77ensa001618* ****66.50 APPLIC-4(TION FOR STRUCTURAL PERMIT REC I B DATE RECEIVED D EJE) FERMI A.P. N % BUILDING ADDRESS ti TRACT RACT L4F�7D P / � - VALU$ PEGROUP F• /}9 DAT --/;71 ' 1 Z NO. OF USE OF NEW PLANS BUILDING YARDS APPROVED YARDS APPROVED MAIN BUILDING ACCESSORY BUILDING (FROM C/L STREET) A DISTANCE BET. MAIN SLOGS. BET. MAIN & ACCESS. SLOGS. VAR.* DATE C.U.P. * APPROVED APPROVED/��UA4 —_ —_ r /_2 I hereby acknowledge that I have read this application and state n that the above Information is correct and agree to comply with m all laws regulating building construction, and I shall not employ any person In violation of the workman's compensetlon laws of m the State of California. I hereby certify that I am properly licensed as a contractor under SQ. FT. N the State of California Business and Professions Code, Division 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR M Chapter 9, and that such licenses are In full force and effect, or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ON Y: " am exempt from the provisions of the State of California BusinessVALUATION PERMIT FEE $ v and Professions Code, Division 3, Chapter 9. m Signature o/p(` �Lj`/ /fid-7_�+lJ—[SZi � PLAN CHECK �r o � Permittae,i, ,�r% $ VV TAX S $ U Authorized Agent TOTAL PAID $ I � CI Y OF COSTA ML JA D Development Services, Division of Building and Safety CERTIFICATE.OF OCCUPANCY This certificate is issued pursuant to the.requirements of the Uniform Building Code, Section 308 adopted by the City of Costa Mesa certifies that at the time of its issuance the building structure herein below described was inspected and approved for occupancy as follows: Building Address 3333 B r is t o.i -; s t <. , S t e-] _4:21 Bldg. Permit Number a C 0 7- 0 0 2 6 6 Use Gift Retail {1;,;:3:67 _s. f.) Group Omer of Building Address 3315 l -FR= XXXXXPDC Type of Construction Fire. Zone h: Use Zone South 'Coast ,Pka'za Fairview Rd::,;: -Costa :Diesa., BUILDING OFFICIAL-Khanh Q. Nguyen; C.B.O� Tenant' LAhSQUE, CA 3.2626- By Date 07/ REQUIRED TO BE POSTED IN A CONSPICUOUS PLACE A CITY OF COSTA MESA BUDDING DIVISION e r 77 FAIR DRIVE, COSTA MESA, CA 92626 (714) 754-5273 •Fax (714) 754-4$56 www.ci.costa-mesa.ca.us FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER. BC07-00266 PERMIT TYPE: B_COMBO Sub Type: COM—ALT JOB ADDRESS: 3333 1421 BRISTOL ST CM APN: 41250107 Zoning:PDC, , Vicinity: SPACE 1421 Const Type: I -FR SO. FT: 0 STATUS: ISSUED DATE ISSUED: 0311012008 ISSUED BY: ?? Suite/Unit: 1421 Primary Occ: M Valuation: $10,000.00 SCOPE OF WORK: 1,387 S.F. INTERIOR TENANT IMPROVEMENT FOR "LALIQUE" IN SPACE 1421. DRYWALL PATCHING, FINISHES AND REPLACE/RELOCATE LIGHT FIXTURES. OWNER: SOUTH COAST PLAZA Address: Unit: COSTA MESA CA Phone: City/State/Zip: 3315 FAIRVIEW ROAD APPLICANT: J BARRY Phone: 949-798-9080 CONTRACTOR: ONE -BERRY INC Phone: 310-753-5797 Cell: ARCHITECT: S J BARI ENGINEER: Address: City/State/zZip: License No. 833395 Address: 2380 CRENSHAW BLU nit: City/State: 'TORRANCE, CA License No.C22471 License No. COMBINTATION PERMIT FEE SUMMARY Building Plan Check: 529.45 Building Fees: $181.25 Electrical Fees: $38.90 Mechanical Fees: $0.00 Plumbing Fees: $0.00 SMIP Residential: $0.00 SMIP Commercial: $2.10 TOTAL FEES: $251.70 "Refer to fee receipts for all tees paid for project Unit: . - i "_r',r7J`, ZipCode 90501 PHONE:949-798-9080 PHONE: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE S. INSPECTION TYPE DATE INTMALS CODE! INSPECTION TYPE DATE INTMAL 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing p 200 Final Re -Roof 210 Final Electrical p/A 201 Final BloOJRetaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site •rr r' 204 Final Demolition 250 Final BuildinglOccupancy �i/} % i'7 X J'17-0 WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: Cl I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the tabor Code, for the perfor ce of the work for Which this permit is issued. -IFhave and will maintain workers' compensation insurance, as required by s tion 3700 of the Labor Code, for the performanc the work for which this permit is issued. M wo is cam ensatian Ins ra ce carrier and policy number are: Carrier: (ribs secnua treed rpt be �mrtrpW ed Oft p[md a vahied t hemdVed ab ars 157A7 Policy Number: I (.7 ) 1,3 27 T6 O ❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensalign laws of California, and agree that if I should become subje t to ;he workers' compensation provisions of Section 3700 the Labor e, LAall forthwith comply with these provisio . 1 -ant's Signalute WARNIN AILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UN UL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTI S AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTOR% DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Prof Bions Code, and my license i i full force and effect. Lic. # Class #- i7 ure ate CONS CTION LENDING AGENCY: ❑ ereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature tate OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the builging or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTOR$ to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractors) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature 3057-a6 (3107) Owner ID verified by drN_ . lice.._ _. ❑ Yes ❑ No Driver's License No. Expires: .i Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) of more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Division of Industrial Safety Permit Number: Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? [:]Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be riled with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (if "yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any build' authorized by this permit until final inspection. Si tur Legal to 12DO Anivor Aut ,zed Applicant - Rate CITY OF COSTA MESA ;-v Sul MFS BUILDING DIVISION i 77 FAIR DRIVE, COSTA MESA, CA 92626 - (714) 754-5273 • Fax (714) 754-4856 • www.costamesoca.gov 1- FOR INSPECTIONS CALL: (714) 764-5626 PERMIT NUMBER: BX12-00129 PERMIT TYPE B_MISC STATUS: ISSUED APN: 41250107 DATE ISSUED: 04/13/2012 Zoning: PDC, ISSUED BY: JOB ADDRESS: 3333 1421 BRISTOL ST CM Suite/Unit: 1421 Vicinity: ROGER VIVIER Primary Occ: Const Type :?? SO. FT: 0 Valuation: $0.00 SCOPE OF WORK: SUPPLEMENTAL PERMIT FOR DEFER INSPECTION OF OUTSTANDING ITEMS IN ORDER TO FINAL SC12-00068. OUTSTANDING ITMES TO INCLUDE REVISED SHELVING TO DELETED SOME SHELVING (PLANS MAY BE REQUIRED SUBJECT TO INSPECTOR), . INSTALLATION OF GRATED SHELVING VS SOLID, HANDICAP PULL FOR POCKET SLIDER FOR "ROGER VIVIER", SPACE 1421. OWNER: SOUTH COAST PLAZA Address:: 3315 FAIRVIEW RD Unit City/State: COSTA MESA, CA Zip Code: 92626 Phone: $0.00 SMIP Commercial APPLICANT: FAUCHALO, MARK Address: Unit: City/State: Final Re -Roof Zip Code: Phone: 201 Final Block/Retaining Wall CONTRACTOR: DICKINSON CAMERON CONSTRUCTION INC License No. 690239 Address: 6184 INNOVATION WAY Unit: City/State: CARLSBAD, CA Final Sign Zip Code: 92009 Phone 760-438-9114 Cell: ARCHITECT: Final Demolition License No. Phone ENGINEER: License No. Phone FEE SUMMARY Building Plan Check: $0.00 Building Permit: $0.00 Electrical Permit: $0.00 SMIP Residential $0.00 SMIP Commercial $0.50 Bldg Std Admin Fund $0.00 TOTAL FEES $147.50 HOURS FOR CONSTRUCTION ACTIVITY: EFFECTIVE 3/18/2010 - PER CMMC Sec. 13-279 Monday thru Friday - 7:00 am thru 7:00 pm. Saturdays -9:00 am thru 6:00 pm. Prohibited all hours - Sundays and the following Federal Holidays: New Years Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day and Christmas Day NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE i, INSPECTION TYPE DATE INTMAL CODE r INSPECTION TYPE 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy L1l�ELt�1�: WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' Compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Cartier: --or 7_J�_ W&J—i`C.At& {Trus mcbm need nor corn 0 pemtd is vakied at onee hurtdR+C dollars {S foo) or fess-) Policy Number: �:Z � 5—� O � I ❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Califomia, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code I II fP. . comply with these provisions. Appricarlt's ignaZure Dale ' WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and ffect. Lic. # ' U Class # IV r 1-3— Date rDate CONSTRUCTION LENDING AGENCY: 0 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Data OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that i am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property. or my employees with wages as their sole compensation, WILL 00 THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not appy to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). QJ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). [I I am exempt under sec. Business and Professions Code for this reason: --- signature 3057.46 (3147) Date Owner ID verified by driver's license. 0 Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: C1 I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, Califomia Administrative Code). C1 As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division, Applicant's Signature pate Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present Or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP Is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be fumished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from The outer boundaries of a school? ❑ Yes 0 N (If "yes', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by Califomia Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If 'yes", attach certificate of compliance from the appropriate air pollution control Officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND' AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. nature of L ga e ► Date j `'l - - Antller Auilwrixetl Applicant Dale = CI'T'Y OF COSTA Mr,A JDevelopment Services, Division of Building and Safety CERTIFICATE OF 'CCUPANCY This certificate is issued pursuant to tHerequireiiierits of the Uriiform•Building Code, Section 308 adopted by the City of Costa Mesa certifies that at the time of its issuance the building structure herein below described was inspected and approved for occupancy as follows:, , Building Address 3 3 33 :a k, i `s`t o I M -S t.;, S tFSe 142.0 <' Bldg; Permit Number B07-00349 Use Group M Retail (2.831, s. f Tyoe of Construction 1 F R Fire Zone X X"X X X X X X X Use Zone South.:. Co'ast, Plaza* '33VLGARz - : Tenant,- Address 3315 Fairvieaa'-Rd : =:.:Costa ',�Nle'sa s=CA 9 2 6 BUILDING OFFICIAL-Khanh Q. Nguyen,. C.B:O: Date Owner of Building oavl REQUIRED TO BE POSTED IN A CONSPICUOUS PLACE PDC CITY OF COSTA MESA �. -BUILDING DIVISION ' > 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 • www.cLcosta-mesa.ca.us t- FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER M07-00380 PERMIT TYPE MECH STATUS: ISSUED DATE ISSUED: 06/1412007 ISSUED BY: RMD JOB ADDRESS: 3333 1420 BRISTOL`-STCM�$uitelUriit:;'s ' x'1420 Vicinity: BVLGARI SQ. FT: 0 SCOPE OF WORK: MECHANICAL PERMITFOR A 2,871 SF INTERIOR T.I. FOR "BVLGARI" ,- SPACE}J420. REF#: B07-0049.2 VAV BOX, 1 VENT FAN; 1 FIRE DAMPER. --,,r OWNER: SOUTH COAST PLAZA:, -,,-"-- Address: :-Unit:C05TA MESA CA PHONE: City/State/Zip: 3315 FAIRVIEW ROAD - APPLICANT: JOHN BOWERS _ Address: Unit: PHONE: 714-883-5172 City/State/zZip: CONTRACTOR: SNEDEN AND BOWERS INC License No. 811856 Address: ' 1081 ST REGIS PLUnit: PHONE: 714-838-4112 CitylState: SANTA ANA, CA ' -`; ` `' ZipCode,..92705 7 CELL: 714-'542-1232., MECHANICAL PERMIT FEE~SUMMARY MECH ITEM FEE: "...,I $59.30 . PLAN CHECK FEE: X` $O:OOj'i' INVESTIGATION FEE: .$0 ' 00 REINSPECTION FEE: l.'.. $0.00 ' TOTAL. FEES: $59.30..jA NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: in order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE S. INSPECTION N TYPE INTMA 5 CODE t INSPECTION TYPE 1 INTMALS 1616 Fixed System Final Fire Prevention 206 'Final Mechanical 7�_ 1266 Pool Spa Final 208 Final Plumbing o �. JIV 200 Final Re -Roof 210 Final Electrical 201 Final SlocklRetaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the tt,,,_mng declarations:' ❑ I have and will maintain a certificate of consent to self-Insure,for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carie rr: / u •-7 (This sedion need not be completed d the permit is valued at one hundred dollars f$ 100) or less.) Policy Numbed: (bc>a Z_ 2 9 r 2 Z Cs Z— -2- ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Zodl s 11 forfhvvi h comply with these pro visi S. Applicant'sgna Dale W NG: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS NLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Cale, and my license,is in full force and effect. lass # nlractoT Signawre je,12 CORUCTION LENDING AGENCY: ! he affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature 3057-46 (31071 Dale Owner ID verified by drive ise. j] Yes ❑ No Driver's License No. Expires: Verification: of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Division of Industrial Safety Permit Number: Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration farm for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution- control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be fumished on applications for iron -residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code), 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No. 8. (if 'yes-, attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under. penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that t have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. t agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Si ur f Legal Owner(s) AndhN AU1[gnxed Applicant— Date- !/ Date •CITY OF COSTA MESA BUILDING DIVISION t` 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 www.ci.costa-mesa.ca.us FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BX07-00008 PERMIT TYPE B_MISC STATUS: ISSUED DATE ISSUED: 07/12/2007 ISSUED BY: RMI JOB ADDRESS: 3333 1420 BRISTOL ST CM:, I -h + SuitelUnit .: ,1420��� �r f��04 Vicinity: SPACE 1420 ',i`` - s Primary _ Const pe:?? ' & SQ. FT: 0 "' Valuation S2,DDD.DV40R F' SCOPE OF WORK: INSTALLATION OF:2 CHANNEL LETTER SIGNS FOR "BVLGARI,;'�SPACE 1420.WI2 SIGN CIRCUITS. REF#: OWNER; SOUTH COAST PLAZA y ' Address: �Umt COSTAWESA CA PHONE: City/State/Zip: 3315 FAIRVIEW ROAD° APPLICANT: MANCHEL, CARR J Address: 14938,SANDROCK DR Unit"-- PHONE: 661-492-3744. t City/State/zZip: LAKE HUGHES CA, - CONTRACTOR: MANCHEL WHOLESALE SIGN;INSTALLATION `-".., Y `License No. 847806'. ; Address: 14938 SANDROCK DRUnit: ' ' PHONE: -661492-3744 City/State: LAKE HUGHES CAi, ZipCode 93532. - CELL:; �. ARCHITECT; Llcense.Na. a - PHONE - s' ENGINEER: License No. fFa. PHONE:!„ MISCELLANEOUS PERMIT FEE`SUMMARY Building Plan Check:` k ='t $45-01- Building Permit: + $69 25 Electrical Permit: Other Fee:$oa]0'� SMIP Residential w SMIP Commercial TOTAL FEES=$140.46 NOTICE: The work authorized by this permit stiall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. Mg # LECTION TYPE 1616 Fixed System Final Fire Prevention 1266 Pool Spa Final 200 Final Re -Root 201 Final Block/Retaining Wall 202 Final Factory Fire Place 203 Final Sign 204 Final Demolition PAR INTITIALS CQQE t INSPECTION TYPE 206 Final Mechanical 208 Final Plumbing 210 Final Electrical 212 Final Fire Prevention 220 Final Planning Approval 222 Final Site 250 Final BuildinglOccupancy QATE INMALS �ORKERS' COMPENSATION DECLARATIO§.Mrig hereby affirm under penalty of perjury one of the declarations` ' ❑ 1 have and will maintain a certificate of consent to self-lnsure.for workers' compensation. as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain workers' compen„ation insurance, as required by section 3700 of the Labor Code, for the performance of the worn for which this permit is issued. My workers' compensation Insurance carrier and policy number are: . (This section need rot be completed it the permit is vafued at one hundred dollars {$100) or less.) Pc1-,vf wjQber: Vl certify that in the performance of the work for which this permit is Issued, I shall not employ any erso in any manner so as to become subject to the workers' compensation ws o California, and agree that if I should e me su 'eci t the worker ' o nsation provisions of Section 3700 of the abor C de, I s I forthwit m with those ro "stone A JA IM Ap 0 e s WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and imylicen i in full force and effect. �s$i9tlaN+rs 'Dale CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the fallowing reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the atleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are' not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or.she did not build or improve for purpose of sale.). ❑ . I, as owner of the property, am "EXCLUSIVELY CONTRACTING. WITH LICENSED CONTRACTORS to construct the project {Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature - - Date 3057-46 (3107) OwnerJD verified by dri se. Driver's License No. ❑ Yes ❑ No Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby Certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Date Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. if a permit from the South Coast Air Ouality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No" 8. (If "yes'', attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND -AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct.. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. AM 1,1111. Job Address: 3333 BRISTOL ST Status: ISSUED Suite: 1420 Applied: 03/2312007' Vicinity: SPACE 1620 BVLGARI Issued: 05/09/2007 Primary Occ: M Display/Sale Merchandise Type of Construction: I -FR Parcel Number: 41250107 Zoning: PDC Applicant: SNEDEN, KENT Address: _ Phone: 714-350-2415 ISSUED BY: „ ,Zip: - 000"7- Owner; SOUTH COAST PLAZA Address F COSTA MESA CA:� Phone: 3315 FAIRVIEW ROAD- Zip: 92626 ' Contractor. SNEDEN AND BOWERS INC = . , Address: 1081 ST REGIS PL. ` f . Phone: 714-838-4112 SANTA ANA, CA Zip: 92705 License: 811856 Arch : 'JOHN FABROCINI Eng: , Address: 21319 PROVIDENCIA ST f Address: - Phone: 8187704-6292 •,` !Phone: WOODLAND HILLS, CA Zip: 91364 License:, C12736, License: SCOPE OF PERMIT 2,871 SF INTERIOR T.I. FOR "BVLGARI", SPACE 1620. WORK TO INCLUDE: CONSTRUCT A NEW STORE FRONT, NEW NON -LOAD BEARING PAF WALLS, CREATE A NEW BATHROOM, ALL NEW INTERIOR FINISHES, ELECTRICAL, MECHANICAL AND PLUMBING WORK.. INTERIOR DEMO WILL BE ISSUED UNDER PERMIT. FEE SUMMARY Plan Check: $252.49 Calc Valuation: $200,000.00 Permit: $1,553.75 Cl aim Valuation: $zoo oob.00 SMTP Res:.. $0.00 - - - ' "` - � -- - _ - . SMIP Com: $42.00 _ i f Other: $0,00 !' Inspection: $0.00 Total: `$1,848.24 ,PLANNING &'ZONING SETBACKS'-.' MAIN STRUCTURE Front . 0-01 - ,Rear, 0-0 Left 0-0 Right ',,/`O- 0 ACCESSORY Front 0=,0, `' `Rear. 0=0 Left - 6-0 ° Right 0 0 PARKING -'Existing: 0. Required: 0 Proposed:-" 0, } NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related - regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 , 244s.ae (Bron) `prig DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code. for the performance of the work for which this permit is Issued. My work mpe sation Ins nce carrier and policy number are: Carrier: Policy Number: ` vW (This tali ra not plef ape ' .Is slued alone hundred dollars f$100) or less.) ❑ 1 certify that in the ce of the or' for which this permit is Issued, I shall not employ any person in any manner so as to become subject to the workers' compensation of Cato and hould become subject to the workers' compensation provisions of Sectio 3700 of the Labor Code, I shall forthwith comply with thea Applic_ snt'Signature: Date: I_� 9 7 WARNING: FAILURE TO CURE E PENSA71ON COVERAGE IS UNLAWFUL AND SHAM SUBJECT AN EMPLOYER TO CR:MINAL ES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,004), I I TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST. AND ATTORNEY'S FEES. LICENSED CONTRACTORSWC��N: d Professions Code, and my license is in lullhereby affirm that I am nlO sof Chapter 9 (commencing with Section 7000) of Division 3 of the Buslnes force and effect. Lic, # Class # Contrabr0_r;`_Stgnature: Date: CONSTRUCTION LENDING AGENC - ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is Issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Data: OWNER -BUILDER DECLARATIONS: I hereby affirm that under ponalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031 S, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions (Zode) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than Five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License law does not apply to an owner of property who builds or improves thereon, and who does such work h)msalf or herself or through his or her own employees, provided fhal such improvements are not intended or offered for sale. If, however, the building or improvement Is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ t, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to thtr Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver% license. ❑ Yes ❑ No Driver's License No. Fxpires: verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ i hereby certify that no excavation five (5) or more feet in depth Into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Cade). ❑ As ownor-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Data: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to, file a registration form for acutely hazardous materials? ❑Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity o1 acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .... ....................................... ..................................... .......................... ........................................................................ .................................. ... .................................................. .....-.............,,,......................... ......-.................. ... .............. ........ 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No Section 25534 of the California Health and Safety Coda provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ............................................................................................................................................................................................................................................ ............................................................................................. 4 If an RMPP Is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑Yes ❑ No ........................................................................................................................................................................................................................................................................................................................................................................... 5 Does or will the appllcrmnt or present or future building occupant require for the work which is the subject of this p plication agermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes a No (Section 65850.2 of the California Goverment Code requires that the requested information be furnished on applications for non-residential building permits). ............................................................................................................................................................................................................................... •.......................... ........................................................................................... fi WIII any part of the facility to be constructed under this permit be within 100D feet from the outer bountlaries of a school? ❑Yes ❑ No (If 'yes', the facAity mull meet the requ)ramenl of Sections 25534 and 42303 of the California Health and Safety Code). 7 ii ­a permit from the South Coast Air Quality Management Dlstnct or other air pollution control district o agency is required for the work which Is the subject o! this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (If 'yes", attach cartiflcate of compliance from the appropriate air pollution control officer}. CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. i agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Data: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY. I certify under penalty of perjury that I have read this application and state that the Information given Is correct. I agree to comply)40th all fat s and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-descri prop for ins�tion pu es. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Ot Leg ner(s) ate ndlO uthortzed Applicant Da goDE P. INSPEC710NTYPE INTmALS CODE / INSPEcnON TYPE 2&U INTIDBLJ 1616 Fixed System 4 Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Root 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 2041:*�• Final Demofltion 250 Final BulldingfOccupancy - -N Job Address: 3333 BRISTOL ST Status: ISSUED Suite: 1420 Applied: 03/23/2007 Vicinity: SUITE 1420 Issued: 03/23/2007 Primary Occ: M Display/Sale Merchandise Type of Construction: I -FR Parcel Number: 41250107 Zoning: PDC Applicant: BOWERS, JOHN Address: 1306 E EDINGER AV SUITE C _Phone: 714-838-4112 SANTA ANA, CA — ,,,y N �_. "Zip 92705- _ ISSUED BY: Owner: SOUTH COAST:PLAZA Address �� COSTA MESA CA \ :! F r Phone:" 3315 FAIRVIEW \ROAD - -`--Zipy -92626` Contractor, ,:,SNEDEN AND.BOWER_S-INC Address: .'/1306 E EDINGER•AW , �- .�.� ti SUITE C %r�•'" Phone: 714-838-4112 1 SANTA ANA; 'CA /f /Zip: 9270 J5J//JJ ,� License: 811856 \X Eng:��' . Address: i Address:A Phone: a ° o.�' "' Phone: License: " n ��_ s jLicense: � '� ,ri /-=' .�• '- "" • ' -' ._ '". 'ice;•- -.L �;t. ' , - ;�. SCOPE OF PERMIT 2817SF INTERIOR STORE DEMOLITION FOR "VIE DE FRANCE" IN SUITE 1420 IN PREP FOR A FUTURE Tl FOR BVLGARL '... - FEE-SUMMARY-7.— Plan" Check-, 3181.51 'T rr j ,•' '?` V," Calc Valuation: '$17,000:00 Permit:' $279.25 'Claim Valuation: $17,aoaa)o SMIP Res: $0.00.- r SMIP Com: ' $3.57 Other.' $0.00 Inspection: $0.00 Total: $464.33 PLANNING & ZONING SETBACKS,, MAIN STRUCTURE Front ' 0- 0 Rear :.�0= 0, . Left '0= 0, �- Right O,O f� - j ! S• ACCESSORY Front 0= 0-0 Left' 0- 0 Ig t 0- 0 'Rear: ;� _ �'�- R ' ,0 PARKING .\ Existing-, 0" '�_. Required:, " 0"1 Proposed: =O � � �, i '-� �� �_��: c O •-- Cis, �'�� A� - NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or it work is suspended or abandoned for a period of 180 days. INSPECTIONS: in order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspectlons and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 " 2"6-46 t6r00a DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ` ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Coda, for the performance of the work for which this permit Is issued. r I have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. My workv, cornsation Insure a carrier and policy number are: 2- ZO L Carrier: Policy Number/II� _ (This s or ed rot be complafe ermft Is v ed at one hundred dollars ($100) or less.) ❑ 1 Certify that In the perform Ce of the work for which this permit Is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of C ml and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these pro ns Applicant Signature: Date: WARNING: FAILUR(AEOO. E WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBMJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CL FINES UP TO ONE HUNDRED THOUSAND DOLL4), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 a1 the Business and Professions Code, and my license is in full force and effect. Lic. # paClass # Contractor's Signature:. Date: — 1 Y CONSTRUCTION DING AGENCY: ❑ I hereby e m that there Is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code), Lender's Name: Londoes Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not mare than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). • ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply t0 an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors Liconse Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? 0 Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic foal o1 compressed gas at standard temperature and pressure). ._.._................. -.......... _—.._.._......... —._.._................. __._........................................ ......_.................. ..._...._ ...................... -- ....... _. 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ............................ .......................... ............. ............... ..... _....................................................................... _........................... -............................................................ .......................................... . ..................... . ................................................. 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. --._................_._._..................._..-----._ _ ........... --—......_......—................._ _ .....___._ .. —.......... ........_-....._-...._... -. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes [I No ---....__................ _. ---._._............................. _... _........................ _......... ...............__... .................. _ ....... - ............----................_.................—_.............................. 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application aermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes f No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). --...............--_..............._-..__..._.._.....---......__... _. 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'fres", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures proscribed by California Health and Safety Code Section 42303 boon made? ❑ Yes ❑ No _._............---._................._...--- .....-.... _ — .._................. _ .._... __—._................. ---...- _.............. _ ...................._....................—.............._... 8 (If ryes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Masa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature egelOwner(s) Date An orize pp I <I -Date- INSPECTION TYPE QAIE INTMA4S QPQE t INSPECTION TYPE RAN INTMALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Root 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final BulldinglOccupancy L � / (714) 754-5273 • Fax (714) 754-4856 • www.cf.costa•mesa91E. tCTRICAL PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: Suite No Vicinity: Parcel Nunmber: Applicant: Address: Owner: Address Contractor. Address: ISSUE FEE Temp service test Res. a/c package New Res (1-2 units) New Res (3+units) Pool 1 Spa Lighting Fixts Recept Outlets Switches Non Res Appl Res Appl Service to 200a Service to 1000a Service over 1000a Motors to 1hp Motors to 10hp Motors to 50hp Motors to 100hp Motors over 100hp Communication drops Sub panel to 200a Pole Light Pkg Sign Circuits Temp Pwr Pole Intermed Pole 3333 BRISTOL ST 1420 BVLGARI 41250107 SCHELIN, KEVIN 136 E GARRY SANTA ANA, CA SOUTH COAST PLAZA COSTA MESA CA 3315 FAIRVIEW ROAD Phone: 714-556-8591 Zip 92707 Phone: Zip: 92626 SMALLCOMB WIRING CORPORATION 136 E GARRY Phone: 714-556-8591 SANTA'ANA, CA Zip: 92707 License: 145961 ISSUED SCOPE OF PERMIT ELECTRICAL PERMIT FOR A 2,871 SF INTERIOR T.I. FOR "BVLGARI", SPACE 1420. REF#: B07-00349 WORK TO INCLUDE: 259 LIGHT FIXTS, 87 OUTLETS AND 8 SWITCHES. status: ISSUED Applied: 05/29/2007 Issued: 0589/2007 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12.21-92) EXPIRATION: This permit shall automatically expire and become void If work Is not commenced within 180 days, or if work is suspended r abandoned for a period'of 180`days. INSPECTIONS: in order for the work authorized under this permit to be considered legal, such work must comply with all-applicabl" a codas, and all required Inspections and final approval must be obtained, Failure to obtain inspections and final approval will result in the`explration of this permit. FOR INSPECTIONS CALL: (714) 7545826 2448-40 (8=) FEE SUMMARY Quantity Quantity $23.50 Temp Dist System I Lighting $0.00 0 $0.00 Busway /100 H $0.00 0 $0.00 Standing Section $0.00 0 $0.00 0 Misc Electrical Equipment $0.00 0 - $0.00 0 Transformers up to 1 kvalkw $0.00 0 $0.00 0 ................up to 10 kvalkw $0.00 0 $196.47 259 ..............:..up to 50 kvalkw $0.00 0 $70.91 87 .................up to 100 kvalkw $0.00 0. $8.80 8 '• ..................over 100 kvalkw $0.00 0 $0.00 0 Low Voltage Equipment $0.00 0 $0.00 0 Low Volt Wiring System 1 Ckt $0.00 0 $0.00 0 Misc. Conduit $0.00 0 $0.00 0 Misc. Conductor $0.00 0 $0.00 0 Circus ( gen or ride) $0.00 0 $0.00 0 Circus (mech ride or lights) $0.00 0 $0.00 0 Christmas Tree Stand $0.00 0 $0.00 0 Fireworks Stand $0.00 0 $0.00 0 Other Electrical Fee $0.00 $0.00 0 $0.00 0 Investigation Fee $0.00 $0.00 0 Pian Check Fee $0.00, $0.00. 0 Reinspection Fee $0.00 50.00 0 $0.00 0- TOTAL CALCULATED FEES "$299.68 $0.00 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12.21-92) EXPIRATION: This permit shall automatically expire and become void If work Is not commenced within 180 days, or if work is suspended r abandoned for a period'of 180`days. INSPECTIONS: in order for the work authorized under this permit to be considered legal, such work must comply with all-applicabl" a codas, and all required Inspections and final approval must be obtained, Failure to obtain inspections and final approval will result in the`explration of this permit. FOR INSPECTIONS CALL: (714) 7545826 2448-40 (8=) � e WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following dederations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. �I have and will maintain workers' Compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit Is Issued. —'My wo ers' compensation Insure ce carrier and policy number are: _r , Carrier: Poticy,Number: �3 _ (Tills section ed not be comp et r/ the pefmll Is valued at one hundred dollars ($100) or less.) ❑ I Certify that in the performance of the woAk for which this permit Is issued, l shall not employ any person in any manner so as to become subject to the workers' compensation law Califam[ d a / fMet if I should become subject to the workers' compensation provisions of S tion 3700 of the Labor Code, I shall forthwith comply with these ovisions. r f L Applicant Signature: rDete:`Y- T WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLAR£ (5100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3700 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: (I.hareby.affirm that I am licen ed under provisl of Chapter 9 (commencing with Section 7000) of Division 3 of -the _BusinewflProfessions Code, and my license is In full farce and effect. L)c. N Glass p 1 r Canty ors Slg azure: Date ' ra CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is issued. (Sec. 3097, Civil Code). Lenders Name: Lenders Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself Cr through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or Improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or Improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a conlractor(s) license pursuant to the Contractors License laws.), ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or mare feet In depth into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be --ore than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Tltie 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I Will the applicant or present or future building occupant need to file and certify a Business Pian for emergency response to release Cr threatened release of a hazardous material? Q Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ..................................--........................._....................,m.............................................................,........................ ...................... .... ._.......... _ _...._.._� . 2 Does or will the appllcant or present or future buiiding occupant need to file a registration form for acutely hazardous materisls7 ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ........................................................................................_...-._.,.............................. _........... ,........... ..-................................... ..................................,,,,.,,,,.,..,......................... .......... ................... ............. ..........._............. ............ ....... 3 Does or will the epppllcant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes 13fV0 (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ................ ............... .__ ..... ......_.._._. _ T�_...—._............ _.... ............. .................................................... --_....................... ... - 4 it an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully compiled with? ❑ Yes ❑ No 5 Ones or will the applicant or present or future building occupant require for the work which Is the subject of this a pfication agermit for such construction or modification LJ from the South Coast Air Quality Management District or from any other air pollution control district or agency?Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). —_............ _ _ _ _ _........... ........ ...... _ 6 WIII any pan o1 the facility to be constructed under this permit be within I Doo feet from the outer boundaries of a school? []Yes ❑ No (if 'res", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency Is required for the work which is the subject of this application, have all of the disclosures prescribed by Califomia Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (N yes", attach certificate of Compliance from the appropriate air pollution oontrd officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above Is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signatura: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the Information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above dsc ed props for in pection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. gn tura Of Legal Owner(s) Date n Authorized Applicant Data�� CODE It. INSPECTION TYPE ??AIH Ifs CODE f INSPECTION TYPE 2AM IjMBLI 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1268 Pool Spa Final 208 Final Plumbing 200 Final Re -Root 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 - Fax (714) 754-4856 - www.cl.costa-mesVt1JLNSING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Suite No 1420 Vicinity: SUITE 1420 BVLGARI Status: ISSUED Applied: 05!2512007 Issued: 05/25/2007 Parcel Nunmber: 41250107 Applicant: SNEDEN, KENT ISSUED BY: Address: 1081 ST REGIS PL Phone: 714-838-4112 SANTA ANA, CA Zip: 92705 Owner: SOUTH COAST PLAZA Address COSTA MESA CA Phone: 3315 FAIRVIEW ROAD Zip: 92626 Contractor: SNEDEN AND BOWERS INC Address; 1081 ST REGIS PL Phone: 714-838-4112 SANTA ANA, CA Zip: 92705 License: 811856 SCOPE OF PERMIT 2,871 SF INTERIOR T.I. FOR "BVLGARI", SPACE 0. WORK TO INCLUDE: CONSTRUCT A NEW STORE FRONT, NEW NON -LOAD BEARING PARTITION WALLS, CREATE A NEW BATHROOM, ALL NEW INTERIOR FINISHES, ELECTRICAL, MECHANICAL AND PLUMBING WORK. REF; 807-00349 1 FLOOR DRAIN, 1 WASH BASIN, 1 WATER CLOSET FEE SUMMARY AMT QTY AMT QTY AMT QTY ISSUE FEE $23.50 Laundry Tub 1 Washer' $0.00 0, _ Sump Pump $0.00 0 Backflow irrigation $0.00 0 Landscape Irrigation. $0.00 0 Swimming Pool $0.00 0 Backflow Preventer $0.00 0 P -Trap $0.00 0 Trap Primer $0.00 0 Bathtub $0.00 0 Pressure Regulator $0.00 0 Urinal $0.00 0 Clarifier System $0.00 0 Process Piping (per 10 ft) $0,00 -0 Vacuum Brkr Bkflow(1-4) $0.00 0 Connect (Ice,Soda,etc) $0.00 0 Receptors $0,00 0 Vacuum Brkr Bkflow(5+) $0.00 0 Dental Units $0.00 0 Septic Tank $0.00 0 Wash Basin $9.80 1 Dishwasher $0.00 0 Sewer Cap for Demo $0.00 0 Wash Basin Set $0.00 0 Drain, Floor $9.80 1 Sewer Connect $0.00_ _ 0 Waste and Vent System $0.00 0 Drain, Rainwater $0.00 0 Sewer Private Line $0.00 0 Water Closet (Toilet) $9.80 1 Drain, Roof $0.00 0 _ Shower $0.00 -0'•. Water Heater 1 vent $0.00 0 Drinking Fountain $0.00 0 Sink, bar $0.00 0 Water Piping (Inst or Rep.) $0.00 0 Expansion Tank $0.00 0 Sink, commercial $0.00 0 Water Re -pipe $0.00 0 Gas Earthquake Valve $0.00 0 Sink, Floor $0.00 011 Water Service $0.00 0 Gas (14 outlets) $0.00 _ 0 Sink, kitchen $0.00 0 Water Softener $0.00 0 Gas (Over 4 outlets) $0.00 0 Sink, service/mop $0.00 0 OTHER $0.00 Gas Repipe $0.00 0 Spa (private) $0.00 0 VIOLATION $0.00 Gas Service $0.00 0 Spa (public) $0.00 0 PLAN CHECK $0.00 Interceptors (Grease, Oil) $0.00 0 REINSPECTION $0.00 0 Interceptors (Sand Auto ) $0.00, 0 TOTAL CALCULATED FEES: $52.90 _.. COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shalt comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, g 1, 12.21-92) EXPIRATION: This permit shall automatically expire and become void If work Is not commenced within 180 days, or it work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspectlons and flnal approval must be obtained. Failure to obtain Inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 1__� 244646 (8/001 DECLARATIONS WORKERS' COMPENSATION DECLARATION: hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a Certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. I have and will maintain workers` compensation insurance, as required by section 3700 of the tabor Code, for the performance of the work for which this permif is Issued. My workers' m nsalion Insu nce caller a policy number are: si t 7 q �7 Carrion. Po3lcyNumber� o� of - 2-Z 02Z (This sect! ne nothe aced a parrrUI "valued at ane hundred dollars ($100) or less.) ❑ I certify that in the rice of the woX for which this permit is issued. I shall not employ any person in any manner so as to become subject to the workers' compensation laws Canto is at if I should became subject to the workers' Compensation provisions of Section ;3r Cf th Labor Coda, I shall forthwith comply with those vision . 8III90canh.Signature: I' Date: 2/ WARNING: FAILURE TO SECURE 'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AAD CML FINES UP TO ONE HUNDRED THOUSAND DO LARE (S100,000), IN ADDI HE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECrION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTOR DEC AT10N: I hereby affirm that I am IiC $e r pro o s Of Cha r (commencing with Section 7000) of Division 3 of the Business an rofessions Code, and my license Is in full force and effect. Uc. # Class # Cans t�ctots'lgnature Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that (here is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: _ Lenders Address: Signature: _ Date: OWNER -BUILDER DECLARATION$: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he Or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant 10 a civil penalty of not more than five hundred dollars ($50O).): ❑ I, as owner of the property, or thy employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through hK or her own employees, provided that such Improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ' ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractors) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: T Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from thq division. Signature: Dale: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _._........... I� _..._._-..- _. _ M ....--- ..............._-................ _.................................... .......... ....... .. _ _............................ ..............1..- ._._..-....-.. .._..... - 2 Does or will the app cant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ................................................................-........................................-._................................_-.................. ...... ...............,.,........................................................................................ ---.................. __ _..._..._...._............. _ 3 Does or will the applicant or pregertt Or future building occupant need 10 prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Secllon 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire i]epartment Of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ........... ... ....................................... __....._... __........... _.... ..........._._................ �........................... ......................__..........................._._.._............... � .... _ 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with7 ❑ Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this a plication amit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes � No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). _.._..- ............................... .. .......... -- 6 6 Will any part of the facility to be constructed under this permit be within 1000 foot from the outer boundaries of a school? ❑ Yes p No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the Califomfa Health and Safety Code). _ ----- .. ................... _....... — 7 1f a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all Of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ NO 8 (if Tres", attach certificate of corhpiiance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: _ Date: CERTIFICATE OF COMPLIANqE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to omply all state laws and city Ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described op or fns fon purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Owner(s) 9 0 AuEl+Mized ApQlfeant Data C22E JL INSFECTIG 1XIII am INIMAlf CODER INSPE0011IYPE IPMALS 1016 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing M-1 07 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Bullding7Occupancy t CITY OF COSTA MESA ` } _ r BUILDING DIVISION DEVELOPMENT SERVICES DEPARTMENT V PERMIT (714) 754-5273 • Fax (714) 754-4856 ,lob Address: 3333 BRISTOL ST Suite: 1420 Vicinity: Parcel Nunmber: 41250107 Applicant: MARY ANN BREEN Address: BUILDING PERMIT Zoning: PDC Phone: PDC PERMIT NUIMBER B98-02300 77 FAIR DRIVE, COSTA MESA, CA 92626 F Zip: , f - Owner: SO COAST'PLAZA--MAIN MALL %CJ SEGERSTROM & SONS Address 3315 FAIRVIEW RD Phone:— COSTA hone: COSTA MESA\CA ,/ f Zip: 92626~y': �. Contractor:,' GRICE CONSTRUCTION Address: 2460 CHERRY:HILLS DR ��;` Phone: „925-941-6339 LAFAYETTE,CA Zip:, 94549 "� License:';v, 749414 Arch : Address: ANTHONY STARK 2906 ROWENA AV i Address: X : Phone: _ 323-666-9708 -� L.A.,CA' Zip\ 90039' License: 018639 \ > SCOPE OF=PERMIT /INTERIOR ALTERATION FOR`AESTHETIC CHANGES FOR "VIE bl FRANCE"RESTAURANT. Status: ISSUED Applied: 12!2311998 Issued: 02/22/1999 Phone:• License: , 1' EXPIRATION: This permlt shall automatically expire and become vold if work is not commenced withln 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (71.4) 754-5626 r FEE SUMMARY Plan Check: $257.93 `;_---, --_ t ` `.,' ;'l, ;U. Calc Valuation: $240,000,00 Permit: $1,587.25 — = _ Claim Valuation: ' $240,000.00 S,MIP Resi $0.00 SMIP'Com: $50.40 \'',\Other:r `,•$0.00 i \. 5 Inspection: $0:00 Notal: $1,895'58. '•PLANNING &,ZONING- ����'� . �� � �� , �`-�_��- %' � SETBACKS ' ��;�,✓ MAIN STRUCTURE- Front 0-D `Rear -.0�0Y ..,`� . -� '�-Left 0- 0 Right '0- 0�,% t ACCESSORY Front 0-.0• Rear 0= 0 Left 0-:0 Right 0= 0 PARKING Existing: 0 - Required: 0_ Proposed: -0 NOTES: EXPIRATION: This permlt shall automatically expire and become vold if work is not commenced withln 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (71.4) 754-5626 r - DECLARATIONS WORKERS' COMPENSATION DECLARATION: ..r I hereby affirm under penalty of perjury one of the tollowing declarations: ❑ 1 have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ® I have and will maintain workers' compensation insurance, as required by section 3700.of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation I/n�urance carrier and policy number are: _ Carrier: �(� f'(/1 A) b Policy Number:0Q0 7.� 3"1 6 C (This section need not be completed if the permit is valued at one hundred dollars ($f t)0) or less.) ❑ 1 certify that in the performance of the work for which this permit is issued. I shall not employ any person In any manner so as to become subject to the workers' compensation laws of California, and agree t at If I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provi ions. Applicant Signature: �' Date: 2 -2 2_- O L WARNING: FAILURE TO SECURE *WERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE (SiOD,ODOj,ITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Sectio 000) of Division 3 of (he Business and Professions Code, and my license is in ful force and effect. Lic. ff 7el I Class €r Contractor's Signature: Date: R CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lander's Name: Lenders Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec, 7031 .5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to Its Issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and'Profe`ssions Coda) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the'applicc`ant tdciYl penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property,. or- my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business a'nd'Professions'Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through:hli och9i own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of complsfion,•the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of th;propertyyam EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors LicorU'L:aw does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bili or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certJfy that no excavation five (5) or more feet in depth Into which a person Is required to descend, will be made In connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Tllle 8, Callfomla Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Coda requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by Ovary business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ..........................................................................................................'n.e.......'fi'1............................,..,..-.........-................................................ e. s' ..................................................... 2 Does or will the applicant or present or future building occupant need to fife a registration form for acutely hazardous materials? ❑Yes ❑ No (Section 25533 of the California Health and Safety Code. with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 2DO cubic feet of compressed gas at standard temperature and pressure). ................ ........ .............................. .......... .... ............................................................................................................................. ................ ........................................... I ....... ............ 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No {Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. .......... .............................. ............................................................................................................. ............ ......................................... I ............ .............. ... 4 It an RMPP is presOntly required, has Section 25534 of the Calitomia Health and Safety Code been fully complied with? ❑ Yes ❑ No ........... .... ....................... ............ ............... .......................................... .--- ............................ ........ ............ ..................... ................................... ............ 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this a plication a ermil for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes LJ No (Section 65850.2 of the California Govemment Code requires that the requested information be furnished on applications for non-residential building permits). ............... ....... ....................................................................... ................. I ........................................ ................................ .... ....... .................................................................................. 6 Will any part of tha facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'fres", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Coda). ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------- 7 If a Permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No -•................................................................................................................................................................................................................................................................. yas", attach certificate of compliance from the appropriate air pollution control officer), CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. gnature Of Legal Owner(s) p Date And/Or Authorized Applicant Date COUE-f. DATE CODEf INSPECTION TYPE DAIS QIIIBAL$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy 2446.48 M (714) 754-5273 • Fax (714) 754-4856 • Wvnv.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT Job Address: 3333 BRISTOL ST Status: ISSUED Suite No 1501 Applied: 07/25/2006 Vicinity: Issued: 07/25/2006 Parcel Nunmber: 41249102 Applicant: WARREN DUE'S� Address: ISSUED BY: Address: Phone: 818-625-2697 Zip Owner: SOUTH COAST PLAZA Address 3315 FAIRVIEW AVE MISC. Phone: COSTA MESA,',CA ', ; Zip: 92626 Contractor: NITE-LITE SIGNS CHATSWORTH, CA Address: 21001.SUPERIOR ST Phone: 818-341-0987 CHATSWORTH, CA Zip: 91311 License: 309508 SCOPE OF PERMIT INSTALL 2 INSIDE THE MALL WALL SIGNS FOR "DIOR" ONE SIGN IS ILLUMINATED. RE:606-01236 FEE SUMMARY Quantity . Quantity ISSUE FEE $23.50 Temp Dist System 1 Lighting $0.00 0 Temp service test $0.00 Busway 1100 ft $0.00 0 Res. ale package $0.00 , Standing Section - $0.00 0 New Res (1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0 New Res (3+units) $0.00 0 Transformers up to 1 kvalkw $0.00 0 , Pool / Spa $0.00 0 .:........:....up to 10.kva/kw $0.00 0 Lighting Fixts $0.00 ...- . 0 .................up to 50 We" $0.00 0 " Recept Outlets $0.00 0 ...............:.up to 100 kvalkw $0.00 0 Switche's $0.00 0 ..................over 100 kva/kw $0.00 0 Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0 Res Appl $0.00 0 Low Volt Wiring System 1 Ckt $0.00 0 Service, to 200a $0.00 0 -Misc. Conduit $0.00 0 Service to 1000a $0.00 0 • Misc. Conductor $0.00 0 Service over 1000a $0.00 0, , Circus ( gen or ride) $0.00 0 Motors to 1 hp $0.00 0 Circus (mech ride or lights) $0.00 0 Motors to 10hp x$0.00 0 Christmas Tree Stand $0.00 0 Motors to 50hp,, ,, $0.00 0 Fireworks Stand ,, $0.00 0 Motors to 100hp $0.00 0 Other Electrical Fee W00", Motors over 100hp\ $0.00 . 0 Communication drops, $0.00 -o,, ' ' Investigation Fee $0.00 Sub panel to 200a, $0,00' 0 Plan Check Fee $0.00 Pole Light Pkg ` $0.00 " ; f 0 Reinspection Fee $0.00 Sign Circuits $24.60.. ' , 1� Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $48.10 Intermed Pole $0.00 0 COMMENTS / SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12.21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or it work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 !448-46 (WOO) DECIARAVOINS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of peri ury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. Myworker ' compensation Insurance carrier and policy number are: Carrier: FV )V )> � Policy Number: 1-7 0 l D S` (This section need not be completed if the permit is valued at one hundred dollars ($100J or less,) ❑ 1 certify that in the performance of the work for ich the ermit is issued, I shall not employ any person in any manner so as to become subject to the workers' Compensation law C ifornia, and agree t t f I sh Id ecome subject to the workers' compensation provisions of Section 3700 of the Labor Code, 1 shall forthwith comply with t rout s. ' Applicant Signature. Data: WARNING: FAILURE TO SECURE: WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE (51 D0,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under pro,,sion of Chapter 9 (Commencing with Section 0) of Division 3 of the Business d P ofeSsions Code, and my license is in full force and effect. tic. # Class (J Contractor's Signature: Dater CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or County which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit to file a signed staterrrant that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of safe.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more foot in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Data; Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .....................................................i'o'........_..........................................................................................................-..-..-----.............................................d-o'...................."'I's-.........----.-...-...................................,.,.,............................... 2 Does or will the applicenl or present or future building occupant need to file a registraiicn form far acutely hazardous malaria137 ❑Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feel of compressed gas at standard temperature and pressure). ........................................................................................................................._................................................... ----•-......................................................... .............................................................................. 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No DSection 25534 of the California Health and Safely Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire epartment of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. .......................•........................................................................ --........................................... _................................................. .......................................... _.............. _................. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No I'll ....................................... ........................................................................................................................... ------......................... .......................................................... ........................................................... 1111........................ 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification from the South Coast Air QuaMy Management District or from any other air pollution control district or agency? Yes f No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). .................................................................................................................................................................................................................................................•..................................................-----....................................................................... 6 Wild any part of the fadlhy to be constructed under this permit be within 1000 feet from the outer boundaries of a School? ❑Yes ❑ No (if 'yes', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ....................... ............................................................................ --...................................................................................................................................................................................................................................................................... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency Is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No .....................:....................................................................................................................................................................................................................................................................................................................................... 8 {If yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY. I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature t egel n r(s) -7�� — Date And/Or Authorized AppTcant Date CODE I. INSPECTIONTYPE QM NTITIAL CODED INSPECTIONTYPE INTMA1L$ 1616 Fixed System Final Fire Prevention 2116 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final BuildinglOccupancy n (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.SUILDING PERMIT .lob Address: 3333 BRISTOL ST Suite: 1501 Vicinity: Primary Occ: M Display/Sale Merchandise Type of Construction: I FR Parcel Number: 41249102 Zoning: PDC Applicant: WARREN DUE Address: Owner: SOUTH COAST PLAZA Address 3315 FAIRVIEW AVE - Misc. Permit: COSTA MESA, CA Contractor: NITE-LITE'SIGNS- Address: 21001 SUPERIOR ST.-' 'SMIP Com: $0.63 ^- CHATSWORTH, CA Zip: 91311''." - Arch . $0.00 Phone: 818-625-2697 Zip: Phone: Zip: 92626 Phone: 818-341-0987 License: 309508 Eng: 77 FAIR DRIVE, COSTA MESA, CA 92626 ISSUED BY: Status: ISSUED Applied: 07/25/2006 Issued: 07/25/2006 Address: Address: Phone:-, Phone: Zip: License: License: SCOPE OF PERMIT INSTALL 2 INSIDE THE MALL WALL SIGNS FOR "DIOR" ONE SIGN IS ILLUMINATED. ,- - - FEE SUMMARY Plan Check: $54.11 - Calc Valuation: $3,000.00 Permit: $83.25 Claim Valuation: $3,000.00 SMIP Res: $0.00 'SMIP Com: $0.63 ^- Other:. $0.00 - Inspection: $0.00 - Total: $137.99 _PLANNING & ZONING SETBACKS ' MAIN STRUCTURE Front, ,, 0- 0 Rear _ " 0-0 Left 0-0 Right 0-0 ACCESSORY Front 0.6 Rear 0-0 Left 0-0 Right 0-0 PARKING 0 `- Required: 0 Proposed: 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 1416.46 (0=) W DECLARATIONS WORKERS' G'OMPENSATION DECLARATION; 1 hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the tabor Coda, for the performance of the work for which this permit is issued. ❑ 1 have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued, My workers' compensation Insur nce carrier and policy number are: D /"'] O -- Carrier: ;tom �� ti b Policy Number: 1 ` ` (This section need not be completed it the permit Is valued at one hundred dollars ($13) or lass.) ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of nla, and agree that If should be a subject to the workers' compensation provisions of Section 3700 of the Labor Code, i shall forthwith comply with these trio '�7 r n Applicant Signature: t Date: W ARd`tM,. FAILURE TO SECURE WORKERS' COMPENSATION OOVERAGE IS Ud "WFU AND SHALL SUWECT AN EMPLOYER TO CRSMINAL PENALTSES AND CrAL FINES UP TO ONE HUNDRED THOUSAND DOLLARE (S100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST. AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under�Provisi,Qn�y°I Chapter 9 (commencing with Sectio 00) of Division 3 of the Business and Professions Code, and my license Is in full force and effect. Lic. 0 3 © I SV v Class ff C_ Contractor's Signature: Date: �-r9 CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code), Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (S500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL 00 THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not Intended or offered for sale. if, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ' ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: _ Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: _ HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the Califomia Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ............... ............................................... ................... ..................................................... .......................................................................................................................... ...................................._.............................. .................. ....... 2 goes or wit! the applicant or present or future building occupant need 10 file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity o1 acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ............................................................................................................................................................................................. ... ........... ............................... ,,.,............................................................................................................ 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? 0 Yes ❑ No dSection 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire apartment of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department, ............................................................................................................................................................. __...................................................................................... ................. __.... .............................. -1 ........... __ 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No _....• -__..............w_........._..........____............................................... _.._.... ........................... .._....... ............... __... ......... .._............ _................ _.................... - 5 Does or will the applicant or present or luture building occupant require for the work which is the subject of this a plication a ermil for such construction or modification from the South: Coast Air Quafity Management District or from any other air pollution control district or agency? LJ Yes LJ No (erection 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ..... ........-................................-..........................................................................................- .....-----------............................................. 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (It "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ..... ..................... ....................................... ..................... ............. ................................................................... _.................................................. _._..___.... _.._.._....................................................... ` 11---•----111111.... ...................... _ h...... 7 !f a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescrlbed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ........................................................................................................................................,...................................................................,........................--•---•----•-----................................................... attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. 1 agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the aboverdescribed property for inspection purposes. I agree not 10 occupy or allow occupancy of any building authorized by this permit until final inspection. Sig u 01 Le ner(s) Date �~ `7-2s 06 n r Auth 'za Applicant Date CODE 0 INSPECTION TYPE 26M JPLrTIALS CODE I INSPECTION TYPE f287i 1CTITIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714)754-5273 • Fax(714)754-4856 f.:. "CITY OF COSTA MESA ► BUILDING DMSIGN DEVELOPMENT SERVICES DEPARTMENT M98-00 PERMIT P MI UMBER Job Address: 3333 BRISTOL ST Suite No 1501 Vicinity: Parcel Nunmber: 41249102 Applicant: PUENYE, JOHN MECHANICAL PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Status: ISSUED Applied: 06/29/19981 Issued: 06/29/1998 Address: zip' Owner: SOUTH.COASTPLAZA Address: 3315 FAIRVIEW AVE �� \__ _ _'__zz7 _�-� ��OSTA MESA;CA/� ���-=�" � Zip: 92626 mtractor/�­-T HERMALAIR,INC' Address: 1140,N RED GUM ST /I / /l//\ `F !!%ANAHEIM'CA Zip:92806 .'License: 102216 Arch l Eng.: / �� -I` �,, 4 Iess 1 F Addr1 �_.l -Phone:'- 1 Zip: License: ----SCOPE OF=PERMIT-= - I'-'5 FIRE DAMPERS; SUPPEEMENTALTpM98-001.76.1r'1 i")�l EE i !'i f. •��-'�� �v U u��• 1! l�lr'ii ISSUE'F£E� Inst FAU,'<100 k.BTU • 41`"" \' Inst FAU,>100 k BTU Repair'l`Alt Cooling/Heat���` Inst / Rep Recess Wall Ht,\ Refrig Sysl<100 k BTU \��'' Refrig Sys >100 k BTU Gas Piping\�-� Facto Fire rats - Hood w/Me h'Exhaust 'f VAV Box �., Vent Fan / Single Duct Appliance l\ Fire Dampers Smoke Dampers Inst or Relocate Appl Vent Air Handlers < 10000cfm Air Handlers > 10000cfm Floor Furnace Floor or Suspend Heater $0.007-,i0'- Y E'f `6 -, TC,-, .- 30 To;50 hp 1.1,750 k BTU,'; I / $0.00 �0 \` � y'L1 � `\in fOver 50 hp 1.0 r TU /� 1x$0.00 h FEE SUMMARY %$0.00 �- 0 Cl � r Boilers r r ItRuantitY�"`',r-r 4uaritity $22.00 i— `�—= �- '- Repair /-Alt Alisorbtion Unit ` $0.00 0 -, y $0.00 Repair PAlt,Refrigeration Unit ' , ' $0.00 -`0 fir+ r $0.00 $om.) o Venlillation System EvaporativetCooler '.` $0.00.. ; 0, • r x$0.00 0 !} iso $0.00 0 $0.00 0 Commercia6incinerator r Domestic Incinerator /f bo, 01� $O.QO /0' `\ $0.00 0 �" !.4 pfi,Compressors /Absorption Systems, $0'0o�0 1 \\ $0.00 0$0.00,+ ���$0.00 0 $Q:00 0 a�' �y !'Up,to 3 hp 1100 k BTU fit; - c;.y 3 T6,15"hp 1500 k BTU$4.00�/ �i �r,15'To 3D hp / f,000 k BTU ; s, �/ 0 0 $0,40; 0 $0.007-,i0'- Y E'f `6 -, TC,-, .- 30 To;50 hp 1.1,750 k BTU,'; I / $0.00 �0 \` � y'L1 � `\in fOver 50 hp 1.0 r TU /� 1x$0.00 0 0 %$0.00 �- 0 Cl � r Boilers r 32,50 �� "'� (. r 3 hp $O.DO 0 - i$$0.00', --0To�15 h P.-" \ v // $0.00 0 _ = 10.60' �0 r - _ - _ _ m 15 to 36hp $0.00 0 `, ,som 0/�r�Orier 30 to SO.h 56hP_i ��'. �l�! "� $0.00 $0.00D 0 $0.00 �0 1 !-�` O" Other Mechanical Fee_ $0'0o�0 1 \ - Imiestigation Fee - $0.00 ��. -�h•�. :.t. -j. •PIan,Chkk Fee' _ $0.00 _1---'Reinspec'tion'Fee $0.00 TOTAL CALCULATED FEES $54.50 COMMENTS I SPECIAL CONDITIONS EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7546626 02 DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to salt -Insure for workers' compensation; as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for cite performance of the work for which this permit is issued. My wo rs' compensation Insurance/Farlar and policy ber are: ✓ f�� g� _ Carrier.. - _ /i�i C/� _ (( t/% Policy Number. S_ (J ' / Ly/ — r Mls section need not be completed H the permit fs valued at q5Vhundred dollars ($100) or less.) ❑ 1 certify that In the performance of the work for which this permit Is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Calif la, ogre that it I should become subject to the workers' Compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these p s. �j g Applicant Signature: Date: WARNIN(3: FAILURE TO SE E E4&COMPEN TION COVERAGE 1 UNLA UL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CAVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE (8100,000), IN ADDITION TO THE OF COMPENSATI OE5 A5 PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic. # Class # Contractors Signature: Date: —G CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there Is a construction lending agency for the performance of the work for which this permit Is issued. (Sec. 3097, Civil Code), Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not Intended or offered for sale. If, however, the building or Improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ t am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet In depth Into which a person Is required to descend, will be made In connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more then thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number; HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ................................................................................................................................................................................................................................... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 2DO cubic feet of compressed gas at standard temperature and pressure). ...............................................................................................................................................M--..............-M.a................................n.1I'............................................r.""..----,a'ie........... 3 Does or will the applicant ar present or future building occupant need to prepare an AMPP (Risk Management and Prevemlon Program torr acutely hazardous materials)? ❑ Yes ❑ No b(Section 25534 of the Calitomla Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, Certification and filing with the Fire partment of an AM PIP by businesses which are required to register acutely hazardous materials with the Fire Department. ......................................................................................................................................................................................................................................... 4 It an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes [I No ................................................................................................................................................................................................................................................................................ 5 Does or w€II the applicant or present or future building occupant require for the work which is the subject of this application a ermll for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Ll Yes No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residentlal building permits). .............................................................................................................................................................................................................................. 6 Will any part of the facillry to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (11 yes-, the fatality must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ......................................................................................................................................................................................................................................................... I... ................ I....... 7 if a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which Is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No .................................................................................................................................................................................................................................................................... 8 {If yes', attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certlfy that under penalty of perjury the information given above is correct. I agree to comply with all state laws and cityordinances regarding Hazardous Materials and Emissions. Signature: Dale: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final Inspection. t re OwnerSIG �Q� N4V0_ru ori d Applicant [L Date CODE.6 INSPECTION TYPE I TE INTITALS CODE INSPECTION TYPE DAIS INTITIAL6 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 . Final Demolition 250 Final BuildinglOccupancy 2448-46 } CITY OF COSTA MESA } BUILDING DIVISION DEVELOPMENT SERVICES DEPARTMENT P98-OOM504 PERMIT PERMIT MBER (714) 754-5273 • Fax (714) 754-4856 PLUMBING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92625 Job Address: 3333 BRISTOL ST Suite No 1501 Vicinity: Parcel Nunmber: 41249102 Applicant: SOUTH COAST PLAZA Address: Phone: Zip: Owner: SOUTH COAST PLAZA Address 3315 FAIRViE-WAVE Phone: COSTA MESA,CA ' Zip: 92626 Contractor: L B PLUMBING COMPANY Address: 11632 MARBLE ARCH OR Backflow Preventer Phone:' _ Bathtub SANTA ANA CA Zip:_ _92705 Clarifier System -'License: 287240 Arch 1 Eng $0.00 Address: $0.00 Dishwasher Phone: Drain, Floor Zip: Drain, Rainwater License: AMT ISSUE FEE $22.00 Backflow irrigation $0.00 Backflow Preventer $0.00 Bathtub $0.00 Clarifier System $0.00 Connect (Ice,Soda,etc) $0.00 Dental Units $0.00 Dishwasher $0.00 Drain, Floor $8.75 Drain, Rainwater $0.00 Drain, Roof $0.00 ,Drinking Fountain $0.00 Expansion Tank $0,00 Gas Earthquake Valve $0.00 Gas (1-4 outlets) $0.00 Gas (Over 4 outlets) $0.00 Gas Repipe $0.00 Gas Service $0.00 Interceptors (Grease, Oil) $0.00 Interceptors (Sand Auto ) $0.00 QTY Status: ISSUED Applied: 05118/1998 Issued: 0511811998 SCOPE OF PERMIT INST MISC FIXTURES AND DRAINS,•W_H COMMENTS 1 SPECIAL CONDITIONS 1 AMT QTY Sump Pump' $0.00 F FEE SUMMARY., $0.00 AMT QTY Laundry Tub / Washer $0.00 -0 Landscape Irrigation $0.00 0 P -Trap $0.00 0 Pressure Regulator $0.00 0 Process Piping (per 10 ft) $0.00 0 Receptors, $0,00 0 Septic Tank $0.00 " ' 0 Sewer Cap for Demo $0.00 0 Sewer Connect $0.00 0 Sewer Private Line $0.00 _ _ 0 Shower $0.00 0 Sink, bar $0.00 0 Sink, commercial $0.00 0 Sink, Floor $0.00 0 Sink, kitchen $8.75 1 Sink, service/mop $0.00 0 Spa (private) $0.00 0 Spa (public) $0.00 0 COMMENTS 1 SPECIAL CONDITIONS 1 AMT QTY Sump Pump' $0.00 0 Swimming Pool $0.00 0 Trap Primer $0.00 0 Urinal $0.00 0 Vacuum Brkr Bkfiow(1-4) $0.00 0 Vacuum Brkr BkFlow(5+) $0.00 0 Wash Basin $8.75 1 Wash Basin Set $0.00 0 Waste and Vent System $0.00 0 Water Closet (Toilet) $8,75 1 Water Heater / vent $11,00 1 Water Piping (Inst or Rep.) $0.00 0 Water Re -pipe $0.00 0 Water Service $0.00 0 Water Softener $0.00 0 OTHER $0.00 VIOLATION $0.00 PLAN CHECK $0.00 REINSPECTION $0.00 0 TOTAL CALCULATED FEES: $68.00 EXPIRATION: This permit -shall automatically expire and become void it work Is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: in order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 75445626 y 0 DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a cortificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the labor Code, for the performance of the work for which this permit is Issued. ❑ I have and will maintain workers' compensation insurance, as required by section 3700 of the labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section nerd not be COMPletod It the permit is valued at one hundred dollars ($100) or less.) ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of C 'famle, and agree that it I shout become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these n4. Applicant Signature: Data: WARNING: FAILURE O RE WOWxRS' OOMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUaIECT AN EMPLOYER TO CRIKNAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND 100.000), IN AgDMON TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LAwR CODE, INTEREST, AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed Under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and affect. Lic. # Class # Contractors Signature: Date: 'S- —T — CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is tj construction landing agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Coda). Lender's Name: Lender's Address: Signature: _ Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to Its Issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Prafesalons Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. It, however, the building or Improvement Is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license, ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet In depth Into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sac. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ....................................u.p.a..........'d.'t,...................'a.ii..........................1y' ... z. a...... 's.................,......-.-.......................................................... 2 Ooes or will the applicant orpresent or future building occupant Head to fife a registration form for acutely hazardous materials? ❑Yes ❑ No (Section 25533 of the Califomia Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time hes on hand a quantity o1 acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ........................................................................'c.c................................................................ 'n. a. g. e.-.-.........................................................e...............-.............d.a.I ..... 3 �* . Docs ar will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by 4uslnesses which are required to register acutely hazardous materials with the Fire Department. .................................................................I......I.................•--.--.......................................................................................................................-.............. 4 It an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? [I Yes ❑ No .................................................................................................................................................................................................................................................. 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application apermit for such construction or modification from the South Coast Air Qu4jity Management District or from any other air pollution control district or agency? Yes ❑ No (Section 65850.2 of the California Goverment Coda requires that the requested information be furnished on applications for non-residential building permits), ................................................................................................................................................................................................................................................................... 6 W€II any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (it 'yes", the facility must moot the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ..................................................................................................................................................................................................................................................................... 7 II a permit from the South Coast Air Quality Management District or other air pollution control district or agency Is required for the work which is the subject of this application, have all of the dlgclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ........................................................................................................................................................................................................................ 8 {If yes', attach certificate of Compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the Information given is correct. I gree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the abova-A scribed property f inspec Ion purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. SIg a ure Of Legal Owner(s) k a!V C� And/Or Authorized Applicant Date CODE INSPECTION TYPE Qeg INTMBLS CODE I INSPECTION TYPE ILLS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 2D0 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Oocupancy 24A&46 (714)754-5273 • Fax(714)754-4856 CITY OF COSTA MESA BUILDING DMSION DEVELOPMENT SERVICES DEPARTMENT PERMIT ,lob Address: 3333 BRISTOL ST Suite No 1501 Vicinity: Parcel Nunmber: 41249102 Applicant: PUENYE, JOHN Address: MECHANICAL PERMIT M98-qq PERM<WUMBER. 77 FAIR DRIVE, COSTA MESA, CA 92626 Status: ISSUED Applied: 0511511998 Issued: 05/1511998 Arch 1 Eng Address: Phone: . Zip: License: SCOPE OF PERMIT ADD 4 VAV BOXES, REPLACE EXIST. FAN 8 ALTER EXIST DUCT rr SYSTEM.REFRENCE BI PS B-87979 } r FEE SUMMARY Quantity Phone: ISSUE FEE $22.00 - Zip: - $0.00 Inst FAU >100 k BTU $0.00 0 Repair/Alt Cooling/Heat $12.25 1 Inst I Rep. Recess Wall Htr $0.00 " 0 Ref rig Sys <100 k BTU $0.00 Owner: SOUTH COAST PLAZA'.. $0.00 0 Address: 3315 FAIRVIEW AVE-� 0 Factory Fireplace $0.00 0 ' Hood w/Mech Exhaust $0.00 '0 - Phone: 4, Vent Fan 1 Single Duct COSTA MESA,CA-. Zip: 92626 Appliance $0.00 0 Fire Dampers $0.00 0 Smoke Dampers $0.00 0 Contractor: THERMALAIR INC 0 Air Handlers < 10000cfm Address: 1140 N RED GUM ST Air Handlers > 10000cfm , 0 Floor Furnace Phone: ; Floor or Suspend Heater $0.00 0 ANAHEIM CA ' Zip: 92806: i _- License: 102216 , Arch 1 Eng Address: Phone: . Zip: License: SCOPE OF PERMIT ADD 4 VAV BOXES, REPLACE EXIST. FAN 8 ALTER EXIST DUCT rr SYSTEM.REFRENCE BI PS B-87979 } r FEE SUMMARY Repair/ Alt Absorbtion Unit Repair/ Alt Refrigeration Unit Ventiilation System Evaporative Cooler Commercial Incinerator Domestic Incinerator Compressors I Absorption Systems Up to 3 hp 1.100 k -BTU 3 To 15 hp 1500 k BTU 15 To 30 hp 11,000 k BTU 30 To 50.hp 1 1,750 k BTU Over 50 hp 1 Over 1,750 BTU Boilers Up to3hp 3.To.15 hp _15 to 30 hp 30 to 50 hp Over 50 hp Other Mechanical Fee Investigation Fee Plan Check Fee Reinspection Fee TOTAL CALCULATED FEES COMMENTS I SPECIAL CONDITIONS Quantity Quantity ISSUE FEE $22.00 0 Inst FAU <100 k BTU $0.00 $0.00 Inst FAU >100 k BTU $0.00 0 Repair/Alt Cooling/Heat $12.25 1 Inst I Rep. Recess Wall Htr $0.00 " 0 Ref rig Sys <100 k BTU $0.00 0, Ref rig Sys >100 k BTU $0.00 0 Gas Piping $0.00 0 Factory Fireplace $0.00 0 ' Hood w/Mech Exhaust $0.00 '0 VAV Box $38.00 4, Vent Fan 1 Single Duct $6.50 '1 Appliance $0.00 0 Fire Dampers $0.00 0 Smoke Dampers $0.00 0 Inst or Relocate Appt Vent $0.00 0 Air Handlers < 10000cfm $0.00 0 Air Handlers > 10000cfm $0.00 0 Floor Furnace $0.00 0 Floor or Suspend Heater $0.00 0 Repair/ Alt Absorbtion Unit Repair/ Alt Refrigeration Unit Ventiilation System Evaporative Cooler Commercial Incinerator Domestic Incinerator Compressors I Absorption Systems Up to 3 hp 1.100 k -BTU 3 To 15 hp 1500 k BTU 15 To 30 hp 11,000 k BTU 30 To 50.hp 1 1,750 k BTU Over 50 hp 1 Over 1,750 BTU Boilers Up to3hp 3.To.15 hp _15 to 30 hp 30 to 50 hp Over 50 hp Other Mechanical Fee Investigation Fee Plan Check Fee Reinspection Fee TOTAL CALCULATED FEES COMMENTS I SPECIAL CONDITIONS EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 Quantity $0:00 ' 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 $0.00 $0.00 $78.75 EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' oompertsation Insurance carrier and policy number are: 0 Carrier. w • Policy Number. (nis section need not be completed it rho permit is valued at one hundre ollars ($100) or less.) ❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation taws of California, and agree that If I should become subject to the workers' compensation provisions of Section 3700 of the Labor Cade, I shall forthwith comply with these pr Applicant Signature: Date: g; WARNING: FAILURE TO ECU ORKERS' GOMP NSA�CCYVER6LV�NLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO 0067 OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LA90R CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that i am lice ed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic. # 0 Class # �7,10 Contractor's Signature: Date: r CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there Is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or Improves thereon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not intended or offered for sale. if, however, the building or improvement is sold within one year of completion, the owner-buitder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(B) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No, Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet In depth into which a person is required to descend, will be made In connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high, (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, 1 will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number. HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to fife a registration form for acutely hazardous materials? []Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ............................................................................................................................................................................................................................................................................. 3 Does or will the applicant or present or future building occupant need to prepare an RMPA (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ........ .... ..................... I ... ............................................................................................................................................................................................ ....... 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No ............................ .......................... ....... .......................................................................................................... I.............................................................. 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ppermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? jJ Yes j] No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ...................................................................................................................................................................................................................................... B Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the Califomia Health and Safety Code). .................................................... ........................... I.- ........................................................................................................................................................................ 7 If a Permit from the South Coast Air Quality Management District or other air pollution control district or agency is requlred for the work which Is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑Yes ❑ No ................................................................................................................................................................................................................................... e (Ii yes", attach certificate of compfiance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. tur L IOwner(s) Date An Date =Df -L INSPECTION TYPE pSjE m1>ilels CODE INSPEcn0N TYPE � lil7mAL$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical R 1266 Pool Spa Final 208 Final Plumbing 20D Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy 2446-46 CITY OF COSTA MESA a BUILDING DIVISION DEVELOPMENT SERVICES DEPARTMENT PERMIT PERMI�NAZBER (714) 754-5273 Fax(714)754-4856 FIRE SUPRESSION PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Status: APPROVED Suite* •S L7. ? _ Applied: 05/18/1998 Vicinity: CHRISTIAN DIOR Issued: 05/18/1998 Parcel Nunmber. 41249102 Zoning: PDC PDC Applicant: TAYLOR, CRAIG Address: Phone: Zip: Owner: SOUTH COAST PLAZA Address 3315 FAIRVIEW AVE, Phone: ` COSTA MESA,CA Zip: 92626 l Contractor: TRI COUNTY FIRE Address: ' - 23881 VIA FABRICANTE _ Phone:,/ MISSION VIEJO CA Zip: 92692 License' 659326 ` \ SCOPE OF PERMIT ' RELOCATE EXIST FIRE SPRINKLERS FOR T. I. 1 FEE SUMMARY ' Plan Check: ?? Calc Valuation: $0.00 Permit: ?? Claimed Valuation: $0.00 Other: ?? Inspection: Total: $123.34 - 1 r ` EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. ` INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 / V DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: Policy Number. (This section need not be completed it the permit Is valued at one hundred dollars ($ 100) or less.) ❑ I certify that In the performance of ih orWf[iflftFil� permit Is Issued, 1 shall not employ any person in any manner so as to become subject to the workers' compensation laws of Califoml ea that If I should become subject to the workers' compensation provisions of Section 3700 of the Labor Cade, I shall forthwith C prov€si plicantSignature, Date: LURE TO SECURE WORKE PENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOY RIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,0001, IN ADDITI O THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provis' apter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Cade, and my license is in full fo �C. Crass # ConlractoDate: CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work toy which this permit is issued. (Sec. 3097, Civil Code). Lenders Name: Lender's Address; Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter. Improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars MOO).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Cade: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or Improvement is sold within one year of completion, the owner-bullder will have the burden of proving that he or she did not build or improve for purpose of sale.). Cl I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Cade: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Coda for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers license No. Expires: Verification of Ownership by (type of document, Le, - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet In depth Into which a person is required to descend, will be made In connection with work authorized by this permit, and that no building structure, scaffolding, falsowork, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Seo. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 WIII the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the Califomia Health and Safety Cade requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feat of compressed gas at standard temperature and pressure). ......................................................................................................................................................................... 2 Does or will the applicant or present or future builtling occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ........ ................................................."n'-."i't,t'u.r..................c.u.....-......-................................................M.a...g.e............"d-...-.v'e..........................................a.z.a............................. 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program torr acutely hazardous materlals)7 ❑ Yes ❑ No (Section 25534 of the Califomia Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ..................................................................................................................................................................................... ............---.--•................................................-... 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No .............................................................. iId'I.................................. r.Ih....................................................-.-.-.-......................'m. il............................................... *C'a.i...... 5 • Does or will the applicant or present or future building occupant require for the work which is the subject of this applicat€on aQermil for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes I No (Section 65850.2 of the California Government Coda requires that the requested indormation be furnished on applications for non-residential building permits). ............................................... .1-i-..........................................................................-.............................................................................................. 6 Wi11 any part of the facility to be constructed under this permit be within 1000 feat from the cuter boundaries of a 5Chool7 ❑Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 if a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application. have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No .................................................................................................................................................................................................................................................................................... 6 (If yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emiss(oms. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow oocupancy of any building authorized by this permit until final inspection. LegalOwner(s) D to nd/0 thorized Applicant CODE._ty�SPE�oNTYPE 9M dfillllALet CODES INSPECTION TYPE QAIE INTI IA 1616 Fixed System Final Fire Prevention � 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Bla:klRetaining Wall 212 Final Fire Prevention 2� 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy 2446.40 . CITY OF COSTA MESA BUILDING DIVISION DEVELOPMENT SERVICES DEPARTMENT v PERMIT P RM1T BER (714) 754-5273 • Fax (714) 754-4856 ELECTRICAL PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 .lob Address: 3333 BRISTOL ST Suite No 1501 Vicinity: Parcel Nunmber: 41249102 Applicant: SCHELIN, KEVIN Address: Phone: Zip Status: ISSUED CI�F Applied: 05!14/1998 Issued: 05!1411998 Owner: SOUTH COAST'PLAZA . Address 3315 FAIRVIEW AVE Phone: . COSTA MESA,CA Zip: 92626 Contractor; Address:, Phone:'' Zip: �., , License: i N. SCOPE OF PERMIT INST MISC FIXT, OUTLTS AND RECPT AN D1 SUB PANEL. l FEE SUMMARY Quantity Quantity ISSUE FEE $22.00 Temp Dist System ! Lighting $0.00 0 Temp service test $0.00 Busway 1100 ft $0.00 0 Res. a/c package $0.00 Standing Section `. $0.00 0 New Res 0-2 units) $0.00 - 0 Misc Electrical Equipment $0.00 0 New Res (3+units) S0.00 0 Transformers up,to 1 kvalkw $0.00 0 Pool ! Spa $0.00 0 ................up to •10 kvalkw $0.00 0 Lighting Fixts $164.30 242 ..............!:.up to 50 kvalkw $0.00 0 .Recept Outlets $52.50 70 .................up to 100 kvalkw $0.00 0 Switches $10.00 10 ..................over 100 kvalkw $0.00 0 Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0 Res Appl $0.00 0 Low Volt Wiring System 1 Ckt $0.00 0 Service to 200a $0.00 0 Misc. Conduit $0.00 0 Service to 1000a $0.00 0 Misc. Conductor $0.00 0 Service over 1000a $0.00 0 Circus ( gen or. ride) $0.00 0 Motors to 1 hp $0.00 0 l Circus (mech ride or lights) $0.00 0 Motors to 10hp $0.00 -0 Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 0 Fireworks Stand $0.00 0 Motors to 100hp $0.00 0 Other Electrical Fee $0.00 Motors over 1 00h $0.00 0 Communication drops $0.00 0 Investigation Fee $0.00 Sub panel to 200a 527.25 1 Plan Check Fee $0.00. Pole Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $0.00 0 Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $276.05 Intermed Pole 50.00 0 COMMENTS 1 SPECIAL CONDITIONS EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or If work Is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result In the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 x DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following dedaradons: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the w for which this permit Is issued. have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: Policy Number. (This section need not be completed it the permit Is valued a1 one hundred dollars ($ 100) or less.) ❑ 1 certify that in the performance of the ork for which this permit Is Issued, I shall not employ any person in any manner so as to become subject to the workers' Compensation law of California, rid a �ee t at if I should become subject to the workers' Compensation provisions of Section 3700 of the tabor Code, I shall forthwith comply with these ovlslons. �_! r Applicant Signature: Data: ?� . WARNING: FAILURE TO SECURE WORKERS' CO16WAATI0N CONEAAGE IS UNLAWFUL AND SHALL SURJE•CT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADOMON TO THE COST OF OOMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LAMA CODE, IMEREST, AND ATTORNEYS FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licen ed under rovislo s of Chapter 9 (commencing with Section 7000) of Division 3 of the Busines and Professions Code, and my license is in full force and effect. Uc. p Class a Contractor's Signature: s b Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there Is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lenders Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to Its Issuance, also requires the applicant far such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Divlslon 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (5500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or Improves thereon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not Intended or offered for sale. If, however, the building or improvement Is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of Sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING VW H LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Slgnafure:. Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, I.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more loot In depth Into which a person Is required to descend, will be made In connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number, HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure), ......................................................................................................................................................................................................................... I................... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? [3 Yes 0 No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which of any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ................................................................................................................................................................................................................................................................................ 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes 0 No (SeOon 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fre Department. ..............................................................................................................................................','b"a................-................................................................................................... 4 If an RMPP is presently required, has Section 25534 of the California Health and SafetyCode been fully complied with? ❑Yes ❑ NO 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a pilcation efermlt for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes LJ No (Section 65(350.2 of the Caliiomia Government Code requires that the requested Information be furnished on applications for non-residential building permits). ............. ........................................................... ............. ..... ........... ................................................ ................................................ t3 Will any part of the facility to be constructed under this permit be withln 1000 feet from the outer boundaries of a school? ❑ Yes ON a (it'yee, the facility must meat the requirement of Sections 25534 and 42303 of the Califomia Health and Safety Code). .. .......................................................................................................................................................................................................................................................... 7 if apermit from the South Coast AIr Quality Management District or other air pollution control district or agency Is regnlred for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Coda Section 42303 been made. ❑Yes ❑ No ... ..................... ......--- ..................................... ................................... ........... .......................................................................................................... ....... ...... I........................ 8 {If yes', attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to Comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for i spection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. i alure Of Legal Owner(s) -`4� tee D� 19nd/Or Authorized Applicant i? Date CODE_ f• INSPECTION TYPCODE INSPEMN TYPINTMA $ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 206 Final Plumbing 200 Final Re -Roof 210 Final Electrical 2D1 Final Block/Relaining Wall 212 Final Fire Prevention 202 F1nal Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy 244846 7 J ADDRESS OF BUILI)INO: 3333 BRISTOL ST DNT.. 1501 OWNER'SNAMEIFKNM:C J SEGERSTROM FLOOD: AO -38 ADw$&, 3315 FAIRVIEW RD COSTA MESA, CA 92626 APDL. M UNG ADDRESS: ARCHITECT OR ENGMEFR: A I t J K Inc. NO' C 1 1 5 1 9 ARCH. OR Un-$ ADDRESS: 16 5 9 11 TH S T DM: 200 SANTA MONICA CA 90404 comwTorsNAw-RS HAGLUND CONSTRUCTION (714)673-8106 CONTRACTOR.S MAI H ED R I C K AV 3�,I: tIVERSIDE CA mw. 412567 l0 92505 Dom= UCENSEO CONTRACTORS DECLARATION: I hereby alfrm leder party d pwjuy that I am licensed oder provisions d Chapter o (commencing with Section 7000) of OivWon 3 of Ma Business and Prafassiord Code, and my license Is In full force and effect. CITY LIC. ND.:O 3 5 2 0 5 LIC. CLASS: B UC. No,: 412567 E : 04/98 11 Date: 4 ` 3 g Caruredoc A OWNER BUILDER DECLARATION: I hereby affirm reader penalty at pwj" that I am exempt from the Contractors License Law for the fdbwig reason (Section 70315 Business and Prdessiors Coda: Any cy or ouaty which requ bm a perm'[ to Corstrurl, ager. 'Improve. demolish. repair any structure, prior to its issuance. also requires the applicant fa such pem)d to file a sipped statemera that he or she e licensed pursuant to the provisions of the Contractors Lioense Law )Chapter 9 (oommancing wish Section 7000) of Division 3 of the Business and Professions Coda) or that he or she is exempt therefrom and the base for the alleged eaemplion. Any violation of Sedion 7031.5 by any applioeru for a permit w6jects the eypfi=m to a civil penalty of not more than five hundred dollars [SEOOD. ❑ 1. as owrr d the property or my ernployees with wages as their oak compensation. wig do the work. end Ow structure is nor Intended or offered for sale (Section 7044. Btsnass and Prdessiorm Cade: The Contractors License Law does not apply to an owner at property who builds or improves thereon, and who does such work himse8 or hersef or through he or her own employees. provided that such improvements are not imended or offered for sok. 1. however. the building or improvement is sold within one year of compleliom the owner-bw'kfar wilt have the burden of proving he or she did not build or improve for the purpose of sale). ❑ I, m owner of the property, am exclush* ooratadig with boersed contractors to construct On project (Section 7014, Business and Professions Cade: The CaNradors tierne Lew does not apply to an owner of property who builds or improves lhereon and who contracts for such projects with a mntrector(a) howsed praarari to the Contractors Lic rme Law). ❑ I am exempt under Section: B. & P.C.. for this reason: Dade: Owner: I do hereby certify that I am aware of and understand the requirements of California Health and Safely Code Sections 25505, 25533. end 25534. and that I or wry future building occupant wit r will nor (circle ane) need to corrupfy with said sten codes and the requiremaras for a permit 10MM011Jdicn or moddK94011 born the Ai uFt aupanera District, Residential comtnuciion eppYra Torn an exempt from Oman provmo s - Date• Applicant: WORKER'S COMPENSATION DECLARATION: I hereby arae urdar penalty of pajuy arse of the fotowinp dalarations: 1 have and nil maintain a cerlifrace of txrsera to sall4rnras for workers' oargannion. a provided for by Section 3700d the Labor Cade, for the performance of the work for which this permit is issued. I have and wd raitaeih workers' uamparsmion knsuranoe, as required by Section 3700 of the Lebo Cods, for the performance of the work for which Mils pamUt is issued. My workers' compensation inelranae carrier and policy number aro: carrier. gTATF >±TIND EXPIRES Poky Nurrnber 1-4 211 A 6 - 9 7 12/01/98 (71w sectim need nor be ocmpJsred f the perml is kr one faardrad ddlam fS1001 or lar ) ❑ l mniy that in the p»Aornusnce of the work for which the pere>a is issued, I shelf not employ any person in ary manna so as to become nnbjed to the wociaW compensation hive d CaMornis, and aprse that it I shark became ar6)aa to the workers' compensation prcvisitr e of Section 3100 of the Labor Code, I sfhal forthwith comply with those Provisions Date: 4 - 3iiQ b ` `ApV.: ✓I� -Z orKOKS. Wanrin0: FaOun to stwwo warkwo' companutlan coverage Is unkal t( and shall &*IW err, Wer to crintfnal panel!!" and dvA linea up Io arra hundred thousand dollars (SIO9000A H Addition to the coat of companeadar; ala ag" as provkWd for In Sactlon 3708 of flra tabor Coda, lraamt and attorney's fa". CONSTRUCTION LENDING AGENCY: I hereby affirm under penalty of perjury that then is a construction landing agency for the performance of the work for which the permit is issued (Section 3097, Civ. C). LENDER'S NAME LENDER'S ADDRESS: I certily that I have read this application end state that the above idonnation is cosred. I ogres to oDmpy wish all city and county enhances and stats laws relating to building aomeuctron and hereby mahorce represanaiives of this day to enter upon the abon-inamiorled Property for impaction purposes. STEVE HAGLUND -tl prim" Otte _4-3,0-90 Signature of AgatlAppiranuComrador (5151-46.WP) Whife-Buidig 6 Safety. Green -Fie: Canny -Applicant; Pink-Plevenue:0olderaod-Asaesacr tr— CITY OF COSTA MESA - BUILDING PERMIT PERM NO: B 0 79 PERMIT NO: B 087979 PLAN CHECK NO: 01260-98 A GOVT: N S P: N CONSTRUCTION TYPE: I FR PERMIT TYPE: STR PURPOSE: ALT JOB DESCRIPTION : 4000SF STORE TI SQ FT: 400,000 CLAIM VALUE: 400,000.00 CALC-VALUE: 848,000.00 GROUP OCC: M / COMMENTS: "CHRISTIAN DIOR}1 STORE TI rerUex,& ilil,<,rnly mAW, Osos)4 [Urfa. erw4- /3ry?(jSOS) Z O N I N G R E Q U I R E M.E N T S S E T B A C K S ------------ MAIN BUILDING ------- -.--------- ACCESSORY BUILDING--------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RIGHT: FT IN LEFT: FT IN RIGHT: FT IN PARKING REQ: PROV: PARCEL: 41249102 ZNE: FDC REF NO: ' PLANNING NOTES>'INTERIOR ALTERATION > NO INCREASE IN FLOOR AREA FOR THE SUITE IS PROPCSED,i;- iEiEiE��-lE*��irt1F)E�FiEiEiE9F**-1t-)k**itdElEdE�dtdt*aEif-)F�iFiEiFit�it***it,7titat�Eit1t�1l�dkdt�F**ltitiaitifit�tirt"1f lE'dEiEiE*iEiEiE�iEiE D E V E L O P M E N T S E R V I C E S R E Q U I R E M E N -T S ZONING APPROVED BY - DATE: 30 k BUILDING APPROVED BY DATE: APPLICATION ISSUED BY: y(- DATE:��-�- �IEiE�*iE9Ei�irkitiE�E��1E**�***iF�F� ���**atit�l�tititifif iEiE LEGALIZATION:N F E E S U M M A R Y STRUCTURAL SEGMENT:Y BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT 4,366.25 PLAN 709.52 ISSUE FEE BUILDING -DIV-> PERMIT ISSUE PLAN -CHECK TOTALS ---- > 4544.33 0.00 709.52 REVENUE DIVISION TOTALS--> COLLECTED: BLDG PMT PLUMBING ELECTRIC MECHANIC 4366.25 SMIP/NON-RES 178.08 TOTAL PAID DUE 5253.85 5253.85 .00 4544.33 OVER/SHORT: .00 FIRE SMIP/TOT GRADING PLAN -CHECK 178,08 !E♦tf�t*♦��*i4*�iF�iF1E1ElEi[•iFi4iEiFiE1k*9E**IE**iF11EdE*lE9F�k*�Firk�4*{tF�F�iFiE i4f�iEiil4if*aE*irk♦fF��F�*dEzyFlfdEdE9F*iF***iF*iF�FiF�t I N D I V I D U A L F E E B R E A K D O W N TYPE _-QTY D E S C R I P T I O N UNIT COST TOTAL COST SFC. 848000 T.I. STORE BY VALUE/$1 1.00 848,000.00 END OF FEES 04-3C-1998/61:12 WS4544.33 RCP1fi:31 -`;23277 PERMIT. -097'379, 1r CONSTRUCTION AND PLANNING • .'QOL & SPA APPROVALS Permit # Date Inspector APPROVALS Permit # Date Inspector 1. Temporary Electrical.Service or Pole 52, Pool & Equipment Location 2. Soil Pipe. Undrgrnd. ' . 53. Steel Reinforcement 3,. Electrical. n�uitltiiity flncirgrnd. 54. Forms �. ;.L4' Electr'scalTCori luit;U�¢rgrnd. 55. Electrical Bonding ' Steel Reinfofae,"r%�t,j 56. Rough Plumbing & Pressure Test Ilectrical OF'1�•R•Gjnd. 57. APPROVAL TO COVER-GUNITE 7; Footings Crte^ 58. 58. Electrical Conqui�;'Undrgrnd. F J:;$ +Foundation + z 59. Gas Pipe, © Undrgrnd., Test rr 9',I>Yater Pipe•Und grrld. �: 60, Backwash Lines,.P�Trap, © Undrgrnd. 10. •Structural Floors System 61, APPROVAL TO�DECK 11, Property Sewersl!ir+e & Hous4'C,onnecTion 52, Backwash $c Receptor Final 12. Sewer Cap `` `+ 63. Heater & Vent -Final 'k 13, Roof Drains 64• Plumbing System . Final 114. Rough Plumbipg( 65. Electrical -Final 15. Rough Electrical -Conduit �j 66. Solar System Foal+ 1.6, Rou h Electric 1r11iriri 9 " ''' 67. Fencing'& Access.Approval , 17, Rough Wiriog Sign 68. APPROVED Fp!.PLASTERING Fp!.PLASTERING , A -r ' 18. Rough Eiectrica 5T Bar Ceiling" 69. POO USPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT t + Cl APPF01L5 -- PJk_6it # r 20. ou Factory Fi 21. buds, in;Struceture Z7 ^' 70. ;L'}nderg EtR Hydro r + r. , r 22. Vefttiling 1' x '�;�,`. 71. ProduCL'ingkT�1Oil ,Duds' 23. Gas f tpe-Eioug� & test ;rJZ �. ;-i 'r � � + 72. Undergr6Tjnd Fiush ,� - , 24. 'Roof =Framin r ' `. 9Y" � ` " 73j `Clndergrrfid. Stogy V T�nO Gas ❑Oil x > ,4 25. Roof;Sh, B' thing u , v t P)',. 74-,1; Ove head Hydro') '� V 26. T Bat:Ceiling (Str'uctral) &tZCoat r - v a 73y�faryChemict'al '•' �' C _,� . 27, Frame and F13shin >1 # 7f. Dry Sta pipe + 2B. Lathing Br Siding i `" ^'r f 77� FIXED 5Y$TEtA INAL , n 29. Insulation v v+ .i 7W FIRE PREY. FINAL r r� " 30. Drywall Mailing r "VALTHJDEPT.`REQUIREMENT J j 31. Plaster B owrrf_oat�, rr• -+ • 70. FINAL (INOECTroN * 32. Electrical Po%4dr Mate Final � � '" ' � : 80?; FOOD CERTIF;IGATE 1�5�3ED 33. Fina I�Electric� ; . * _ti - y t ' .T NpEes: Y v 34. FinalJ-Ieating*& Air Condkionirtga x { �: `. 35. Final -Gas Pipe est F�oocf-or Canopy ��-- �. -, :A ;_ r' j « _3fi. 37. F�nal Factory Firepii'ce' LA C_ x � D' R' 38. EinahPlumbing. "'1 - � - r j x j `� • 539. Wath Ser vice -,Final i ? x ♦ 7. .� + h .K ! 40. Gas Service -Final K; 3 ;,• r- r'- W �. � C •_> w u L 41. Solar Domesti` -- {y' ? 42. Backflow Preventer :j ."i'= .' f-• V P -1'� -, rr m •J' r 43. Backflow Irrigation' 44 Landscape Irrijation+System .7 r, 46. Sound At enuation nj tr 45. kandicap-. �eguIatians 47. FINAL STRUUTURF & B U I LDING %147A Q//// � ' 1 v ,. n 7. .• 1 48. FINAL PLANNING" • _ 49. Eleciric Release to Edison '" 50. Gas Release to Southern California -Gas Co � x 5.1. CERTIFICATE OF-OCCUPANCY� NoDate j'" yF' 1 ���t;,�+.-;•."r r"" �' v 1'` � `� r ` `y""'_'�+j4Y�%^ "ar-4,.�.• �. � ��iiv�7 t • �rct}3di+ Ate'! i S . � .,� r - • ;. - ... , CITN OF -COSTA MESS' Development Services; Division of Building and Safety am., 7 CERTIFICATE OF OCCUPANCY This certificate is issued pursuant to the requirements of the Uniform Build":' Code, Section 308 adopted by the City of Costa Mesa certifies that at the time cif its issuance the building structure herein=below described was inspected and approved for occupancy as follows: f , Building Address 3333, X15{0 5. ;yB r i.s to l S t ldgr Permit Number B06-00079 U Use Jewelry StoareM`nnt Group Type of Construction .�::. ireFAK Use Zone SDC r Owner of Building Coast l?lFaza TenantlFAt`Y±Q COMPANY ART Address 3315 Fairview AVe ,Costa MeB., .C�.. 926:2 ra BUILDING OFFICIAL-Khanh Q. Nguyen, C B O = y < �.Date`� :�'�`�07 10 Ob REQUIRED TO BE POSTED IN `A CONSPICOUS PLACE �Op of Costa NE Development Services, Division of Building and Safety CERTIFICATE OF OCCUPANCY This certificate is issued pursuant to�the` requirements o- the�Uniform Building Code, Section 308 adopted by the City of Costa Mesa certifie!that. at the time of jrts~i suance the building structure herein below described was inspected and;approyedfo"r,=occupancy_as.follows:, Building Address -4-433 BCR?smr. srggrr_ ____ TMT g. Permit No.B72849 Use Group 3t-7 Typetiokonstruction IYR sp Fire,Zone.-;- ti; Use Zone cis Owner of Building e_.r_ RWORSTRON K``sotas =Tenant ",hERA JENS N -- Address I BUILDING OFFICIAL- COW? it"'N 2�aCa t�� ���� •, Date' 1V REQUIRED TO BE POSTED"IN-XCONSPICOUS PLACE (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesagyll'ILDING PERMIT Job Address: 3333 BRISTOL ST Suite: 1505 Vicinity: SPACE 1505 Primary Occ: M Display/Sale Merchandise Type of Construction: I -FR Parcel Number: 41249102 Zoning: PDC Applicant: HILL, DUANE Address: It t -AIH UHIVt, L:VJIA MtbA, UA VZOZO Y ISSUED BY: Status: ISSUED Applied: 01/18/2006 Issued: 0310612006 Arch : , PAUL BOZARTH Eng: Address: 18661 VALE AV Address: Phone: ,714-538-5777 Phone: SANTA ANA, CA ! . Zip: 92705 .License: C14800 License: SCOPE OF PERMIT INTERIOR T,I. OF "TIFFANY AND CO", SPACE 1505. WORK TO INCLUDE: DEMO OF CEILING AND NON -LOAD BEARING PARTITION WALLS IN ADJACENT SPACE IN ORDER TO COMBINE THE ADJACENT UNIT, REMODEL 2 (E) OFFICES AND CONSTRUCT A NEW STOREFRONT. FEE SUMMARY Plan Check: $1,191.94 Phone: 480-461-0777 Permit: $$1,833.75 Zip: Owner: SOUTH COAST PLAZA Address 3315 FAIRVIEW AVE- ' Other. Misc. Phone: -- - - Inspection: COSTA MESA, CA' = Zip: 92626 Contractor: PWI BUILDERS:_, Address: 155 W MAIN STREET Phone: 480-948-9451 SETBACKS MESA AZ Zip: 85201' License: 815987 It t -AIH UHIVt, L:VJIA MtbA, UA VZOZO Y ISSUED BY: Status: ISSUED Applied: 01/18/2006 Issued: 0310612006 Arch : , PAUL BOZARTH Eng: Address: 18661 VALE AV Address: Phone: ,714-538-5777 Phone: SANTA ANA, CA ! . Zip: 92705 .License: C14800 License: SCOPE OF PERMIT INTERIOR T,I. OF "TIFFANY AND CO", SPACE 1505. WORK TO INCLUDE: DEMO OF CEILING AND NON -LOAD BEARING PARTITION WALLS IN ADJACENT SPACE IN ORDER TO COMBINE THE ADJACENT UNIT, REMODEL 2 (E) OFFICES AND CONSTRUCT A NEW STOREFRONT. FEE SUMMARY Plan Check: $1,191.94 - -` Permit: $$1,833.75 SMIP Res: $0.00 SMIP Com: $52.50 Other. $0.00 _ -- - - Inspection: $0.00 Total: $3,078.19 - -';;1Pt_ANNING & ZONING SETBACKS MAIN STRUCTURE, Front '0-0 Rear D-0 Left 0-0 ACCESSORY Front 0-0 .�` Rear., 0-0 Left 0-0 PARKING Existing:,, 0. Required: 0 Proposed: 0 Calc Valuation: $250,000.00 Claim Valuation: $250,000.00 =Right _0-0 Right 0-0/, e r' NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shalt automatically expire and become void if work is not commenced within 180 days, or it work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 W646 (6=) DECLARATIONS ?0` WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My wprkers' colo satiort In rance c mer and policy number are: Carrier: 1 .) l-I--Inoc— Policy Number. (This section need not be Completed i/ the permit is valued at one hundred dollars (S t 00) or lass.) ❑ I certify that in the pertonnance work for which thl rmit Is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Calif. , jand gree that if I sh b t to the workers' compensation provisions of Sac on 377700 of the Labor Code, I shall forthwith Comply with thane provisions. — ���� Applicant Signature: Date: WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am lice e4 underprovisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full farce and effect. Lic. i# t Class ft Contractor's Signature: Date: Q�2 CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit 10 file a signed statement that h9 or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (5500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. if, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ' ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractors) license pursuant to the Contractors Uconso taws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: _ Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no exwvation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, ialsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division, Signature: „ Data Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or preSjgV gr future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes No (Section 25505 of the$lifornia Health and Safety Code requires, with some exceptions, that a Business Pian be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of.hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, .or 200 cubic feet of compressed.......s at standard• temperature and pressure). ...................................................................................................................................................................................................... 2 boas or will the applicant or resent or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes . No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials}? ❑ Yes J!o (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. : .........._...........................................................................................................................................................•---•----•................................................,........................................... ....................................... _.................... 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? (:1Yes �No ................................................................. ...................._.................................................................................................................................................................................. .............................................................................................. I—,............... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Ll Yes No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ..............................................:........................................ ................................ I ........................ ...---��...................--.............................................................................................................................................................................. 6 1Nill any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yeshlo (If 'yes', the facility must meat the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ... .............. .......................................................... .... ................. ...............-•----................................................... .----- ----.............. — ........................ __._........ ...... ................. _.... 7 It a Permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No _ ..................................... ... ......_..,........... -- _ ..... _ — —-....................................._................................................................................................................�....................._............................................... 8 (it des-, aftach certificate of Compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for Inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature Of Lega ne s) c� i G Date And/Or Authorized Applicant f�i Date CODEC IN5PECTION TYPE S INTITIALQODg 0 INSPECTION TYPiNTMALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining WAIT 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final BuildinglOccupancy, O (714) 754-5273 • Fax (714) 754-4856 • www.cl.costa-mesa.f8[MLDING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Status: ISSUED Suite: 1505 , Applied: 09/16/2005 Vicinity: STE 1508 TIFFANY HOLIDAY SHOP5 Issued: 09/16/2005 Primary Occ: M Display/Sale Merchandise Type of Construction: I-FR Parcel Number: 41249102 Zoning: PDC Applicant: BARTH, EDDY Address: 140 LOMAS SANTA FE SUITE 200 Phone: _ 858-793-9104 ISSUED BY: SOLANA BEACH, CA Zip: --- 92075 Owner: SOUTH COAST,PLAZA-/>:�,:><; Address 3315 FAIRVIEW AVE MISC:, Phone: COSTA MESA, CA Zip: 92626 Contractor. DICKINSON CAMERON CONSTRUCTION INC Address: ` " 140 LOMAS SANTA FE x >` SUITE 200 ' . Phone: 858-793-9104 SOLANA"BEACH, CA Zip: 92075 °`, License: 690239 Arch .� Eng: Address: Address: ' Phone: Phone: Zip;: �License License: SCOPE OF PERMIT ,INTERIOR STORE. DEMOLITION (PREP WORK) OF NONBEARING WALL, T-BAR CEILING AND FLOORING IN CONJUNCTION WITH"THE FUTURE i <'<'1NTERIOR TENANT IMPROVEMENT FOR'-"TIFFANY HOLIDAY SHOP' IN SPACE 1505. TEMPORARYISEASONAUSTORE.w:o REF: B05-01508 FEE SUMMARY , "" Plan Checfc::•.': $0:00 Calc Valiaakioi" y3` $1,500.00. Permit: - $54.00" Claim. Valuation: SMI P` Res:. $0.00 .. .SMIP Com: $0.50 ;- w , Other:. .. $0.00 ,,Inspection: $0,00'...; Total: $54.50 -PLANNING & ZONING SETBACKS MAIN STRUCTURE Front 6-0' Rear 0-0 ." Left 0-0 RightA • 0-0 ACCESSORY Front 0-0 Rear 0-0 Left 0-0 Right 0- 0 , . PARKING 0 Required: 0 " Proposed 0`- NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, g 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or it work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit, FOR INSPECTIONS CALL: (714) 754-5626 r 2"6.46 (6=) ( / DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penafty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to salt -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the tabor Code, for the performance of the work for which this permit is Issued. My workers' compensation f surance rrler and poll number are: � �j' �Camer �� PolicyNum, er:4��y-[20n C>'T (7riis section need rot be completed if the permit is valued at" hundred dollars ($100) or less.) W~^ 3+ ❑ 1 certify that in the performance �Jrgrl k for whl this ed, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Califo i! u be su act to the workers compensation provisions of Section 3700 f the or Cade, I shall forthwith comply with these pravisio Applicant-Slgnature: pa e 7 ry. WARNSN FAILURE TO SECURE WORKERS'COMPENSAPnoN COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTI S AND 4IL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,0001, IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am Ilce a nder provisio of Chap r 9 (comma Eng with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and affect. 116. Classk Contradors'Slgnature:1&0CData: }- CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction I ding agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Cade). Lenders Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractor: License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Coda: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not Intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ' ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws,). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec, 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division, Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous materiel? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which hes at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ..................•....................................... _............................................. _...... ............................................................ ..................................................................................................... •-•---....................................................................................... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ........................................................................................................................................................................................................................ .......................................... ........_......_...........1 ....................... .................... 1111....1..11..1....................... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? E).Yes .......................... ................ es ❑ No 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this application afermil for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes L3 No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ...........................................................................................................................................................-........---------........�.................................................................... ....................--------...................._.............................._..... 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (I1 yes", the facility must meet the requirement of Sections 25534 and 42303 o1 the California Health and Safety Code). _................................................................................... ............................ ............................................................... ............................. ................................ .......... _.................. ............................... ...._........................................ ._................ 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disdosures prescribed by Caltlomla Health and Safety Code Section 42303 bean made? ❑ Yes ❑ No 8 (If yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purpos ree not to occupy or allow occupancy of any building authorized by this permit until final inspection. S, LA I nor(s) pate uthofized Applieant�` iia e CODE 1. INSPECTION TYPE RAIL INTITIAL CODEC INSPECTION TYPE RATE INTITIAL§ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Root 210 Final Electrical 201 Final BtocklRetaining Well 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition % �O 4 250 Final Building/OCcupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT Job Address: 3333 BRISTOL ST Suite No 1505 Vicinity: Parcel Nunmber: 41249102 Applicant: HILL; DUANE FEE SUMMARY ` Address: Quantity ` Phone: 480-461-0777 ISSUE FEE $23.50 Zip Temp Dist System 1 Lighting Owner: SOUTH COAST PLAZA Temp service test $0.00. Address 3315 FAIRVIEW AVE ` - 0 ' misc. -Phone: Standing Section., $0.00 COSTA MESA, CA Zip: 92626 Contractor: 'PWI BUILDERS $0.00 0 Address: 155 W MAIN STREET Transformers up to 1 kvalkw $0.00 0 Phone: 480-948-9451 . 0 MESA'AZ Zip: 85201 Lighting Fixts 547.55 License: 816987 Status: ISSUED Applied: 03/06/2006 Issued: 03/06/2006 ISSUED BY: SCOPE OF PERMIT INSTALL 55FIXTURES, 28OUTLETS, 7SWITCHES, 1-250AMP SERVICE, 22COMM DROPS, 2SIGN CIRCUITS FOR'TIFFANY" STROE TI, RE:12106-00079 'COMMENTS I SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This. permit shall automatically expire and become void it work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754.5626 2448-46 (6=) FEE SUMMARY ` Quantity ` Quantity ISSUE FEE $23.50 Temp Dist System 1 Lighting $0.00 0 Temp service test $0.00. Busway 1100 ft $0.00 0 Res. a/c package $0.00 Standing Section., $0.00 0 New Res (1-2 units) $0.00 0 :a, Misc Electrical Equipment $0.00 0 New Res (3+units) $0.000 Transformers up to 1 kvalkw $0.00 0 Pool l Spa 50.00 . 0 - up to 10 kva/kw $0.00 0 Lighting Fixts 547.55 55 ' .................up to 50 kva/kw $0.00 0 Recept Outlets 527.84 28 .................up to 100 kvalkw $0.00 0 Switches $7.70 7 ..................over 100 kvalkw $0.00 .0 Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0 Res Appl 50.00 0 Low Volt Wiring System l Ckt $0.00 0 Service to 200a $0.00 0 ..Misc. Conduit $0.00' 0 Service to 1000a $62.15 1 ".,°." Misc. Conductor $0.00 0 Service over 1000a $0.00 0 Circus ( gen or ride) $0.00 0 , Motors to 1 hp '"$0.00 0 - ' ' Circus (meth ride or lights) $0.00 0 Motors to IOhp. $0.00. ` "' '' 0 Christmas Tree Stand $0.00 0 Motors to 50hp $0.00; 0 Fireworks Stand $0.00- 0 Motors to 100hp�� ; ' ",$0,00- ;x. 0- . ' Other Electrical Fee $0.00" Motors over 100hp,, $0.00 - 0 Communication drops `; '$21.46'• '22'' "" Investigation Fee $0.00 Sub panel to 200a .$0.00 0 Plan'Check Fee $0.00 Pole Light Pkg $0.00 '. , 0 Reinspection Fee $0.00 Sign Circuits`$49.20 2 Temp Pwr Pole ' 0 j TOTAL CALCULATED FEES $239.40 Intermed Pole _$0.00- 50.00 0 'COMMENTS I SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This. permit shall automatically expire and become void it work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754.5626 2448-46 (6=) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ 1 have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. My wopr�s' compensation, Insur�ance=c\avi rand number are: Carrier: W V r� - 1/CE C - Policy Number: (This section need not be complated if the permit is valued at one hundred dollars ($ f 00) or less.) ❑ 1 certify that in the performance of the work for which this permit is Issued. I shall not employ any person In any manner so as to become subject to the workers' compensation laws of Callfornia(ER6Vgree that if I should bec su the workers' compensation provisions of Sectio 3700 of the Labor Code, I shall forthwith comply with these provisions. Applicant Signature: Bate. WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENAL IES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,D00), kN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DE=CLARATION: I hereby affirm that I am licensed u provi 'onsC ter 9 (commencing with Section 7090) of Division 3 of the Busine and Professions Code, and my license Is in full force and effect. Lic, q Class A Contractor's Signature:Date: CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lendees Name: Lenders Address: Signature: _ Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Coda: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation o1 Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sea 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her awn employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement Is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.J. ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - properly tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excevation five (5) or more feat In depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than Thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sac. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work front the division. Signature: --- _ ..._ Date: Division of Industrial Safely Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 WIII the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume o1 55 gallons, or 200 Cubic feet of compressed gas at standard temperature and pressure). .........._..................-.......__.......-......... ........ ................ ..... ......................................... .._.._...----........................--........................ -.... -.............................................. __.................... _--.......---................._...-........ 2 Does or will the applicant or present Or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ...............................................••-•--•........ --............................................... -.... -........................................ _............................... _................................ ...................... -.................... -_........................ -........................... •---.............. 3 Does or will theappplicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? 0 Yes 11No (Section 25534 of the Califamia Health and Safety Code provides that the Costa Mesa Fire Departmont may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire ... Department. ...... ..................................................................................................................................................................................................................................... --........................................................................ 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No ................................................................................................................................................................................................................................................... .......................................... ............................... .......................................... 5 QOes or will the applicant or present or future building occupant require for the work which is the subject of thisa plication a rmit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? 8 Yes IJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ................................................................................................................................................................................. ............................... 6 WIII any pert of tha facilityto be constructed under this permit be within 1000 feet from the cuter boundaries o1 a school? ❑ Yes ❑ No (If 'yes", the facility must meot the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ......................................................................................................................................................................................................................................................................................._.--......................._.............................. 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the Subject Of this application, have all of the disclosures prescribed by Catifomia Health and Safety Code Section 42303 been made? [3 Yes El No _.. _.......................................................................................................... ----........._----- _.................... —............... __............... .................... ... 8 (If fres", attach certificate of Compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature al.OwnCsDais �C And/Or ALAMTrized Applicant Date CODE It INSPECTION TYPE PBIE iNTITIA4$ COPSE INSPECTION TYPE RAIL INIMALaS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 f=inal Re -Root 210 Final Etectdcal 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 ' Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ei.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Suite: 1505 Vicinity: Parcel Nunmher: 41249102 Zoning: PDC PDC ISSUED BY: Applicant: LOONEY, SHEILA Address: 5200 E HUNTER AV SUITE B Phone: 714-993-2822 ANAHEIM, CA Zip: 92807 Owner: SOUTH COAST PLAZA Address 3315 FAIRVIEW AVE MISC. Phone: COSTA MESA, CA Zip: 92626 Contractor: ALERT FIRE PROTECTION INC Address: 5200 E HUNTER AV SUITE.B, Phone: 714-993-2822 ANAHEIM, CA Zip: 92807 License: 316324 SCOPE OF PERMIT RELOCATE 18 OVERHEAD SPRINKLERS FOR "TIFFANY" IN SPACE 1505. REF.: B06-00079 FEE SUMMARY Plan Check: $63.21 Permit: $97.25 Other: $0.00 Total: $160.46 Status: ISSUED Applied: 03/29/2006 Issued: 04!1712006 Calc Valuation: $3,500.00 Claimed Valuation: $3,500.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92.28, § 1, 12.21.92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 184 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit, FOR INSPECTIONS CALL: (714) 754-5626 C44"a (WWI WORKERS' COMPENSATION DECLARATION: hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the tabor Code, for the performance of the twfor which this permit is issued. e and will ' tai workers' pensatlon Insuranoe. as required by section 3700 of the labor Code, for the rformance of the work for which this permit is issued. orkers' c n Ins cam and policy number are: Policy Numhe on need not be completed i1 the poinid is vaned at one hundred dollars (5 f 170) or less.) ❑ 1 certify that in the performance of the ork for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' mpen tion laws o1 Calilomla, an g that I should b come subject to the workers' compensatiLrovisions of Section 3700 of the Labor Code, I shall forthwith comply th these provisions.pllcanf nature�QWARM : FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLA AND SHALL SUBJECT MPI PENALTIES AND CML FINE$ UP TO ONE HUNDRED DDOLL.ARE fS1 e0,000J IN ADDITION TO THE COST OF COMPENSATION, GES AS PROVIDED FOR IN SEE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby Of4m. that I am licensed under provisionj of Chapter 9 (commencing with Section 7000) C, iv the Business d Pro essions Code, and my license is in full force d Ohgl. US Cant ro: Date: CONSTR LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code), Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for Such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Divislon 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (5500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for safe. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property. am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet In depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsawork, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of industrial Safety, as noted above, unless such person has a permit to do such work lrom the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous materia!? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ... ........................................ _.............. ........__._........................................................................................... ......................................................................................................................................... ................... ............ 2 Does or will the applicant or present or lulure building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 o1 the California Health and Solely Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .. .......... ............................................ __..................................... _._..".._...................................................................... ............................................................................................._...................__........._ 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. —..............................._......................__. -..............................._............................_....................................................................... ................................................�...................................... 4 If an RMPP is presanily requi rod, has Section 25534 a1 the California Health and Safety Code been fully compiled with? ❑ Yes ❑ No _..._..._.......__.............................................................. _.......................................... 5 Does or will the applicant or present or future building occupant require for the wart which is the subject of this a plication armit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ ge Yes L,] No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). .................................................................................................................................................................................................................................................................................................................................................................. 8 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). .-- ........ F. _................... _.... ....�._............................... _ .......... _...._..................... _.............._ ...... � _......__.__------ 7 Ef a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by Caliiomia Health and Safety Code Section 42303 been made? [:]Yes ❑ No 8 (lt yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I cenity under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building Construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described propo for inspection purposes, I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. 1§n r 011e And/Ocant e — CODE -P. INSPl~CIl4NJJPE 28IE INiiTIALS CODE D LNSE€gIlPN JTE€ 2M INTITIA >� 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention J! 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy Job Address: 3333 BRISTOL ST . Suite: 1505 Vicinity: Parcel Nunmber: 41249102 Zoning: RDC PDC Applicant: BASSE, JEN Address: 28245 AV CROCKER SUITE 200 Phone: 661-775-7788 SANTA CLARliA, CA Zip: 91355 Owner: SOUTH COAST PLAZA Address 3315 FAIRVIEW AVE MISC. Phone: COSTA MESA, CA Zip: 92626 Contractor: CONTINENTAL SECURITY INDUSTRIES INC -Address: 28245 AVENUE CROCKER SUITE200 Phone: 661-775-7788 VALENCIA, CA Zip: 91355 License: 776845 Status: ISSUED Applied: 04/13/2006 f Issued: 0 ISSUED BY: SCOPE OF PERMIT MODIFY FIRE ALARM SYSTEM DUE TO INTERIOR TENANT IMPROVEMENT FOR TIFFANY AND CO" IN SPACE 1505' - ' • FEE SUMMARY Plan Check: $81.41 Permit: $125.25 Other: $0.00 Total:, $206.66 Calc Valuation: $5,40D.00 Claimed Valuation: $5,400,00 NOTICE: The work authorized by this permit shall comply with all applicable •handicap access requirements under California statutes and related regulations. (Ord. No. 92.28, § 1, 12.21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 !446-46 (&n4) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under Penalty of perjury one of the following declarations: ❑ 1 have and witl maintalA a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the a for which this permit is Issued. I have will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this perrnil Is Issued. !M e n Ion Insure C carIf rand poli number are: L r L Tom SCS uY nce ��i�( Po11c N�mber� � J IThis s Ctlorl heed not be compfat ff the permit Is valued atone hundred dollars $100) or less.) ❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation law of Callfomla, and agr the I should become subject to the workers' compensation provisions of 9ection 3700 f the Labor Code, I shall forthwith comply with the r . I 1 l _AcantSig7iature: — r Dsta: L _ W Aa uRE so s RE WOF� ' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN O CRI W1L PENAL71E5 AND dVll FINES UP TO ONE HUNDRED rFI6USAND DOLLARE (S ,000), IN ADDrVN TO THE COST OF COMPENSATION, DAMAGES AS P110MDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: Lhefebrafftnwthat•t-a nsed d r sions of Chapter 9 (commencing with Section 7000) of Divisiprf3roLthe Busin s art Profe io Code, and my license is in full for .and.effaG.lJc..tl. [L CONSTRUCTION LENDING AGEN ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is Issued. (Sec. 3097, Civil Code). Lenders Name: Lender's Address: Signature: _ _ Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that unger penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to Its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Professioris Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her awn employees, provided that such improvements are not Intended or offered for sale, If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, Le. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet In depth into which a person Is required to descend, will be made In connection with work authorized by this permit, and that ho building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more then Ihirty-six (36) feet high. (Chap. 32, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division o1 Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 Of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas 41 standard temperature and pressure). 3 Does or will mho aAppticin_T or present or future building occupant need to prepare an RMPP (Risk Management and Prevent[on m Progratot acutely hazardous materials)? ❑ Yes 11 No Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 if an RMPP Is presently required, has Section 25534 of the California Health and Satety Code been fully compiled with? [ Yes ❑ No ..._ �.._...._.................................... ..... __............._....._.._......_............ _......—__........_.._......................,_......... 5 Does of will the applicant or present or future building occupant require for the work which is the subject of this a plication a ffrmit for such construction or modification from the South Coast Air Ouality Management District or from any other air pollution Control district or agency? L) Yes LJ No (Section 65850.2 of the California Goverment Code requires that the requested information be furnished on applications for non-residential building permits). ...------ ................. _... _ — _ ........._... — 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes 0 No (If yes', the facility must most the requirement of Sections 25534 and 42303 of the California Health and Safety Code). .--._....__..._-----._..._..._. ........-........................................ —__.. __ ...._......... ...- .................. - ......... — —--.._.-- ....... _......... ._._.. 7 If apermil from the South Coast Air Ouality Management District or other air pollution control district or agency Is required for the work which is the subject of this application, have all of the disclosures presenbed by California health and Safety Code Section 42303 been made? ❑ Yes ❑ No .......__......._.. -................................................................................................................-•---.................-... ............................................................................................................................... --.._...........................,,............................... 8 pf "yes', attach certificate of Compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty Of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions, Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that 1 have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. 'Signal a Of gal Own r(s 2L14 Data An Au 4 a CODE 1. INSPECTIONTYPep� ^``jJ{j}1J ti-�. CODEI INSPECTION TYPE lt!!IE f�� 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final -208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final BlocklRolaining Wall 212 Final Fire Preventioh 202 Flnal Factory Fire Place • 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST. Suite No 1505 Vicinity: Parcel Number: 41249102 MECHANICAL PERMIT ISSUED BY: Applicant: HILL, DUANE Address: - Phone: 480-461-0777 Zip. Owner:,, " SOUTH COAST PLAZA Address: 3315 FAIRVIEW AVE 0 Inst FAU X100 k BTU MISC. Phone: Repair/ Alt Refrigeration Unit COSTA MESA, CA Zip: 92626 Contractor: PWI BUILDERS 0 Address: 155 W MAIN STREET 0 Repair/Alt CoolinglHeat $13.70 Phone: 480-948-9451 Evaporative Cooler MESA AZ Zip: 85201 Inst 1 Rep. Recess Wall Htr $0.00 License: 816987 Commercial Incinerator $0.00 SCOPE OF PERMIT Refrig Sys X100 k BTU INSTALL 2VAV BOXES, ALT DUCTS FOR-71FFANY" STROE TI, RE306-00079 Status: ISSUED Applied: 03/06/2006 Issued: 03/06/2006 COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with ail applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 taarr46 (6r00) FEE SUMMARY Quantity Quantity ISSUE FEE $23.50. Repair/ Alt Absorbtion Unit $0.00 0 Inst FAU X100 k BTU $0.00- 0 Repair/ Alt Refrigeration Unit $0.00 0 Inst FAU 5100 k BTU $0.00 0 Venlillation System $0.00 0 Repair/Alt CoolinglHeat $13.70 1 Evaporative Cooler $0.00 0 Inst 1 Rep. Recess Wall Htr $0.00 0 Commercial Incinerator $0.00 0 Refrig Sys X100 k BTU $0.00 ," 0 ` Domestic Incinerator $0.00 0 Refrig Sys >100 k BTU $0.00 0 _ Compressors /Absorption Systems Gas Piping $0.00 0 Up to 3 hp 1 100 k BTU $0.00 0 Factory Fireplace $0.00 0 3 To 15 hp 1500 k BTU $0.00 0 . Hood w/Meth Exhaust $0.00 01 15 To 30 hp 11,000 k BTU $0.00 0 VAV Box $21.30 2 .30 To 50 hp 1 1,750 k BTU $0.00 0 Vent Fan / Single Duct $0.00 0 Over 50 hp 1 Over 1,750 BTU $0.00 0 Appliance $0.00 0 . - - , - -. Boilers Fire Dampers $0.00 0 Up to 3 hp $0.00 0 Smoke Dampers $0.00 0 3 To 15 hp $0.00 0 Inst or Relocate Appi Vent $0.00 0 15 to 30 hp $0.00 0 Air Handlers a 10000cfm $0.00 - 0 30 to 50 hp' $0,00 0 Air Handiers - 1000ocfm ,,,,$0-00 . 0 Over 50 hp $0.00 0 Floor Furnace', $0.00 0 , , Other Mechanical Fee - Floor or Suspend Heater' / $0.00 ".0" Investigation Fee $0.00 Plan Check Fee $0.00 Reinspection Fee $0.00 TOTAL CALCULATED FEES $58.50 COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with ail applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 taarr46 (6r00) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My w rkers' compensation Insurance carrier and policy number are: �T Carrier: ���,W'-' -Ta TJ.J t Policy Number. �l� � l�l! WW6 S _ (This section need not he completed it the'Pednit & valued at one hundred dollars ($ f 00) or lass.) C3 I certify that In the performance ork for which this permit Is Issued, I shall not employ any person In any manner so as to become subject to the workers' compensation laws of Californi , and a roe that if 15 ould me ub act to the workers' compensation provisions of Sectio 3700 of the tabor Code, I shall forthwith comply with these provisions. 6 I Applicant Signature: Date: WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL, PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE (S1 OD,D00), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am license under rovlsiOns of Chapter 9 (commencing with Section 7000) of Division 3 of the Busine nd Professions Coda, and my license is in full force and effect. Lic. p Class N Contractor's signature: .� Date, CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a Construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are net intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contracior(s) ficenso pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bili or dead): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth Into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) foot high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number. HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the Califomia Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feat of compressed gas at standard temperature and pressure), —..................................."a—p.I-iC................"ie,..............................bu'i............o'*c-.............................-111............g,i's.......'G,_n,............io, r.....................a, ia-_........................ -l's"......................„_..........................,...................•................ 2 Does ar will the applicant or present or future building occupant need to fila a registration form for acutely hazardous materials? ❑Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ..._......................... _............... --....................------................................ _._.............................._.......................... ........_........................ .............. ..._...-...._._.__.._............ _ 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, cerlificalion and tiling with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. --........_ ................ ..... —. ................. _...................... ....... ............. ...._......_.......... 4 1f an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑Yes ❑ No -.........__ ..... — _..........T .. ................_-----..._..............__......._........_—........._—....----........ 5 Does or will the applicant Or present or future building occupant require for the work which is the subject of this a plication a emill for such construction or modifloatlon from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes f No (Section 65850.2 of the California Government Code requires that the requested Information be furnished on applications for non-residential building permits). T........................—..............................._..---..._...........................---..._.........................................._............................................ .......................................................................................................---.............................. 6 Will any..pa..n....of.....th...e facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). __............................__........_.---- South - ---a t Air----._.._........_............ — -o,r •--•-• ••- --....................--._.....s r'................---_r-ih.—_._......................... .._... t,-i's 7 If a permit from the South Coast Air Rualiry Management District or other air pollution Control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No .......................................................................................................................... -.......................................................................................................................................................................... 8 (If yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the Information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I Certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-descarty for Inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. rib Ignature Of Kga!^4 Date And/Or Authorized Applicant Date CODE I• INSPECTIONTYPE j1yj4>r RITITIALS cooEt INSPECTION TYPE � l �2b>(9 T ` 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final BlocklRetaining Well 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.cl.costa-mesa.8LNLDING PERMIT .lob Address: 3333 BRISTOL ST 1 ILLUMINATED SIGN AND 1 NON -ILLUMINATED SIGN FOR "TIFFANY & CO., SPACE 1505. Suite: 1505 Vicinity: SPACE 1505, TIFFANY AND CO FEE SUMMARY Primary Occ: M Display/Sale Merchandise Type of Construction: I -FR Parcel Number: 41249102 Zoning: PDC Applicant: RODRIGUEZ, LIONEL $0.00 Address: 1384 E FIFTH ST $0.63 Other: Phone: 909-460-2530 ONTARIO, CA Zip: 91764 Owner: SOUTH COAST. PLAZA $137.99 Address 3315 FAIRVIEW AVE MISC. Phone: PLANNING & ZONING COSTA MESA, CA Zip: 92626 . Contractor: SWAIN SIGN INC_. Front 0-0 Rear- 0-0 Left 0-0 Address: 1384 E FIFTH ST ACCESSORY Phone: 909-460-2530 Right,. ,, 0- 0 ONTARIO, CA Existing: "' 0`' Required: 0 Proposed: 0 Zip: 92714 ". License: 543004 Arch : Address: Zip: Phone: License: Eng: Address: 77 FAIR DRIVE, COSTA MESA, CA 92626 Status: ISSUED Applied: 05/31/2006 Issued: 05/31/2006 ISSUED BY: 46� Phone: License: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work Is not commenced wifhin 180 days, or If work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applica codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2448-46 (droo) SCOPE OF PERMIT 1 ILLUMINATED SIGN AND 1 NON -ILLUMINATED SIGN FOR "TIFFANY & CO., SPACE 1505. FEE SUMMARY Plan Check: $54.11 Calc Valuation: $3,000.00 Permit: $83.25 Claim Valuation: $3,000-00 SMTP Res: $0.00 SMIP•Com: $0.63 Other: $0.00 Inspection: $0.00 Total: $137.99 PLANNING & ZONING SETBACKS MAIN STRUCTURE Front 0-0 Rear- 0-0 Left 0-0 Right 0-,0, ACCESSORY Front , 0-0 Rear 0-0 Left. 0-0 Right,. ,, 0- 0 PARKING Existing: "' 0`' Required: 0 Proposed: 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work Is not commenced wifhin 180 days, or If work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applica codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2448-46 (droo) DECLARATIONS WORKERS' COMPENSATION DECLARATION: 4 I hereby affirm under penalty of perjury one of the following declaratlans: ❑ and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the for which this permit is issued. e and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. workers' coat nsatipn Insurary a CarrineInd policy number are: r / -Cardo-r: 1(l ^te (This-section need not be colholoted ifhe permU 3 valued of one hundred dollars (S 100) or less.) ❑ I certify that in the performanco of the work for which this permit Is issued, I shall not employ any person In any manner so as to become subject to the workers' compensation laws of Callfornla nd agree t' I I should become subje t to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisignS. ApplicantS#gnature:— Date: WARNING: FAILURE,TO SECURE ORKERS' NSATIONc&ERA S UNLA AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOU.ARE ($100,000), IN ADDITION TO THE COST OF OOMPENSATiON, DAMAGES AS PRO%nDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: hereby affirm that I am licensed Under pr"sJons of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and,P fessions Code, and my license Is In full force and effect. LIQ # l �C1ass;.rr. [Q Carltracto ar�'Stgnaturea t7aie:-- r&W0216 CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is issued. (Sec. 3097, Civil Code). Lander's Name: Lander's Address: Signature: _ Data: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to Its Issuance, also requires the applicant for such permit to file a signed statement that he Or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a Civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sate (Sec. 7044, Business and Professions Code: The Contractors License taw does not apply to an owner of properly who builds or Improves thereon, and who does such work himself or herself or through his or her own emptoyess, provided that such improvements are not Intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to Construct the project (Sec. 7044, Business and Professions Code; The contractors LICanse Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a Contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: R Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, Le. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more toot in depth Into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature; ___ _ Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Pian for emergency response 10 release or threatened release of a hazardous material? ❑ Yes a No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight Of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _.............._..._..................................__ _ ...... ... _......—•---._. __ —.. 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materiats7 ❑ Yes ❑ No (Section 25533 of the Calilomla Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater then a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feel of compressed gas at standard temperature and pressure). .__.._...............'h-e........................'r' p.......e,n"........_........,..........."I'n......c"c''......-n-t-'n, o..d---.....,............................_............................a-g-.......................................ilo,...,,...,..,..,.,.,.....................-fy, ..........-d-'.....,............................... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP {Risk Management and Prevention Program for acutely, hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. _..._...._..................._.._.._.................................................. ........................... _..__... _......... ................... .................................. ................_..... _ _-._...............................---.--............................. ,.... -- ... -..... _............... 4 If an RMPP Is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No _.__..__............_.. p...........................m..._....._..._e..................................................__._......... .........................._.....-...._.__.._..................................._.... ._......................._ .. 5 Deas or will the applicant or resent or future bulldln occupant r require for the work which is the subject of this application a ffrmit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes Ld No (Section 65850.2 of the Catifomla Government Code requires that the requosled Information be fumished on applications for non-residential building permits). 6 Will any part of the fed[!ty to be constructed under this permit be within 1000 foot from the outer boundaries of a school? ❑ Yes ❑ No (11'yes , the facility must Meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). _ .............. _.._.............................................--•--.._.................................................. _..._.—_....................... _ .._......... 7 It a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures proscribed by Callfomla Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (11 yes", altach certificate of compliance from the appropriate air pollution control otficor), CERTIFICATE OF COMPLIANCE: I cerlify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. S! nat Legalr(s) Date r_ Authorized.Applicant" LJ 1, 9` CODE INSPECTIOfi TYPE f7AI€ INTITA CODE II INSPLi'cIION TYPE 1?AIF. I!TMA 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Finai Re-Root 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign % 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesaftStbTRICAL PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Jot) Address: 3333 BRISTOL ST Suite No 1505 Vicinity: SPACE 1505 Parcel Nunmber. 41249102 Applicant: RODRIGUEZ, LIONEL Address: 1384 F FIFTH ST Phone: 909-460-2530 ONTARIO, CA Zip 91764 Owner: SOUTH COAST PLAZA Address 3315 FAIRVIEW AVE MISG. Phone: COSTA MESA, CA Zip: 92626 Contractor. SWAIN SIGN INC. Address: 1384 t="FIFTH ST Phone: 909-460-2530 ONTARIO, CA Zip: 92714 License: 643004 ISSUED BY: SCOPE OF PERMIT 1 ILLUMINATED SIGN AND 1 NOWILLUMINATED SIGN FOR 'TIFFANY 8 CO., SPACE 1505. Status: ISSUED Applied: 05/31/2066 Issued: 05/31/2006 FEE SUMMARY Quantity ISSUE FEE $23.50 Quantity Temp service test $0.00 0 Res. a/c package $0.00 0 New Res (1-2 units) $0.00 0 New Res (3+units) $0.00 0 Pool / Spa $0.00 0 Lighting Fixts - $0.00 0 Recept Outlets $0.00 0 Switches $0.00 0 Non Res Appl $0.00 0 Res Appl , $0.00 0 Service to 200a $0.00 0 Service to 1000a $0.00 0 Service over, 1000a $0.00 0 Motors to 1hp $0.00 0 Motors to 10hp . 3000, 0 Motors to 50hp $0,00-- 0 Motors to 100hp $0.00 0 Motors."over 100hp ' ' $0.00 b , Communication drops $0.00 0 Sub panel to 200a $0.00 0 Pole Light Pkg $0.00 0 Sign Circuits $24.60 1 Temp Pwr Pole $0.00. 0 Intermed Pole $0.00 0 ' ' ' Status: ISSUED Applied: 05/31/2066 Issued: 05/31/2006 FEE SUMMARY Quantity Temp Dist Syitem / Lighting $0.00 0 Busway /100 ft $0.00 0 Standing Section' $0.00 0 Misc Electrical Equipment $0.00 0 Transformers rip to 1 kvalkw $0.00 0 . ................up to 10 kvalkw $0.00 0 .:...............up to 50 kva/kw $0.00 0 , .................up to 100 kvalkw $0.00 0 ..................over 100 kva/kw $0.00 0 Low Voltage Equipment $0.00 0 Low Volt Wiring System / Ckt $0.00 0 , Misc. Conduit $0.00 0 Misc. Conductor $0.00 0 Circus ( gen or ride) $0.00 0 Circus (meth ride or lights) $0.00 0 Christmas Tree Stand. $0.00 0 Fireworks Stand $0.00 0 Other Electrical Fee $0.00 Investigation Fee r $0.00 Plan Check Fee $0.00 Reinspection Fee $0.00 , TOTAL CALCULATED FEES $48.10 COMMENTS I SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Catifornia statutes and`ielated regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void it work is not commenced wiihin 180 days, or it work is suspe ed or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446-48 (8100) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ have and will maintain a certificate of consent to sell-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the, rk for which this permit is issued. fl bhvei7and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the perforrnance of the work for which this permit Is Issued. ork`ergromps tion nsurance arrler and Ilcy number are: Garnier / policy Number:-, (This section need not be corn a if the permits va ued at one hundred dollars ($160) or fess,) ❑ 1 certify that in the performance of the work for which this permit is Issued. I shall not employ any person In any manner so as to become subject to the workers' compensation laws of California, and agree that t I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisions Appll��t,Signature:Data:__ - - 1424 WARNING: FAILURE Tp SECURE WORKERS' COMPENSATION OOVERAGE C WFUL AND SHALL SUE;IECT AN EMPLOYER TO CRIMINAL TIES AND CIVIL FlNES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am likens under provisI s of Chapter 9 (commencing with Section 70W) of Division 3 a1 the Business and Professions Code, and my license Is In full faroa'end eNect. LIC. i���ii 5f' 00 traolkir'9Sighatwre � �—�1 Date:_. CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a conslruclion landing agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lenders Address: Signature: Data: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city Or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 11 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than (Iva hundred doffars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for safe (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended of offered for sale. If, however, the building or Improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sate.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Prolesslons Code for this reason: Signature: Data: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet In depth into which a person is required to descend, Oil be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Indugtrial Safety Permit Number: _ HAZARDOUS MATERIALS AND EMISStONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certity a Business Plan for emergency response to release or threatened rolease of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity o1 hazardous materials equal to or greater than a weight Of 500 pounds, or a volume of 55 gallons, or 200 cubic foot o1 compressed gas a1 standard temperature and pressure). _..............................—__.................. _.—_ .......... _w ---...._..—............._----.._.._..................... - _ ...—_..... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes Q No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). —._-- _ .......� ..............------- .......... ..... ........... ................ _...__......_.._................ ---•--..•.-....... ...... _... _............................... -... --....... _.................. .__........ ... 3 Does or will the applicant or prosent or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? es No (Section 2.% 3 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ... ................................. ..................... ........... ..............................-................................................ _............................................ _........................ .....�•__ .., .......... ............................................ ._..---....................... _..�. a 1t an RMPA is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑Yes ❑ No ................................ ............................................... __. _.... ................................................ ............................... _.. . .............. .................................................................. 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this a plication a germit for such construction or modification from the South Coast Alf Quality Management District or from any other air pollution control district or agency? Yes L.] No (Section 65650.2 of the California Government Code requires that the requested information be famished on applications for non-residential building permits). _ ._.. _..••••••.. ....... ......... --- _.... _ .._. .. s—.-...._N ...........-_� 6 Will any pan of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes ❑ No (If 'yes', the facility must meet the requirement o1 Sections 25534 and 42303 of the California Health and Safety Code). 7 11 a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all o1 the disclosures prescribed by California Health and Safety Code Section 42303 boon made? [3 as ❑ No ......................................................................................_.............. ._................ _............................ _ ........._... --•---­- —I,,--,' ............ 8 (N yes", attach Certificate of Compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above Is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the Information given is correct. I agree to comply with all state laws and city ordinances relating to bullding construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for Inspection purposes, I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Si are L al or(s) r Date rAndCr'A ized Appt"rit- —,, CODE 0. aVJCPghJ= QAIE INMIAL CODE INSFECTIONME 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 206 Final Plumbing 200 Final qe-Roof 210 Final Electrical 201 Final giocklRetaining Wall 212 Final Fire Prevention 2D2 Final Factory Fire Piece 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy NOTICE: The work authorized by this permit shall comply with ail applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) I r r EXPIRATION. Thisr perrntt shall automatically expire and become void it work Is not commenced within 180 days, or it work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with ail applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final appro{ aI will result In the expiration of this permit. FOR INSPECTIONS CALL. (714) 754-5626 �< 2448.46 (M) ! (714) 7545273 • Fax (714) 754-4856 • www.ci.costa-mesa-8LNLDING Job Address: %;3333 BRISTOL ST PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Status: ISSUER] suite: 1505 Applied: 09/06/2005 Vicinity: SPACE 1505 Issued: 09/22/2005 Primary Occ: M Display/Sale Merchandise Type of Construction: I -FR Parcel Number: 41249102 Zoning: PDC Applicant: EARTH, EDDY Address: 140 LOMAS SANTA FE ,. SUITE 200 Phone: (858) 793-9104 ISSUED BY: SOLANA BEACH, CA Zip: 92075 u owner: SOUTH COAST PLAZA Address 3315 FAIRVIEW AVE Misc. Phone: COSTA MESA, CA Zip: 92626 Contractor: DICKINSON CAMERON CONSTRUCTION INC Address: 140 L:OMAS SANTA FE SHITE 200 Phone: (858) 793-9104 SOLANA BEACH, CA . Zip; 92075 License: 690239 Arch : BARTELUCE ARCHITECTS AND ASSOCIATES Eng: Address: 36 W 25TH ST Address: Phone: 212-691-7200 V Phone: NEW YORK, NY - Zip: 14010 License: C262331' License: SCOPE OF PERMIT 654 S.F. INTERIOR TENANT IMPROVEMENT FOR "TIFFANY HOLIDAY SHOP" IN SPACE 1505, TEMPORARYISEASONAL STORE. FEE SUMMARY Plan Check: $127.36 k: Calc Valuation: $70,040.00 Permit: $783.75 Claim Valuation.- $70,000.00 SMIP Res: $0.00 SMTP Carrs: $14.70 Other: 40.00 Inspection: $0.00 Total: $925.81 PLANNING & ZONING SETBACKS MAIN STRUCTURE 10ront 0,0 — Rear. Rear. ` 0-01 Left. -0-0 ;" - Right 0-0, ACCESSORY Front Q 0 dear 0-0 Left 0-0 Right', 0-0 . PARKING Existing'. 0 Required: 0 Pro ose : 0 - NOTICE: The work authorized by this permit shall comply with ail applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) I r r EXPIRATION. Thisr perrntt shall automatically expire and become void it work Is not commenced within 180 days, or it work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with ail applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final appro{ aI will result In the expiration of this permit. FOR INSPECTIONS CALL. (714) 754-5626 �< 2448.46 (M) ! I DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: I have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work far which this permit is Issued. I have and will malnialn workers' oompensation insurance, as required by section 3700 of the Labor Code, for the performance of the worts for which this permit is issued. y workers' oorriplensation Insurance carrier and policy number are: �J /� / Ca ' r. � � ��[ HL �� r: �� Zn fl�©d Se is ction Head naf be corrlple t1f a pamNr s valued of one hundred dollars ($100) or less.) ❑ 1 Certify that In the performance of the w far whit It Is issued, I shall net employ any person in any manner so as to become subject to the workers' compensation laws of Cal a, and roe that s uld be a subject to the workers' compensation provisions of Section 700 of th Labor Code, I shall forthwith comp th these Wovi JApvlD ig re: �FITC;R'IiNAL URE TO SE WORKERS' COMPENSATION COVERAGE I$ UNLAWFUL AND SHALL SUBJECT AN EMP TIES CIVIL FINES UP TO ONE HUNDRED DOLLARE (3100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I her Inn that I am licensed nder ro s of h r 9 (commencing with Section 7000) of Div€sio '3' uslne nd Professions Code, and my license is In full t e and ef} . # sic Class # C fs SI Date: STRUCTION LENDING AGENCY: ! hereby affirm that there is a construction lending agency for the performance of the work for which this permit is Issued. (Sec. 3097, Civil Code). Lender's Name: Lenders Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any qty or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or Improves thereon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or Improve for purpose of sale.). ' ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of properly who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner iD verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification o1 Ownership by (type o1 document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, talsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous malarial? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes 0 No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ... ........ _._................... .......... ............................... _.................................................................................................................................................... ............... ..................................................... -_—...................... _ _.................._ .. 3 Does r will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? es co Section 255M of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, cartif€cation and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. _.._...............__ _ ............_ ........._........ —......................... ... 4 1f an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? j] Yes EJ No .. _.......................... __.......................................................................... ............................................................................... .............................._.-..................-..................... .....__......................... _. 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this a plicalion aggermit for such Construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes LJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the fac€Iity to be constructed under this permit be within 1000 fsel from the outer boundarias of a school? ❑ Yes ❑ No (if yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). —-......--- _....... _........_ �.._.._............... .......... ...... ................_._................................................................ ....................... ........................ _—._.. _....._. 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have ell of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No —_............................... ................................ .........................._.......... ............................................................................ ---.......................... _..--.......... --- Battach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Data: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penatty of perjury that I have read this application and state that the Information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costs Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Sig eget er(s) D A rized ppi� nt ata CODE r. INSPECTION TYPE Ddj$ f[iTITiBLS CODF, j INSPEnON TYPE Qom. I 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Well 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 2D4 Final Demolition 250 Final BultdinglOccupancy (714) 754-5273 - Fax (714) 754-4856 • www.cLoosta-mese.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Status: ISSUED Suite: 1505 Applied: 1010512005 Vicinity: SPACE 1505, TIFFANY HOLIDAY SNAP Issued,. 1010512005 Parcel Nunmbef: 41249102 Zoning: PDC PDC ISSUED BY: Applicant: MANCINO, RANDY Address: 818 N GRAND AV Phone: 626-913-6720 COVINA, CA Zip: 91724 Owner: SOUTH COAST PLAZA Address 3315 FAIRVIEW AVE misc. Phone: COSTA MESA, CA, Zip: 92626 Contractor: ALLREADY FIRE SPRINKLER Addfess: $18 N GRAND AV Phone: 626-913-6720 COVINA, CA Zip: 91724 License: 358795 SCOPE OF PERMIT RELOCATE 3 SPRINKLER HEADS FOR 654 S.F. INTERIOR TENANT IMPROVEMENT FOR 'TIFFANY HOLIDAY SHOP" IN SPACE 1505. TEMPORARY/SEASONAL STORE. REF#: B05-01508 "-FEE SUMMARY Pian Check: $21.22 Calc Valuation. $800.00 Permit: $32.65 Claimed Valuation: $80o,00 Other: $0.00 Total: , $53.87 NOTICE: The worts authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related rogulatlons. (Ord. No. 92-26, § 1, 12-21.92) EXPIRATION, This permit shall automatically expire and become void It worts Is not commenced within 180 clays, or it work Is suspended or abandoned for a period of 18Q days. INSPECTIONS- in order for the work authorized under this permit to be considered legal, such wont must comply with all applicable Godes, and all required Inspeo Ions and final approval must be obtained. Failure to obtain Inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL. (714) 754-6626 >.saa-o Imm DECLARATIONS WORKERS' COMPENSATION DECLARATION: t . I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the workdor-which this permit is issued. _t' ave and will maintain workers' compensation Insurance, as required section 3700 of the Labor Code, for the performance o1 the work for which this pe eq by pe permit is Issued. My works s' compenSallon Insurance carrier and policy number are: aarnar- T -4,_3 j —�� P mbe G `� ((This-s'o iun need not be comp-�jetsdI( the permit is valued at one hundred dollars ($100) or less.) ❑ t car 0ty that in the performance of the work for which this perm$ Is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Call mla, d agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith �ING:FAJWRE h those pr s. eAppfiuro: rDatai - 142 - — 49 TO SECURE WORK RS' COMPENSATION COVERAGE 1S UNLAWFUL AND SHALL SUBJECT AN EMPLOYEWM-CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND OOLLARE (57 00,000), IN ADDI ON TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3-La siness and Professions Code, and my license is In full for anted aife_ct�. I�'C #�V s Gi;,— CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lenders Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for (he following reason (Sec. 7031.5, Business and Professions Code: Any city or County which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to Its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the properly, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not Intended or offered for safe (Sec. 7044, Business and professions Coda: The Contractors License Law does not apply to an owner of property who builds or Improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. It, however, the building or improvement Is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ' ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) licenso pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, I.e. - property tax bili or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth Into which a person is required to descend, will be made In connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, t will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater then a weight of SW pounds, or a volume of 55 gallons, or 200 cubic feet o1 compressed gas at standard temperature and pressure). _ 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ..... .......... ..-............-.............. -•----.......,..... ....-............... ............. ................,.,........ ....._..... ............... ....._................._ ___.................... ,.._............. .........._...................... _—._................... ....................... ....... 3 Does or will th❑e applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? 0 Yes No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. _ ............ _............_......._ __ — _ _..._.. �.......---- .._...._� _ ... —. ....... 4 if an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No — _ ..._ ..... ....... ......... _........._-----._ _ ..w 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? I8 Yes 6 No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residentlal building permits). 6 Will any part of the facility to be constructed under this permit be within 1DOO toot from the oufar boundaries of a school? ❑ Yes ❑ No (11 "yes', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ..............................................................................................................................................................---.._..................................................................... 7 It a permit from the South Coast Air Quality Management District or other air pollution control district or agency Is required for tho work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Coda Section 42303 been made? ❑ Yes ❑ No 8 (If "yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZAT10M OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct, I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final Inspection. Signal a Of Legal Owner(s) Date gOOE �• INSPEC110H TYPE I RM lt(BILA COpE i INSPECTION TYPE RATE lily:$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Root 210 Final Electrical _ PA ��,{y�� 201 Final BlocklRetaining Wall 212 Final Fire Prevention 6L7 -V7/61 ' r 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 -Final Demolition 250 ^ Final Building/Occupancy ' (714) 754-5273 - Fax (714) 754-4656 - www.ci.costa-mesa.9LTCT RICA L PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Suite No 1505 Vicinity: TIFINAY AND CO Parcel Nunmber: 41249102 Applicant: BARTH, EDDY Address: Phone: Zip Owner: SOUTH COAST PLAZA Address 3315 FAIRVIEW AVE MISC. Phone: COSTA MESA, CA Zip: 92626 Contractor: DICKINSON CAMERON CONSTRUCTION INC Address: 140 LOMAS SANTA FE SUITE 200 Phone: 858-793-9104 SOLANA BEACH, CA Zip: 92075 License: 690239 Status: ISSUED Applied: 09/22/2005 Issued: 09/22/2005 4� ISSUED BY: SCOPE OF PERMIT 654 S.F. INTERIOR TENANT IMPROVEMENT FOR "TIFFANY HOLIDAY SHOP" IN SPACE 1505. TEMPORARY/SEASONAL STORE. REF B05-01508 11 NEW LIGHTS. 6 OUTLETS 1 MOTOR UP TO 10 HP. COMMENTS / SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become vold if work Is not commenced within 160 days, or If work Is suspended or abandoned for a period of 180 days. ' INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspectiona and final approval must be obtained. Failure to obtain Inspections and final approval will result In the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446-46 (&W) FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 Temp Dist System 1 Lighting $0.00 0 Temp service test $0.00 Busway 1100 ft $0.00 0 Res. a/c package $0.00 Standing Section $0.00 0 New Res (1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0 New Res (3+units) $0.00 0 Transformers up to 1 kvalkw MOO 0 Pool 1 Spa $0.00 0 ................up to 10 kvalkw $0.00 0 Lighting Fixts $12.10 11 .....up to 50 kvalkw $0.00 0 Recept Outlets $6.60 6 .................up to 100 kvalkw $0.00 0 Switches $0.00 0 ..................over 100 kva/kw $0.00 0 Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0 Res Appl $0.00 0 Low Volt Wiring System 1 Ckt $0.00 0 Service to 200a $0.00 0 Misc. Conduit $0.00 0 Service to 1000a $0.00 0 Misc. Conductor $0.00 0 Service over 1000a $0.00 0 Circus (gen or ride) $0.00 0 Motors to 1hp $0.00 0 Circus (mech ride or lights) $0.00 0 Motors to 10hp $12.30 1 Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 0 Fireworks Stand $0.00 0 Motors to 1 00h $0.00 0 Other Electrical Fee $0.00 Motors over 100hp $0.00 0 Communication drops $0.00 0 . investigation Fee $0,00 Sub panel to 200a $0.00 0 Plan Check Fee $0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $0.00 0 Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $54.50 Intermed Pole $0.00 0 COMMENTS / SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become vold if work Is not commenced within 160 days, or If work Is suspended or abandoned for a period of 180 days. ' INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspectiona and final approval must be obtained. Failure to obtain Inspections and final approval will result In the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446-46 (&W) L DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ f h,pve and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the rk for which this permit is issued. e and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the pe a of the work for which this permit Is issued. My rkers' compensation Insurance carrier a d Iicy number are: arrier:P licy Numb ( ction need not be completed if thb permit is valued at one hundred dollars ($100) or less,) ❑ I certify that in the performance oft ork I hich IN slued, I shall not employ any person in any manner so as to become subject to the workers' corn s oT Cefifomi nd vee 1 s Id b me bject to the workers' compensation provisions of Section 00 at the ahor Code, I shall forthwith with ase provisions - nt S! re: Data: AR . AILURE TO SECURE WO S' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPL RIMINAL PENALTES ND CIVIL F1NE5 UP TO ONE HUNDRED SAND DOLLARE (5100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONT ORS DECLARATION: I hr am license un r routs of Ch ter 9 (commencing with Section 7000) of Divi s sine -ss d Professions Code, and my license Is In full fo n effect. Llc. # R Cont r gnature: CONSTRUCTION LENDING AGEN ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title B, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be tiled with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity o1 hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ...................................... _......................................... ...................................................... ................"................................................................................................ I......... _........................ —....................... 2 Does or will the applicant or present or future building occupant need to file a registration farm for acutely hazardous materiels? [:)Yes ❑ No (Section 25533 of the California Health and Safety Coda, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ........................... ..................................... ......... ........... -................................. _.......................... -................... _-................................................................................................... ......................... -....... ............... ...... ...... I.................. 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. w_ ................-....._............ -- ............................._ ..................._......................----................._................................................................-............ ............. ......-.......... .._...... 4 11 an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fulty complied with? ❑ Yes ❑ No ..............._. ....................... _.................. ............................. ............................. .........._................................ ..................... ................................................................................................. -•------.... .....-.................. -...-.................. -....................... 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this a plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes No (Section 65850.2 of the California Goverment Code requires that the requested information be furnished on applications for non-residential building permits). --.._................_.............................. .....................................-•--•-••----............................... ............................................................................ ...................-•--.........-.................._-...................-- 6 Will any part of the facility.....to be constructed under this permit be within 1000 feet from the outer boundaries of a school? El Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ... .............................. __........................................... ....... .................................... _..................................................................................................... ......... ...................... _.-- .... - ................ _..... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures proscribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (if 'yes". attach certificate of compliance from the appropriate air pollution control officer'. CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Data: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state lawA and city ordInawm relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described prorty f on p uses. I a n o y or allow occupancy of any building authorized by this permit until final inspection. ign An pp nt a COPE P. INSPECTIONTYPE Qty INTRIALS CODE! INSPECTIONTYPE pb¢ jam$ 1616 Fixed System Final Fre Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy City of Costa Mesa, ' Development Services Department CERTIFICATE O F OCCUPANCY No. Building Safety Divisionvision P. O. Box 1200 Costa Mesa, California The Building located at 3333 Bristol Street, Space 1500 has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group B2 Occupancy. Use of Building Retail Legal Description 412-501-02 (See reverse side for Metes and Bounds) Building Permit No B 47539 Electrical Permit No. E 48578 Plumbing Permit No. P 47771 Mechanical Permit No Fire Prevention F 47772 ISSUED TO: C.J? Segerstrom & Sons :1333 Brlstpi St., Sp. 1 Costa Mesa, CA 92526 Number of apartments and/or guest rooms Building Official Tony C'De Baca by Date May 21, 1991 `This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 (el U.B.C. �MF 1015-46 rev. 1/83 white . Owner; Canary - Numerical File; Pink - Bldg. Permit File City of Costa Mesa Development Services Department Building Safety Division CERTIFICATE OF OCCUPANCY No.Q Q 17 9 5J P. O. Box 1200 Costa Mesa, California The Building located at 3333 Bristol Street, Suite 1500 has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group A-7 Occupancy. Use of Building Pei+-.qi 1 �tnra Legal Description 41 7—sir1i—n7 ISee reverse side for Metes and Bounds) E-25478 Building Permit No 12--1941A Electrical Permit No. T? -71;71 Q Plumbing Permit No. p-256RS Mechanical Permit No. Number of apartments and/or guest rooms �! ISSUED TO: Rally of Swit ZPrlAnr3 _ 3333 Bristol. Street, Suite 1500 C oRta MPGA. rA 92R29 I Building Official by Date A r I 1 This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. CMF 1015.46 rev. 1/83 White - Owner; Canary - Numerical File; Pink - Bldg. Permit File PROJECT ADDRESS: 3333 BRISTOL S} OWNER'S NAME: , S EG ER S T ROM ADDRESS: SAME AS ABOVE ARCHIENGINEER: 714/523-1990 ADDRESS: UNIT: 1 500 F C REO.NO.: UNIT: PERMITTEE: WESTM4 ALLIED CORP. M4)523-1990 523-1990 ADDRESS: 12045 E.' FLORENCE AVE SANTA FE SPRINGS CA 90670 LICENSED CONTRACTOR OECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7DOO) of Division 3 of the Business and Professions Code, and my license is in full force and effect. CITY uc.►/ �0 �32777 STATE UC -:1 8 8 21 cess: C 2 0 Date: 4: ' Signature: WORKERS' COMPENSATION DECLARATION: l hereby affirm that I have a certificate of consen to self -Insure or a certificate of Workers' ^ampensation Insurance, or a certified copy thereof (Section 3800, Lab. Q. .ICY NO.: 600809251 ' 1 EXP. DATE: 0 8/ 01 / 9 0 OMPANY: CNA CASUALrTY Certified copyis hereby furnished. Certified copy is ti d h th city Build' g D' io . Cl 'ate: ,.� O� •� rV _ _. Applicant: EXEMPTION FROM WORKERS' COMPENSATION DECLARATION: (This section need not be completed if the permit is for one hundred )3100) or less). I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of Caldomia. Date: Signature: NOTICE: 11, after making this declaration, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Section 3097, Civ, C). LENDER: ADDRESS: OWNER BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractors' State License Law for the following reason (Section 70.31.5 Business and Professional Code: Any city of county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that helshe is licensed pursuant to the provisions of the Contractors' State License Law (Chapter 9 (commencing with Section 7000♦ of Division 3 of the Business and Professions Code) or that helshe Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7{131.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($.500). i 1, as owner of the property or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Section 7044, Business and Profession$ Code: The Contractors' State License Law does not apply to an owner of a property who builds or improves thereon, and who does such work himself/herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however the building or _improvement is sold within one year of completion, the owner will have the burden of proving he/she did not build or improve for the purpose of sale). I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Section 7044, Business ❑ and Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon and who contracts for such projects with a contractor(s) license pursuant to the Contractors' State License Law). I am aware that proof of their Worker's Compensation insurance should be provided to me. ❑ 1 am exempt under Section: B. IS P. C. tar this reason: Date: —. _ Owner: I do hereby certify that I am aware of and understand the requirements of Catitornia }iealth and Safety Code Sections 25505, 25533, and 25534 and that I or any future building occupant will/will not (cirde one) need to comply with said state codes and the requirements for a permit for construction or modification from the Air Quality Management District. Residential construction applications are exempt from these provisions. Date: - - Applicant: I hereby certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction and here y authorize represen f Pis city to enter upon the above-mentioned property for inspection purposes. Date: to Signature: LLZ Driver's License or Social Security 8 1641-0 White --Building; Green -Code Enforcement; Canary—Applicant; P6zk—Revenue; Goldenrod—Assessor C C Iii F F '1 i I N A CITY OF COSTA MESA — BUILDING PERMIT I PERM NO:.M 047918 ERMIT NO: M 047918 PLAN CHECK NO: N GOVT: N SUPP: N ONSTRUCTION TYPE: PERMIT TYPE: MEC PURPOSE: OTH OB DESCRIPTION MECHANICAL FOR COMMERCIAL T.I, SQ FT: LAIM VALUE: CALC--VALUE: GROUP OCC: / OMMENTS: BUILDING PERMIT #B-47638 �����a������•r������*����##iF#�t-�*��rr������t����##amara€��at�#a��t*�a���*�t�t������t�t���•��a��•;e#� Z O N I N G R E Q U I R E M E N T S S E T B A C K S ----------- MAIN BUILDING ----------- - --------- ACCESSORY BUILDING ---------- 'RNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN ' EFT; FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN ARKING RE8; PROV: PARCEL: 00000000 ZNE: REF NO: LANNING N�5TES> > )F # 3h iF fit• i': ih 3E # # �E # # #'.t # # # # �# �F iE �F 3E # 9E # aE �F it # i!• �E # i� •fE TF+K?E'rE #'rE # !E # # ie lE # h dF TE 3E i( # jE # # # # jf iL iF 3E iE it'1E iE 9E # iF 3E # iE # TE dE # D E V E L O P M E N T S E RVI C E S R E Q U I R E M E N T S ONING APPROVED BY `G!� DATE: UILDING APPROVED BY DATE: ,PPLICATION ISSUED BY: f DATE: ###'1I#####*iE3FaE9F#•fk##### ###it##ifriEiEiE ## #dFdFiF###########iEjEi(-#####14•#aEif•####Tt#dEiF3EiF#########i4#####iE#it3F9ETEiFdF####�tTE�riE'lE9F##iE3E'FjE## EGALIZATION:N F E E S U M M A R Y STRUCTURAL SEGMENT:N BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMTP/RES GRADING ERMIT 18.00 25% SMIP/NON—RES LAN SSUE FEE 1.5.00 UILDING—DIV—> PERMIT ISSUE PLAN -CHECK TOTAL PAID DUE 'OTALS ---- > 18.00 15,00 �; 0.00 33.00 33.00 .00 ,EVENUE DIVISION TOTALS--> COLLECTED: 33,00 OVER/SHORT: .00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK 3r3' . 0 0 ##}E###•iE•3FiF#iEifiFaE############TE#•iE####'lE#'1E-!E##iE#r9f•3fr3E'k'hdE�EiE##a(•aE#'1EdF3EiE�E##3F#####'rF#######3E#aE I N D T V I D U A I;= E E B R E A K D O W N YPE QTY D E S C R I P T I O-NUNIT COST TOTAL COST CJ r, EC 1 REPAIR/ALT COOLING UtTIT/SYS W/CNTLS 9.00 9.00 IEC 2 VENTILATION FAN CONN TO SINGLE DUCT 4.50 9.00 END.'. -OF FEES vj • %t 01 0006Y043 -000645Q TOT 33.00 DATE: 06/27/90 ME: !0:26 4 CONSTRUCTION AND PLANNINv r Date APPROVALS Permit # -; Inspector 'L 'A APPROVALS Permit # Date Inspector 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd. s' 53. Steel Reinforcement 3. electrical Conduit Utility-Undrgrnd. 54. Forms 4. Electrical Conduit-Undrgrnd. 55. Electrical Banding 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6. electrical LIFER Grnd. 57. APPROVAL TO COVER-GUNITE 7. Footings 58. Electrical Conduit-Undrgrnd. 8. Foundation . =� 59. Gas Pipe, ❑ Undrgrnd., Test = 9. Water Pipe-Undrgrnd, f _ 60. Backwash lines, P -Trap, ❑ Undrgrnd. 10. Structural Floor System �� I 61. APPROVAL TO DECK 11. Property Sewer Line & House Connection y' 62. Backwash & Receptor -Final 12. Sewer Cap Y ' 63. Heater & Vent -Final - 13. Roof Drains 64. Plumbing System - Final 14, Rough Plumbing 65. Electrical -Final 15. Rough Electrical -Conduit jo i 66. Solar System -Final 16. Rough Electric Wiring 67. Fencing & Access Approval 17. Rough Wiring Sign 68, APPROVED FOR PLASTERING 18. Rough Electrical -T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning 9� (�� FIRE DEPT. REQUIREMENT APPROVALS Permit # 20. Rough Factory Fireplace 21, Ducts, in Structure 70, Underground Hydro 22. Ducts, Ventilating 71. Product Piping ❑ Gas ❑ Oil 23, Gas Pipe -Rough & Test 72. Underground Flush 24. Roof Framing 73. Undergrnd. Storage Tank ❑ Gas ❑ Oil 25. Roof Sheathing 74. Overhead Hydro 26. T -Bar Ceiling (Structural) & Monocoat 75. Dry Chemical 27. Frame and Flashing 76, Dry Standpipe 28. Lathing & Siding 77. FIXED SYSTEM FINAL 29. Insulation 76. FIRE PREY. FINAL 30. Drywall Nailing HEALTH DEPT, REQUIREMENT 31. Plaster Brown Coat 79, FINAL INSPECTION 32. Electrical Power Meter -Final 80. FOOD CERTIFICATE ISSUED 33. Final Electric Nates: 61U110 64L 7V 9094P Q,jCT.- L60 34. Final Heating & Air Conditioning 35. Final Gas Pipe -Test 36. Hood or Canopy ' i 37. Final Factory Fireplace 38. Final Plumbing 39, Water Service -Final 40. Gas Service -Final 41. Solar Domestic -Final 42. Backflow Preventer 43. Backflow Irrigation 44. Landscape Irrigation System 45. Sound Attenuation 46. Handicap Regulations 47. FINAL STRUCTURE & BUILDING 48. FINAL PLANNING 49. Electric Release to Edison 50. Gas Release to Southern California Gas Co 51, CERTIFICATE OF OCCUPANCY No. Date w 9 PROJECT ADDRESS: 3333 BRISTOL ST UNIT: 15 0 0 YOWNER'S OAME: CHANEL INC ADDRESS: 9 W 5 7 if H ST, N. Y•, N• Y. 10019 212-6-88-5055 ARCH/ENGINEER: REG.NO,: ADDRESS: UNIT: PERMITTEE: PLANT BUILDERS (213)312-9571 ADDRESS: 11444 OLYMPIC BL 10THF L.A. CA 90064 LICENSED CONTRACTOR DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license Is In full force and effect. Cm LIc.: 0 5 019 4 STATE UC.: 0 15 1 4 CLW: B _�� �� Signature: +01(ERS' COMPENSATION DECLARATION: I h that I have a I' a at consent to sell insure or a certificate of Workers' Compensation Insurance r cgrtified copy thereof on 3800, POLICY NO.: P C 9 9 T8 EXP. DA / 0 1/ 9 0 COMPANY: REPUBLIC INDEM • Certified copy is hereby furnished. ❑C rtified copy is filed the city Building j � nate: U _ rplicant EXEMPTION FROM WORKERS' COMPENSATION trw �1,h�"permM21ills section need not completed if the permit is for one hundred (Si00) or les). I certify that in the performance of the work foissued, I s not employ any person in any manner 5o as to become subject to the Workers' Compensation Laws mia. Dater Signature: NOTICE: If, after making this declaration, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith Comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Section 3097, Giv. Q. LENDER: ADDRESS: L OWNER BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractors' State License Law for the following reason (Section 7031.5 Business and Professional Code: Any city of county which requires a permit to construct, after, improve, demolish, or repair any structure, prior to Its issuance, also requires the applicant for such permit to file a signed statement that he/she Is licensed •rsuant to the provisions of the Contractors' State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business 1 Professions Code) or that he/she is exempt therefrom and the basis for the aileged exemption. Any violation of Section 7031.5 by applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (1500;. I, as owner of the property or my employees with wages as their sole compensation, will do the work. and the ❑ structure is not intended or offered for sale (Section 7044, Business and Professional Code: The Contractors' State License Law does not apply to an owner of a property wt* builds or improves thereon, and who does such work himself/herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however the building or improvement is sold within one year of completion, the owner will have the burden of proving he/she did not build or improve for the purpose of sale). 1, as owner of the property, am exclusively contracting with licensed contractors 10 construct the project (Section 7044, Business E] and Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon and who contracts for such projects cith a contractors) license pursuant to the Contractors' State License Law). I am aware that proof of their Worker's ComperistIon insurance should be provided to me. ❑ I am exempt under Section: B. & P. C. for this reason: Data: Owner I do hereby certify that I am aware of and understand the requirements of California Health and Safety Code Sections 25505, 25533, and '25534 and that l or any future building occupant will not (circle one) need to comply with said state codes and the requirements for a permit for construction or modification from the Air Quality Management District. Residential construction appltcations are exempt from these provisions. Date: Apprrcant: I hereby tertity that I have read this application and state that the above ordinances and state laws relating to building construction and hereby am property for inspection purrpposes, Date:. /�� r 7 D Signal Driver's License or Social Security N: 1641.48 Whlte—Building: Green—Code EMomemeni: Canary --Al is correct. I agree to comply with all city and county ntativMof th4 city to enter upon the above-mentioned Pink—Revenue; Goldenrod—Assessor COMMENTS: Z O N 'I N GS E R T E B Q A U C IKRS£ M E N T S r' — MAIN BUILDING o------------ — ACCESSORY BUILDING --------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN - PARKING REQ: PROV: PARCEL: 00000000 ZNE: CIS REF NO: PLANNING NOTES_> TENANT IMPROVEMENTS FOR CHANEL TO CITY OF COSTA MESA — BUILDING PERMIT PERM NO: B 047638 PERMIT NO: B 047638 ir!' 3t iE 34 dF ik i(• i4i4 i4 � it iE i(iE iE iE #E # it i(!F iE � ii i4 #,�:''1(' riE ale PLAN CHECCNO: 04334-90 A GOVT: N SUPP: N CONSTRUCTION TYPE: I—FR PERMIT TYPE; STR PURPOSE: ALT JOB DESCRIPTION ; 5654SF RETAIL STORE T.I. SQ FT: 5,654 CLAIM VALUE: 84,810,00 CALC—VALUE: 71,127.32 GROUP OCC: B-2 / COMMENTS: Z O N 'I N GS E R T E B Q A U C IKRS£ M E N T S r' — MAIN BUILDING o------------ — ACCESSORY BUILDING --------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN - PARKING REQ: PROV: PARCEL: 00000000 ZNE: CIS REF NO: PLANNING NOTES_> TENANT IMPROVEMENTS FOR CHANEL TO OCCUPY UNITS 1500, 1508 & > 1512, F. . ir!' 3t iE 34 dF ik i(• i4i4 i4 � it iE i(iE iE iE #E # it i(!F iE � ii i4 #,�:''1(' riE ale � iE if iE iE �E 9i iE � iE iE �E iE iF iE iE it �E iF �F iE dE i4' ?f iF'lE ii ii iP it it 4f- jE iE iE � TE 4E jE ih it• % TE iE iE iE iE iE R E V E L O'P : M E N� S E R V I C E S R E Q U I R E M E NT S ZONING APPROVED BY rr J f �o- [• DATE: ?� BUILDING APPROVED BY. ; "'-i; DATE; APPLICATION ISSUED' BY; f,' i(•'lt• it• i(• iE if 1E ii iE'� iE iE iE 9E iE � iE i[- �! ii• rr `fig DATE:-- �.* i4 it• it ![• �1E iE ?tE i6'tE �E 3E i6 iE 4E iE 9E if 9E iE iE iE 9F iE iF iE iE iEtiE iE iE iE iE iE iE �E iE 3E if• is iE � * iE it it• ib it- � � 9t if- i[• �t aE iF 9F dE iE iE � dE � i4 iE #E dE'lf iE * * if- it it iF iE �E iE if• iE it is �- 3t it aE ar• iE it• !t !f iF LEGALIZATION:N F E E S -,U M M A R Y STRUCTURAL SEGMENT:Y FJ BLDG PMT PLUMBING ELECTR'T�C MECHANIC FIRE SMTP/RES GRADING PERMIT 513.50 f"' %' SMIP/NON—RES PLAN 83.45 �. '� 10.67 ISSUE FEE BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK ' TOTAL PAID DUE TOTALS ---- > 524.17 0,00 83,:45 607.62 607.62 ,00 REVENUE DIVISION TOTALS--> COLLECTED: 607.62 OVER/SHORT: 00 BLDG PMT PLUMBING ELECTRIC MECHANIC AFIRE SMIP/TOT GRADING PLAN—CHECK 513.50 r,-` i,�! 10.67 83.45 r i 'lk'de' iE'dE iE iE iE 4E 4E iE iE iE �f iE iE dE 9E 9F dE df• iF iF �E iE it'll ik � if' dt jf ri4 if i4 il;iE iE if fk i f �E'1f * iF �t-,it• ik jt- iE �E �t � iE iE it iE iF iE * it- iF iF 4E 4E 4E iE iE if 4k it- iE iE if if ifr 4F 9t it• 4t I N D I V I D U A L; F t E E /I B R E A K D O W N Ij TYPE QTY D E S C R T P T I Ol, N UNIT COST TOTAL COST SFC 5654 STO—INT. ALTER TYPE'I,II F.R. —AVER 12.58 71,127,32 END OloFEES Al 's ./ 01 00062533-000625335 T O T c07.62 DATE: 06106190 TIDE! 1507 ,'CONSTRUCTION AND PLA._ .NG APPROVALS Permit # Date Inspector POOL PA APPROVALS Permit 4#- Date r Inspector I "y. Temporary Electrical Service•or'Pole 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd. ' 53. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. 54. Forms + 4. Electrical Conduit,Undrgrnd. 55. Electrical Bonding 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6• Electrical LIFER Grnd. ; 57. APPROVAL TO COVER-GUNITE 7. Footings ,. 58. Electrical Conduit-Undrgrnd. ' v 8. Foundation r 59. Gas Pipe, 0 Undrgrnd.; Test 9. Water Pipe-Undrgrnd. r 60. Backwash Lines, P -Trap, ❑ Undrgrnd. 1 10. Structural Floor System , ' 61. APPROVAL TO DECK . 11. Property Sewer Line,& House Connection 62. Backwash &Receptor -Final 12. Sewer Cap / + 63. Heater & Vent -Final 13. Roof Drains 64. -Plumbing System - Final 14. Rough Plumbing 65. Electrical -Final 15. Rough Electrical -Conduit 66. Solar System -Final r 16. Rough Electric Wiring, 67. Fencing & Access Approval 17. Rough Wiring Sign 68. APPROVED FOR PLASTERING 18. Rough Electrical -'T Bar Ceiling - 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. RE=QUIREMENT APPROVALS' Permit # 20. Rough Factory Fireplace 21. Ducts, in Structure '70. Underground Hydro 22. Ducts, Ventilating " .71. Product Piping 0 Gas 0 Oil ,23,•Gas Pipe -hough & Test I 4 "' • • 72• Underground Flush 24. Roof Framing 73. Undergrnd. Storag;. Tank 0 Gas 061 j 25. Roof Sheathing 74: -Overhead Hydro - 26. T -Bar Ceiling (Structural) & Monocoat 75. 1. Ory Chemical 27. Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding 77. FIXED SYSTEM FINAL 29. Insulation 78:_FIRE PREY. FINAL 30. Drywall.Nailing ,Z/ rc � HEALTH -DEPT. REQUIREMENT 31. Plaster Brown Coat '79. FINAL INSPECTION ,32.;Electrical Power Meter -Final- 80.`FOOD CERTIFICATE ISSUED 33. -Final Electric -. Notes; •-34. FinalHeating & Air Conditioning _ t ` 35. Final Gas Pipe -Test 36. Flood or Canopy 37. Final Factory Fireplace 38. Final Plumbing A / 39. Water Service -Final 40. Gas Service -Final - 41. Solar Domestic -Final 42, Backflow Preventer 43. Backflow Irrigation 44. Landscape IrFigation System 45, Sound Attenuation- ttenuation46. 46.Handicap Regulations A7. FINAL STRUCTURE & BUILDING 48. FINAL PLANNING = 49. Electric Release to Edison 50. Gas Release to Southern California as Co 51. CERTIFICATE OF OCCUPANCY No. Date PROJECT ADDRESS:3333 BRISTOL ST UNIT: 15 0 0 .OWNWS NAME: C . i _ SEGERSTROM & SONS ADDRESS: 3 315 FAIRVIEW RD. COSTA MESA CA 92626 ARCHTENGINEER: (714)546-0110 REG.NO.: ADDRESS: UNIT: PERMITTEE: MOON & CROCKETT PLMBING (714)779-8111 ADDRESS: 5260 E. HUNTER AVE ANAHEIM CA 92807 LICENSED CONTRACTOR DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license Is In full force and effect. CITY LC.: 05 0 8 0 7 ST`ATEELIG.: 5 5 0 3 CLASS: _ Date: a—. — / Sign0. WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to se ure or a certificate of Workers' Compensation Insurance, or a certified copy thereof Section 3800, Lab. C). ILICYNO.:73WC0010350002 Face. DATE: 07/01/90 •OMPANY: NATIONWIDE Certified copy is hereby fumQished. 13d Certified copy is filed with the city Building Division Its: ..Sr` Cy Applica ---S:.Gd4 EXEMPTION FROM WORKERS' CDMPENSATION DECLARATION: (This section need not be completed it the permit' rte hundred ($1 OD) or less). I certify that in the performance of the work for which this permit is issued, I shall not employ any person a manner so as to become subject to the Workers' Compensation Laws of California. Date: _ - Signature: NOTICE: If, after making this declaration, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked - CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for th6 performance of the work for which this permit is issued (Section 3097, Civ. C). LENDER: ADDRESS: OWNER BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractors' State License Law for the following reason (Section 7031.5 Business and Professional Code: Any city of county which requires a permit to construct, after, improve, demolish, or repair My structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that helshe is licensed pursuant to the previsions of the Contractors' State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that helshe is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty o1 not more than five hundred dollars ($5001. h as owner of the property or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Section 7044, Business and Professional Code: The Contractors' State License Law does not apply to an owner of a property who builds or improves thereon, and who does such work himseUlherself or through his or her ownemployees, provided that such improvements are not intended or offered for sale. If, however the building or improvement is Said within one year of completion, the owner will have the burden of proving helshe did not build or Improve for the purpose of sale), I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Section 7044, Business 0 and Professions Code: T Contractors' State License Law does not apply to an owner of property who builds or improves thereon and who contracts for such projects csth a contractor{s) license pursuant to the Contractors' State License Law), I am aware that proof of their Worker's Compensaion insurance should be provided to me. ' I am exempt under Section: e. S P. C. for this reason: Date: Domer: 'do hereby certify that I am aware of and understand the requirements of Califomia Health and Safety Cade Sections 25505, 25533, and 25534 and that 1 or any future building occupant willtwlll not (circle one) need to comply with said state codes and the requirements for a permit for construction or modification from the Air Quality Management District. Residential construction applications are exempt from these provisions. Date: Applicant: I hereby certify that I have read this application and state that the above Information is correct. I agree to comply with all city and County ordinances and state taws relating to budding constructlorl and hereby authors representatives of this ' upon the above-mentioned propertV for inspection purposes. Date: _�y l p� Signature: Driver's License or Social Security 0 164146 White—Wiling; Green—Code Enforcement: Canary—Appllcant: Pink—qwoonue; CITY OF COSTA MESA — BUILDING PERMIT PERMIT NO: P 047771 PLAN CHECK NO: N CONSTRUCTION TYPE; I—FR PERMIT TYPE; PLU JOB DESCRIPTION : 5654SF RETAIL STORE T.I. (COMMERCIAL) CLAIM VALUE: CALC—VALUE: PERM NO: P 047771 GOVT: N SUPP: N PURPOSE: OTH SQ FT: GROUP OCC: B-2 / COMMENTS: RE: B47638 PRIMARY BLDG. PERMIT. Z O N I N G R E Q U I R E M E N T S S E T B A C K S — MAIN BUILDING ---------- ----------- ACCESSORY BUILDING --------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN PARKING REQ; PROV: PARCEL: 00000000 ZNE: REF NO; PLANNING NOTES> D E V E L O P M E N T S E R V I C E S.,'.R E Q U I R E M E N T S ZONING APPROVED BY DATE: BUILDING APPROVED BY : DATE: APPLICATION ISSUED BY: DATE: S' O * eE i4 it 9E 1k it dE 1F �E +x+ iF iE iE' !E 1E 9E iE 94 if iE iF 9E * iF if lE iE iF )E it 9k it if fit• * �1- �E -lf iI- 34 iE dE it• �E � �F * #E !E 3F �[-?fE jE � �F ?!E it TE iE TF � * # iE if �E -It -lf iI- TE iE iF � elf � � � it• iE- 3F TE iE it iE if � ?f iE iE iE iE iE iE iF iE 3E iF )f aF iE iF TE iI- iF LEGALIZATION:N F E E S U M M A R Y STRUCTURAL SEGMENT:N BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT 16.00 25% SMIP/NON—RES PLAN ISSUE FEE 3.00 BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE TOTALS ---- > 16,00 3.00 0.00 19,00 19.00 .00 REVENUE DIVISION TOTALS--> COLLECTED: 19.00 OVER/SHORT: .00 - BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMTP/TOT GRADING PLAN—CHECK 19,00 if ik if if f>k * riF iE �F iE• �E'lE'JE ii yh j(- iE 9E TF TE 9(- if• it• Tf'1F � � Tt- 9t it iE ib'# iE * iE � iE 3F it- iE 3E iE it iE iE• iE iF iE iE 9F TE ib iF e< at iE 1tif !t iE aF iE �(• ir- ir• !(- * iE � at jt 4k � * j(_. � 9F � I N D I V I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST PLU 1 SINK, KITCHEN 2.00 2,00 PLU 2 WASH BASIN 2,00 4.00 PLU 2 WATER CLOSET (TOILET) 2.00 4,00 PLU 3 WATER HEATER AND/OR VENT 2.00 6.00 END OF FEES 1 01 00063302-00063302 T 0 T DATE& 06/15190 TI11E: 13:24 19.01rn /CONSTRUCTION AND PLANNING Date - 3 APPROVALS Permit # � .- ,..� Inspector L. ,,PA APPROVALS- Permit # Date Inspector , ' 1. Temporary Electrical Service or Pole l 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd. '' 53. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. 54. Forms 4. Electrical Conduit-Undrgrnd. } •1 55. Electrical Bonding 0 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6. Electrical UFER Grnd. �. 57. APPROVAL TO COVER-GUNITE 7. Footings r 58. Electrical Conduit-Undrgrnd. " 8. Poundation 59. Gas Pipe, 0 Undrgrnd., Test 9, Water Pipe-Undrgrnd. 60. Backwash Lines, P -Trap, ❑ Undrgrnd. 10. Structural Floor System 61. APPROVAL TO DECK 11. Property Sewer Line & House Connection 62. Backwash & Receptor -Final 12, Sewer Cap 63, Heater & Vent -Final ! 13. Roof Drains 64. Plumbing System - Final r 14. hough Plumbing 7 �0 G4d 65. Electrical -Final - 15. Rough Electrical -Conduit + 66. Solar System -Final 16. Hough Electric Wiring 67. Fencing & Access Approval 17. Rough Wiring Sign 68. APPROVED FOR PLASTERING 18, Rough Electrical -T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19, Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit # 20, Hough Factory Fireplace 21. Ducts, in'Structure _ 70. Underground Hydro 22. Ducts, Ventilating 71. Product Piping ❑ Gas ❑ Oil 23. Gas Pipe -Rough & Test 72. Underground Flush 24. Roof Framing 73. Undergrnd. Storage:Tank ❑ Gas ❑ Oil 25. Hoof Sheathing 74. Overhead Hydro 26. T -Bar Ceiling (Structural) & Monocoat 75. Dry Chemical 27. Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding. 77. FIXED SYSTEM FINAL 29. Insulation • r 78. FIRE PREV• FINAL 30. Drywall Nailing w % HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat _i 79, FINAL INSPECTION 32. Electrical Power Meter -Final f _' 80. FOOD CERTIFICATE ISSUED 33. Final Electric Notes: 34. Final Heating & Air Conditioning �. 35. Final Gas Pipe -Test: 36. Hood or Canopy f 37. Final. Factory Fireplace 38. Final Plumbing 2 Lb/ _ 39. Water Service -Final 40, Gas Service -Final 41. Solar Domestic -Final 42. Backflow Preventer 43. Backflow Irrigation 44, Landscape Irrigation System 45. Sound Attenuation .46. Handicap Regulations 47. FINAL STRUCTURE & BUILDING 48. FINAL PLANNING f F 49. Electric Release to .Edison ; 50. Gas Release to Southern California Gas Co 51. CF_RT1FICATEOF OCCUPANCY No. Date PROJECT ADDRESS: 3333 BRISTOL ST UNIT: 15 0 0 OWNEWO NAME: C. J. SEGERSTROM & SONS J' ADDRESS: 3315 FAIRVIEW RD COSTA MESA CA 92626 (714)546-0110 ARCHIENGINEER: REG.NO.: ADDRESS: UNIT: PERMITTEE: MULTER ELECTRIC (213)946-8828 ADDam, 13209 BARTON CIRCLE SANTA FE SPRINGS CA 90670 LICENSED CONTRACTOR DECLAfIATION: I hereby affirm that i am gcenWd under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is In full force and effect. CITY LIC.: 0 2)510 0 STATE LIC.: 9 6 0 4 3 c sS: %j10 Data: —+5— U Signature:_Sdr 'J v WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of oousent to seltansure or a certificate of Workers Compensation 9�q�q pprq c led,p thereof (Sect= 3800, Lab.02 POLICY NO.: �7 0 9 G 3 7 EXP. DATE: 2 1 1 7 1 9 1 'MPANY: REP INDEMNITY Certified copy isherebyfumed. I/Certified copy is fled wJithh the city q EXEMPTION FWm 1NoRXM, ComPENSATION DECLARATION: (Tars section need not be completed d the permit is for one hundred (5100) or less). I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of CaTdomia. Date: ' Signature: NOTICE: It, after making this declaration, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Section 3097, Civ. Q. LENDER: ADDRESS: OWNER BUILDER OECLARATION: I hereby affirm that i am exempt from the Contractors' State License Law for the following reason f Section 7031.5 Business and Professional Code: Any City of county which requires a permit to construct, alter, improve• demolish, or repair any structure, prior to its l5suatice, also regti:res the apptirant tot such permit to We a s4ned statement that helshe is licensed pursuant to the provisions of the Contractors' State License Law {Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he/she is exempt therefrom and the basis for the alleged exemption. Any violation o1 Section 7031.5 by arty applicant for a permit subjects the applicant to a cMl penalty of riot more than five hundred dollars (5500). I, as owner of the property or my a with wages as their sofa mpertsation, will do the work, and the 0 structure Is not intended or offered for sale�W 7044, Business and Professional Code: The Contractors' State License Law does not apply to an owner of a property who builds or improves thereon, and who does such work himself/herself or through his or her own employees. provided that such Improvements are rpt intended or offered for sale. If, however the building or Improvement is sold within one year of completion, the owner will have the burden of proving he/she did not build or Improve for the purpose of -sale). I, as owner of the property am exclusively o on:racdnq with licensed contractors to Construct the project (Section 7044, Business 0 and Professions Code: Tate Contractors' State License Law does not apply to an owner of property who hullds or improves thereon and who contracts for such projects vIlh a contractor(s) license pursuant to the Contractors' State License Law). I am aware that proof of their Workers Compens:lloo insurance should be provided to me. © I am exempt under Section: B. d P. C. for this reason: P C J C C R T Date: Owner: IE I do hereby certify that I am aware o1 and understand the requirements of Calftomia Heafth and Safety Code Sections 25505, 25533, and I 25534 and that I or any future building occupant W11 Mrid not (Cttrde one) need to comply with said state codes and the requirements for a permit far construction or modification from theWFUEiq Management Oistficf. Residential construction applications are exempt from these provisions. Date: Applicant: I hereby certity that I have read this application and state that the above information Is correct. I agree to comply with city and county ordinances and state haws relating to hooding construction and hereby authoria represdrtdthres of this to enter u above-mentioned property for inspection pu �II Date: _ J J Signature: Driver's License or Social Security p: 1841.413 Whit"u0ding; Green—Code Entorcement Canary—Applicant; Pink—Revenue; Goldenrod—Assessor CITY OF COSTA MESA — BUILDING PERMIT PERM NO: E 048573 ERMIT NO: E 048573 PLAN CHECK NO: N GOVT: N SUPP: Y ONSTRUCTION TYPE: I—FR PERMIT TYPE: ELE PURPOSE: OTH OB DESCRIPTION 5654SF RETAIL STORE T.I.,UPGRADE METER SQ FT: LAIM VALUE: CALL—VALUE: GROUP OCC: B-2 / OMMENTS: RE; B47638 PRIMARY BLDG. PERMIT. Z O N I N G S E T B A C K SR E Q U I R E M E N T S ------------ MAIN BUILDING -------------------- ACCESSORY BUILDING RNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN EFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN ARKING RE • PROV: PARCEL: 00000000 ZNE: REF NO: LANNING NOTES> D E V E L O P M E N T S ;ER' V I C E S R E Q U i R E M E N T S ONING APPROVED BY ��� DATE: UILDING APPROVED BY : DATE: G PPLICATION ISSUED BY: r7 DATE: '� (p 9E TETE tt if � iE iE iE iE � Tic iF �E � * iE iE �E iE iE t iE iE �E iE iE �!- 9E iE iE dE •>E ;he'll iE iE iE iE iE �E iF iE iE �E ,til iE �E * � * iE dE iE iE iE iE iE iE iE iE �E iE � i� iE,it•�E iE'1E'JE TETE iE TE ,rE � � * i(• � TF � it � iE iE 1E iE TE iE 1E iE iE iE 1E � iE � 9E �E iE iE BE 9E � iE iF iF �E ;# EGALIZATION : N F ,E" E �'� S U M M A R Y STRUCTURAL SEGMENT : N BLDG PMT PLUMBING rELEC4RIC MECHANIC FIRE SMIP/RES GRADING ERMIT ,18.50 �- LAN 50% SMIP/NON—RES SSUE FEE 4,50 UILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE OTALS----> 18.50 4.50 0.00 23,00 23.00 .00 EVENUE DIVISION TOTALS--> COLLECTED: 23.00 OVER/SHORT:00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK 23.00 iE IE it 1E iE iE iE iE iE it it it dE iE iE >tiE aE dE dE it TE iE iE iE iE iE Tt iE iF iE iE iE it iE it dE aE ,til * 3E it it• 9t 9E �E 3E TE iE iE !E � �E iE iE iE aE �E •!E ;# 9E 1l iE * ,rE �l ?'E iE'rE iE it * iE iE 3E TE iE iE iE I N D I V I D U A L F E E B R £•A K D 0 W N YPE QTY D E S C R I P T I O N UNIT COST TOTAL COST LE 1 SERVICES BELOW 600 V & BELOW 201 AMP 18.50 END OF FEES 18,50 01 00067607-00067607 T 0 7 '5,K DATE: 08/15/90 TIME: I1•°554 CONSTRUCTION AND PLANNING 'APPROVALS Permit :# L Date Inspector PO PA APPROVALS Permit # Date Inspector ..1, Temporary Electrical Service or Pole 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd, 53. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. 54. Forms 4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6. Electrical LIFER Grnd. 57. APPROVAL TO COVER-GUN)TE 7. Footings 58. Electrical Conduit-Undrgrnd. B. Foundation 59. Gas Pipe, ❑ Undrgrnd., Test 9. Water Pipe-Undrgrnd. 60. Backwash Lines, P -Trap, ❑ Undrgrnd. 10. Structural Floor System 61. APPROVAL TO DECK 11. Property Sewer Line & House Connection 62, Backwash & Receptor -Final 12. Sewer Cap 63. Heater & Vent -Final 13. Roof Drains 64. Plumbing System - Final 14, Rough Plumbing 65. Electrical -Final 15. Rough Electrical -Conduit 66.. Solar System -Final 16. Rough Electric -Wiring 67. Fencing & Access Approval 17, Rough Wiring Sign 68. APPROVED FOR PLASTERING 18, Rough Electrical -T Bar -Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit # 20. Rough Factory Fireplace 21: Ducts, in Structure 70. Underground Hydro 22. Ducts, Ventilating 71, Product Piping ❑-Gas ❑Oil 23. 'Gas Pipe -Rough .& Test 72. Underground Flush 24. hoof Framing -73. Undergrnd,Storage.Tank ❑Gas QOiI 25, Roof Sheathing 74. Overhead Hydro 26, T•Bar Ceiling (Structural) & Monocoat 75, Dry Chemical 27. Frame and Flashing T 76. Dry Standpipe 28. Lathing & Siding 77, FIXED SYSTEM FINAL 29. Insulation 78. FIRE PREY, FINAL 30. Drywall Nailing HEALTH DEPT,, REQUIREMENT 31. Plaster Brown Coat 79 Al_ INSPECTION' ,32. Electrical Power Meter -Final CERTIFICATE ISSUED 33. Final Electric 34. Final Heating & Air Conditioning 35. Final Gas Pipe -Test 36. Hood or Canopy 37. Final Factory Fireplace -38. Final Plumbing 39. Water Service -Final 40. Gas Service -Final 41. Solar Domestic -Final 42, Backflow Preventer 43. Backflow Irrigation 44, Landscape Irrigation System 45. Sound Attenuation 46. Handicap Regulations -47. FINAL STRUCTURE & BUILDING 48. FINAL PLANNING 49. Electric Release to Edison 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY No. Date M tOJV a4DDR&S: 3333 BRISTOL ST UNIT: 1 so 0 DWNER'll-VAME: C . j . S EGERSTROM & SONS t ADDRESS: 3315 FAIRVIEW RD COSTA MESA CA 92626 ARCHIENGINEER: (714)546-0110 REG.NO.: ADDRESS: UNIT: PERMITTEE: EIDSON FIRE PROT (213)514-5535 ADDRESS: 1881 N GAF F EY ST B SAN PEDRO CA 90731 LICENSED CONTRACTOR DECLARATION: I hereby affirm that I am licensed under provislons of Chapter 9 (commencing with Section 7000) of Division 3 o1 the Business and Professions Cod and my ' e is In lull torte a CITY uc.: 0 5 018 9 STATE uc.: 5 7 4 5$ c ss: C 16 Date: =/_—[� Signature: WORKERS' COMPENSATION DECLARATION: I hereb aHir ha a of consent to self•insure or a certificate of Workers' Compensation Insurance, or a certified copy thereof rSection �. lhiucY NG.: 1141498-89 EP• DATE: 0 7 / 01 / 9 MPANY: STATE Certified copy is hereby furnished. Certified cop s filed 'th Ili iry Building ' ' ion- mate: �o --- iplicent: EKEMPTION FROM WORKERS' COMPENSATION DECLARATION: s secti need n be le pemdt is for one hundred ($100) or less►. I certity that in the performance o1 the work for which this permit 'sue , I Stroll n oy any person in any manner so as to become I subject to the Workers' Compensation Laws of Calitomia. Date: Signature: NOTICE: If, after making this declaration, you should become subject to the Workers' Compensation provisions of the Labor Code, you must torthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Section 3097, Civ. C). LENDER: ADDRESS: OWNER GUILDER DECLARATION: I hereby affirm that I am exempt from the Contractors' State License Law lot the following reason (Section 7031,5 Business and Pro essional Code: Any city o1 county whish requires a permit to construct, alter, improve, demolish, or, repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he/she is licensed pursuant to the provisions of the Contractors' State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that helshe is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500). I, as owner of the property or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Section 7044, Business and Professional Code: The Contractors' State License Law does not apply to an owner of a property who'builds or improves thereon, and who does such work himself/herself or through his or her own employees, provided that such Improvements are not Intended or offered for sale. If, however the building or improvement is sold within one year of completion, the owner will have the burden of proving he/she did not build or Improve for the purpose of sale). I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Section 7044, Business ❑ and Professions Code: The Contractorsrs' State License Law does not appy to an owner of properly who builds or improves thereon and who contracts for such projects filth a contractor{s) license pursuant to the Contractors• state License Law), I am aware That proof of their Worker's Compensction insurance should be provided to me. E] I am exempt under Section: B. & P. C. for this reason: Date: Owner: I do hereby certify that I am aware of and understand the requirements of California Health and Safety Code Sections 25565, 25533, and 25534 and that I or any future building occupant willtwill not (circle one) need to comply with said state codes and the requirements for a permit for construction or modification from the Airuality Management District. Residential construclion applications are exempt from these provisions. Date: Appgeant: I hereby certity that I have read this application and state that thea n o ation is ecL I to comply with all city and county ordinances and state laws relating to building constructs%dherely horiaa resen f to enter upon the above-mentioned property/for inspection purposes. Date: y -,( Signatu Driver's License or Social Security —\641,46 White—Building; Green—Code Enforcement; Canary --Applicant; Pink—Revenue: Goldenrod—Assessor CITY OF COSTA MESA - BUILDING PERMIT PERM NO: F' 047772 PERMIT NO: F 047772 PLAN CHECK NO: 04320-90 S GOVT: N SUPP: N CONSTRUCTION TYPE: PERMIT TYPE: FIR PURPOSE: ALT JOB DESCRIPTION ; TENANT IMPROV, SPRINKLER SYSTEM SQ FT: CLAIM VALUE: 4,800.00 CALC-VALUE: GROUP OCC: / COMMENTS: RE: B47638 PRIMARY BLDG. PERMIT, Z O N I N G R E Q U I R E M E N T S S E T B A C K S ------------- MAIN BUILDING ---------- --------- ACCESSORY BUILDING------------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN PARKING REQ: PROV: PARCEL: 00000000 ZNE: REF NO: PLANNING NOTES> D E V E L O P M E N T S E R V I C E S R E Q U I R E M E N T S ZONING APPROVED BY HATE: BUILDING APPROVED BY ; DATE: APPLICATION ISSUED BY: DATE: --te S iE iE iE iE 1E iE # iE it- � jE i4 iE iE i(- iE iE iE �E �F iF it• r� iE iE iE �F �E iF '!i ii iE ik � � it• iP iE iE• it• +>F dE it � if• �(- if- it it * � ie � T4 � 9t * ik it it it it iE iE iE ifiE iE iE iE iE if iE iE iE iE 9t it # 're iE kt'r(iE � it 9f- i(if iE iF 9F it• 1tah ie iF !( !t it• dE iE if iE it it- iF it �F iF �t � LEGALIZATION:N F E E S U M M A R Y STRUCTURAL SEGMENT:N BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE' SMIP/RES ' GRADING PERMIT 72.00 65% SMIP/NON—RES PLAN �; '� 46.80 ISSUE FEE ; BUILDING -DIV->( PERMIT ISSUE PL`AN-xCHECK TOTAL PAID DUE TOTALS-----> 72.00 0.00 446.80 118.80 118.80 ,00 REVENUE DIVISION TOTALS--> COLLECTED: 72,00 OVER/SHORT: ,00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMTP/TOT GRADING PLAN -CHECK ` 72.00 1 �E �E 9E iE iF iE 9E iE }E it Tt * it- tit * iE iE iE iF -)f dS- it --1F iE �f if'lE iF iE iE iE �E -IF �F 11 -ilk �E �F 1t- tit--lE it-iEir� -IE iE iE �F � tit iEit iE it -1E iEiE 9c --1F .� dE -iE fit- �k tit iF 1t 9E ->f dE � iE # i1- iE it it -it I N D I V I D U A Li :F E E B R E A K D O W N TYPE QTY D E S C R I P T I O.'V -i UNIT COST TOTAL COST FIR 72 FIRE EQUIP FEE (FROMBLDG VAL TABLE) 1.00 72.00 END OF FEES • .w G1000S3305-000 305 TOS" 72.00 DATE: 06/15/90 TIME: 13:39 ;CONSTRUCTION AND PLANNING APPROVALS Permit # Date Inspector RW ?A APPROVALS Permit # Date Inspector 'a. Temporary Electrical Service or Pole �' 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd., �l 53. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. 54. Forms 4. Electrical Conduit-Undrgrnd.' 55. Electrical Bonding ' 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6. Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE • 7. Footings 58. Electrical Conduit-Undrgrnd. 8. Foundation + 5 59. Gas Pipe, ❑ Undrgrnd., Test 9. Water Pipe-Undrgrnd. l N �,ti 60- Backwash Lines, P -Trap, © Undrgrnd. 10, Structural Floor System ` p 61. APPROVAL TO DECK r 11. Property Sewer Line & House, onnection `. ` 62. Backwash & Receptor -Final ti 12. Sewer Cap 63. Heater & Vent -Final 13. Roof Drains 64, Plumbing System - Final ^ ` , 14. Rough Plumbing r 65. Electrical -Final i 15. Rough Electrical -Conduit 66. Solar System -Final 16. Rough Electric Wiring 67. Fencing & Access Approval 17. Rough Wiring Sign 68. APPROVED FOR PLASTERING 18. Rough Electrical -T Bar Ceiling 69.'POO L/SPA SYSTEMS FINAL 19. Rough Heating &Air Conditioning FIRE DEPT- REQUIREMENT APPROVALS Permit # 20, Rough Factory Fireplace 21. Ducts, in Structure 70. Underground Hydro 22• Ducts, Ventilating 71. Product Piping ❑ Gas C3 Oil 23. Gas Pipe -Rough & Test 72. Underground Fiush 24, Roof Framing 73. Undergrnd. Storage Tank ❑ Gas ❑ Oil 25. Roof Sheathing 74, Overhead Id-�u ,%�►-�4'J � 26. T -Bar Ceiling (Structural) & Monocoat 75.- Dry Chemical 27. Frame and Flashing 76. Dry Standpipe 28, Lathing & Siding 77. FIXED SYSTEM FINAL 29. Insulation 78. FIRE PREV. FINAL 30, Drywall Nailing _ HEALTH DEPT, REQUIREMENT 31. Plaster Brown Coat 79. FINAL INSPECTION 32, Electrical_Power Meter -Final *f 80. FOOD CERTIFICATE ISSUED .33. Final Electric �'`� Notes: 34• Final Heating-& Air Conditioning 35. Final Gas Pipe -Test 36. Hood or Canopy 37. Final.Factory Fireplace r f, 38. Final Plumbing +' 39. Water Service -Final 40, Gas Service -Final 41. Solar Domestic -Final 42. Backflow Preventer 43. Backflow Irrigation 44. Landscape Irrigation System 45, Sound Attenuation 46. Handicap -Regulations 47. FINAL STRUCTURE & BUILDING , 48. FINAL PLANNING 49. Electric Release to Edison 56. Gas Release to Southern California Gas Co C. 511 CERTIFICATE OF OCCUPANCY No. Date It ADDRESSOFBUILDING: 3333 BRISTOL ST UNIT' 1500 OWNER5NAMEIFKNOn:C,J. SEGERSTROM & SONS FLOOD: AO -38 ADDREss:3315 FAIRVIEW RD 'OSTA MESA, CA 92627 546-0110 AVPL, MAULING AODRES& ARCHITECT OR ENmtEER:B RAND S ALLEN Lic- Na: C-99999 ARCH. OR M'S ADDRESS: 900 NORTH POINT UNIT: 400 SAN FRANCISCO CA 94109 CORMACTORSIIAME:CAUSEY ELECTRIC (714)855-9610 CONT114TOITSMAILING 3 VANDERB ILT ADDRESS: I R V I N E CA uc. No.: 331064 92718 UNIT: LICENSED CONTRACTORS DECLARATION: I hereby affirm under penalty of pedury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is i farce and effect. c C. NO.017 7 5 4 LIC. Class: C 10 Lac 1064 P: 02/97 'e: Contractor ` } " ER BWLDER ECLARATION: I hereby affirm under penalty of perjury that,—. exam from the Contractors License Law for the __, wing reason (Section 7031.5 Business and Professions Code, Any city or county which fres a permit to construct, aler, improve, `x;,'iholish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she icensad pursuant to the provisions of the Contractors License Law [Chaplet 9 (commarncing with Section 7000) of Division 3 of the Business and Professions Code) or that he a she is exempt therefrom and the basis for the alleged exemption. Any violalion of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars IMI). ❑ 1, as owner of the property or my employees with wages as Ihei sole compensation, will do the work, and the structure is not intended or offered for sale (Section 7044. Business and Professions Code: The Contractors License Law does not applyto an owner of property who builds or improves thereon, and who does such work himself m homel or through his or her own employees, provided that such improvements are riot intended or offered for sale. lf, however, the building or improvement is sold within one yea of complelion, the owner -builder wit#1 have the burden of proving he or she did not build of improve for the purpose of sok). ❑ 1. as owner of the property, am exclusively contracting with licensed contractors to construct the project (Section 7044, Business and Professions Code: The Contractors License Law does not appy to an owner of property who builds of improves thereon and who contracts for such projects with a contractor(s) licensed pursuanl to the Contractors License Lew). ❑ I am exempt under Section: B. A P.C., for this reason: Date: Owner. I do hereby certify that I am aware of and understand the requirements of California Health and Safety Code Sections 25505, 25533, and 25534. and that I or any future building occupant will I will not (circle ore) need to comply with said state codes and the requirements for a perms for construction or modification from the At anagernmi District. Residential construction applications are exempt from these provisions. Data: Applicant: WORKER'S COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and wil maintain s corlincale of consent to sellwinsure for workers' compensation, as provided for by Section 3700 of the Labor Code, fa the performance of the work for which this permit is issued. X'--' I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' cont Eaton insurance carrier and policy number are: Carter: FEISERAL INS. EXPIRES Policy Number: 97GVVVV224 10/01/96 Thi action need mol be completed if the permit is for one hundred dollars IS1001 or kits.) ❑ cortly Chet in the performance of the work for which this pmnil i I mol empty sn 'in any manner so at to me subject to the workers' compensation laws of Celitomi and agree lf I shoe eubjed to the workers' compensation pro tom d action 3700 of the Lebo Code, I shall hwith can with 1 . Data: Appricant ; Warning: Fallure to sscuro wortrers' compensallon coverage la unlet , and shelfsub/ ct en arnployer to criminal penalties and civil fines up to one hundred thousand dollars ($100,000), In sdttition to the cost of mpeneatloM damage as provided for In Secdon 3706 of the Labor Code, lnroves7 and attorney's fees. CONSTRUCTION LENDING AGENCY: 1 hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work fa which this permit is issued (Section 3097, Civ. C). LENDER'S NAME: LENDER'S ADDRESS: I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. � C LEWW I/ Date: 'dlllpl� (5151-4b.WP) White -Build d, Safety: GrserrFle; Canary-Appkam; Pink -Revenue: Goldenrod--Pssessa CITY OF COSTA MESA — BUILDING PERMIT PERMIT NO: E 077194 PLAN CHECK NO: N CONSTRUCTION TYPE: I—FR PERMIT TYPE: ELE JOB DESCRIPTION : SUPPLEMETAL TO E-76976 CLAIM VALUE: CALC—VALUE: ERM NO; E 077194 GOVT: N SUPP: Y PURPOSE: ALT SQ FT: GROUP OCC: B / COMMENTS: T.I FOR "CHANEL" STORE TI, RE:#B76526 4E �E �E iE >� � ♦k f� *'IE'1E 4E iE IE'JE ![� iE 5F � jf' iE �(- � ib iE iE if")E"1f"YF �(- IE �E IE'IE 4E * �E 3E �f � 4E iE jE �1E �IE iE i6 �E � iE IE iF iE iE iF * iE iE iE'lE• iF ♦4 � * * iE• * �E -1E iE * � � 9E dE iF iE 'IE Z O N I N G R E Q U I R E M E N T S S E T B A C K S ------------ MAIN BUILDING ---------- --------- ACCESSORY BUILDING--------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RIGHT: FT IN LEFT: FT IN RGHT: FT IN PARKING REQ• PROV: PARCEL: 41249102 ZNE: REF NO: PLANNING NOTES> > 4E 4F �E 4E 9("1E'1E dE iE 4E 4E iE lf � fE lE 4E � 4E aE dE'1E �E 'IE �E 4E �E'IE 4E jE 3E �E"IE �E �E iE iE �E iE �E 1E iF �E � * * iE iF iE �E iF iE iE iE iE iE iE iE 9E iE * iE it• 14- * � � * 4E * 4F dE dE'1E iE iE i@ iE iE D E V E L O P M E N T S -E R V I C E S R E Q U I R E M E N T S — ' l ZONING APPROVED BY DATE: BUILDING APPROVED BY : DATE: APPLICATION ISSUED BY: DATE: LEGALIZATION:N F E E S U M M A R Y STRUCTURA�4G :N BLDG PMT PLUMBING, ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT 18.50 50% SMIP/NON—RES PLAN ISSUE FEE 4.50 BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE TOTALS ---- > 18.50 4.50 0.00 23.00 23.00 .00 REVENUE DIVISION TOTALS--> COLLECTED: 23.00 OVER/SHORT: .00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK 23.00 4E 4E iE dE �'lE'IE 4E 4E iE iE �(' 4E fE if 'fE'!E * �E 4E 4E 4E iE iE iE iE iE iE 4E 4E iE dE'1E'1F }E n1E 'IE iE'1E 3F'1E'1(' -IE iE 4E �E iE it- fE iF iF �E iE iF )F * if 4E iF dE')E �E iE iE iE iE it• iE * 4E iE• iE �E aE 4E 4E aE � 4E I N D I V I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST TELE 1 SERVICES BELOW 600 V & BELOW 201 AMP 18.50 END OF FEES 18.50 01_ 00204tJ0`CQ206S35 1`0T _3.60 CONSTRUCTION AND PLANNING APPROVALS Permit # Date Inspector PO+ a SPA APPROVALS Permit # Date Inspector 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location. , 2.' So H, Pipe-Undrgrnd. 53. Steel Reinforcement 1 Electrical Conduit Utility-Undrgrnd. 54. Forms 4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding 5.- Steel Reinforcement 56. Rough Plumbing & Pressure Test i 6. Eler_16Ca1LIFER Grnd. 57. APPROVAL TO COVE R-GUNITE 7.- Footings 58. Electrical Conduit-Undrgrnd. 8. Foundation 59. Gas Pipe, ❑ Undrgrnd., Test 9. Water Pipe-Undrgrnd. 60. Backwash Lines, P -Trap, 0 Undrgrnd. 10. Structural Floor System 61, APPROVAL TO DECK 11. Property Sewer Line & House Connection 62. Backwash & Receptor -Final 12. Sewer Cap ' 63. Heater & Vent -Final ; 13. Roof Drains - • 64. Plumbing System • Final ? 14. Rough Plumbing 65. Electrical -Final r 15, Rough Eigctrical-Conduit 66. Solar System -Final 16, Rough Electric Wiring 67. Fencing & Access Approval 17. Rough Wiring Sign 68. APPROVED FOR PLASTERING 18. Rough Electrical -T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air.Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit # 20. Rough Factory Fireplace 21. Ducts, in Structure- 70. Underground Hydro 22, Ducts, Ventilating 71. Product Piping O Gas ©Oil 23. Gas Pipe -Rough & Test 72. Underground Flush 24. Roof Framing 73, Undergrnd. Storage Tank 0 Gas 0 Oil 25. Roof Sheathing 74. Overhead Hydro 26. T•Bar Ceiling (Structural) & MonQcoat 75. Dry Chemical 27, Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding 77: FIXED SYSTEM FINAL 29. Insulation. 78. FIRE PREV. FINAL 30. Drywall Nailing HEALTH DEPT, REQUIREMENT 31. Plaster Brown Coat - 32. Electrical_Power Meter -Final 33. Fina[ Electric i) fi 7p FINAL INSPECTION ,. FOOD CERTIFICATE ISSUED -� otes:' - - 34. Final Heating & Air Condi,ioning 35. Final Gas Pipe -Test .L 36. Hood or Canopy `. 37. Final Factory Fireplace- -38. Final-Plurrmbing 39. Wate'r'Service-Final ._ Gas Service -Final 1. Solar Domestic -Final ` 42. Backflow Preventer ' 43. Backflow Irrigation 44. Landscape Irrigation System 45, Sound Attenuation ' 46. Handicap Regulations , 47. FINAL STRUCTURE & BUiLbING - 48. FINAL PLANNING 49. Electric Release to Edison { I� LaJ `iQ 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY No. Date ADDRESS OFBtltLDIAG: 3333 BRISTOL {ST uNT: __ 1500 OWNEITSNAME IFgA. �. J. SEGERSTROM & SONS FLOOD: AO -38 ADDRESS`3315 FAIRVIEW RD CA. ,92627 546-0110 ARCHITECT OR ENGINEER: LIc. NO.: ARCH. OR ENG: S ADDRESS: UNIT: CONTRACTOIrsNAMe: WESTEC SECURITY INCORPORA (714)951-1806 CONTRACTORS MkWih_ 5 MASON ST AR�!--_.IRVINE CA L!�No, 269590 92718 UNIT: LICENSED CONTRACTORS DECLARATION: I hereby affirm under penalty 'ury that I am licensed under provisions of Chapter 9 (commencing with Section 7DDO) of Division 3 of the Business and Profess' s C , and my license is in full torte and effect. 771- NO.: 038462 LIC.CL"Si C 61 LIC.N .: 2 959 EXP: 03/97 ate: 7— 9 Contractor. Com+ 1W R BUILDER DECLARATION: I hereby affirm under penalty of perjury that I am eurridilh.191 rom the Contrectars License law for the owng reason {Section 7031.5 Business and Professions Cade: Any city or county wires a permft to construct. after, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for to file a signed statement ftraf he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 ( with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basid for the alleged exemption. Any violation of Section 7031.5 by any applicant for a parmft subjects the applicant to a civil penalty of not more than five hundred dollars )S500]). ❑ I, as owner of the property or my employees with wages as their ode aompenswion, will dD the work, and the structure is not intended or offered for sale (Section 7044, Business and Prolessions Code: The Contractors License Law does not appyto an ownerof property who builds or improves thereon. and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or Offered for sale. H, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving he or she did not build or improve tot the purpose of sale). ❑ 1, as owner of the property. am exduer sly contracting with licensed contractors to construct the project (Section 7044. Business end Profession* mit d Code: The Contractors Licee Law doss napply to an owner property who bulks or improves thereon and who contracts for such projects with a conrractor(a) licensed pursuant to the Contractors License Law). ❑ I am exempt under Section: B. d P.C., for this reason: Date: Owner: I do hereby certify that I am aware of and understand the requirements of California Health and Safely Code Sections 25505, 25533, and 25534, and that I or any future building occupant will / will not (circle one) need to comply with said state codes and the requirements for a permit for construction or modification fromlhsA'r ua Iy anagement Disind. Residential winalruc ion appicetiorts are exempt from these provisions. Dale: Applicant: WORKER'S COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one ol the following dedareliwts: ❑ I have and will maintain a certificate d content to se&nsure for waken' oompansation, as provided for by Section 3700 of the Labor Code, tot the performance of the work for which this permit is issued, I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Coda, for the performance of the wok for which this permit is issued. My workers' compensation insurance carrier and poky number are: Carrier: EXPIRES Policy Number: RCRC41 I S51 2-710/01/96 (This section need rrd be completed if the perms is for one hundred &Zs Jsiao) a Jess.) ❑ I certify that in the performance of the work for which this permft ' ued, shall not employ any person in any manner so as to FWar subject to the workers' compensation Laws of Galifom' ,and roe that it I ld become subject to the worers' pensstion Provjsjons d S/action 3700 of the Labor Code, I provisions, '1Applicant: Failure ro secure workers'comparrsetlon coyerape Is unlmo 1, and sfll Jett an employer to crlmfnal peneWas and s rip to ons hu ndred thousand dollars ($700,000), In eddlton ro the of cornponsatfan, damepss as provided for fn 3706 at the labor Cads, interest and ettomey's fess. CONSTRUCTION LENDING AGENCY: I hereby affirm under penalty d per/that there is a construction lending agency for the performance of the work far which this permit is issued (Section 3097, Civ. C). LENDER'S NAME: LENDER'S ADDRESS: I certify that I have read this application and stale that the above information is conect. I agree to comply with all city and county ordinances and state laws relating to building Construction and hereby authorize representatives of this city to enter upon the above-mentioned property for ins DAVID ALLEGOS Print Name •�� Date: (5151-415XP) W�'6-8uifding 5 SaWy, Breen -File: Canary -Applicant Pink-Revsnua; Goldenrod-Pssesaa CITY._ OF COSTA._ MESA —_.BUILDING PERMIT PERM NO:.F__ .078183 PERMIT NO: F 078183 PLAN CHECK NO: 02248-96 L GOVT: N SUPP:..N CONSTRUCTION TYPE: I—FR _ PERMIT TYPE; FIR _ r .....,,PURPOSE: ALT. JOB DESCRIPTION FIRE ALARM SYSTEM _ SQ_FT: . CLAIM VALUE: 1,500.00 CALC—VALUE: GROUP OCC: M / COMMENTS: T.I FOR "CHANEL" / REF B-76526 Z O N I N G R E Q U I R E M E N T S _ S E T B A C K S . =------------ MAIN BUILDING —•------------------- ACCESSORY BUILDING_ -------- w N _ FRT:._,_. FT _ ,IN REAR; FT IN FRNT: FT IN REAR: FT IN LEFT; FT. IN RGHT: FT IN LEFT: FT IN RGHT: FT IN PARKING REQ• PROV: PARCEL: 41249102 ZNE: REF NO: PLANNING .NOTES>„ it• iE iE iE � iE � !f * if !E � � it iE �E � � � 1E iE iE '!tiE iE * iE * !E !F rlE * fIE * * �E iE 'IE iE � * if � * !E!E!E !E ?rElE !E �f IE'lE df if 1f if 9E iE'lf >7f 1f t}E 1! t1E �E !E �E !E it'1(iE')E iF it iE i(� D E V E L O P M E N T S E R V I C E S R E Q U I R E M E N T S ZONING APPROVED BY DATE: BUILDING APPROVED BY : DATE: Q f APPLICATION ISSUED BY: I DATE: 1 V 'IE 1f 9E iE it !F iE• !4 iE !E !E iF �E iE'If k #E 1� 1f * jf if iE iE• iE irk �E !E * i� * ?IE 'If LEGALIZATION;N F E E S U M M A R Y STRUCTURAL S GMENT:N BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT 49.00 658 SMIP/NON—RES PLAN 31.85 ISSUE FEE BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE TOTALS ---- > 49.00 0.00 31.85 80.85 80.85 .00 REVENUE.DIVISION TOTALS--> COLLECTED: 49.00 OVER/SHORT: .00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK 49.00 �'If if iE iE if if -K- iF 9E if * it !E iE iE � 9E it •IE •IE aF iE iF iF * � •1E dE * * iE � iE iF if iE * � * * 9E * i4 if �4 it it IF * � lE it iF i4 lE iE i4 it• iE 1F iE'lF * iE iE it it• # iE iE iE iE � � it• dE iE'1E I N D I V I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST FIR 49 FIRE EQUIP FEE (FROM BLDG VAL TABLE) 1.00 49.00 END OF FEES ;i- :1 �-- X11 mm+:'.rl z •fir_ -- _� , v .' .y �' 4 . • y' CO Mt AND PLANNING POOL &SPA APPROVALS Permit # ' Date Irtspecior APPROVALS Permit # . Date Inspector 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location "I 2. SoPipe Undrgrnd. `' 53. Steel Reinforcement - 3t;-Elegrical Condu7{; Utility-Undf9rnd. 54. Forms 4 L Electrical Condut►~i•rUAIrgrnd. 55. Electrical Bonding tr l: , Steel Reinforcerrmerif 56, Rough Plumbing & Pressure Test ' Electrical UFEf'-G'nd. r 57, APPROVAL TO COVER-GUNITE r` 1 . ✓ � � C Footings M L' 'v 58. Electrical Condtsft�Undrgrnd. Foundationoz's 59. Gas Pipe, ©Un'ii[F�rnd., Test c 1 -QF�Wa2er Pipe-Undrgrnd. �l 60. Backwash Lines-44rap,-0 Undrgrnd. }rf}. StrAptural Floorystem 61. APPROVAL TCE CK �t �. Praperty Sewer PneA HouseTl hnection 62. Backwash & Receptor -Final 12. Sewer Cap t+- 63. Heater & Vent -Final 1=3. Roof Drains 64. Plumbing System - Final . Rough Plumbing-' 65. Electrical -Final . Rough ElectricaL71poguit 66, Solar System Fsraa', 1c6. Rough Electricring, 0 67. Fencing & Accegltpproval ru 7. Rough Wiring SiT 68. APPROVED F4ILASTERING 18. Rough Electrical- Bar Ceiling 69. POOL/SPA SYSTEMS F INAL 19, RQugAWe,5in�& Sir Candition�g� F4F3� I�'T.,i�EQU1Fi,�MEqj F, tr * PPR�V�A9:BHF•, Permit 20. u Fay or Fir ace ; *. - Ohm n �rurttur�� 21. i z - n � ' 70. Pnder�i 40 H,�oroF7 , n x 7 22. G?uc4jV406 ng* x -i 0 1-- <X 71. Produe±i3Ersping O'Oas DOil 23. (hs Ripe- oueM & Test , r ' t? 72. Undergrq�r d F%si 'h , 24. foof-'�ra�+ n ` ��i 9 ri:K C * " �: � �' �� " ~ � 73� Undergrnd.5torac�ETank'� Gas 0 Oil 25. Roof Shea -tiling 7 Overhead HYdrft' 26. TBar-Ceiling (Structysral) & i,& --at 7f 17- 75Y, Dry Chemical 27. Fname•an&Flashin k 76. Dry Stan pe X28. LathtggSr�Si i g * ' ' [ r 1 77.9 FIXED STESVI FINAL C. 29. Insulatior4� �-; r S s 1 ;�` 7i FIRE PREY. F I L x l?Lz 1I1(o 1A LL_ y30. Drywall filing REQUIREMENT ,,XEALTI�DEPT. 431. Plaster Brown s I !" + 79. FINAL In ECT1_5N " 't '32. Electrical owtat M�t�ipal �$O FOOD CERTIF)' ISSN -E D_ rr :=33. P-1nal lec7_cic: { C7 `Z i N�tes: 41 11 Cr' X34. F�nal;7-Heating 9 A-�tff 'toning 35. gnal-Gas Pipe-estj* G �• is +-+ �ti C3 G?" P.- X36. I:.00d�!ir Canopyr {, t tv-r a * r I t': X37. .nal Tactory Fireplace x i -j fu r•• d -• 4 J 38. Proal"Plumbing * CO 39. VWter Service -Final T Z tr W .• m40. G'as Service -Final rn <1 S X: tY K00 0t;, ;: 41. Solar Domestic.Finalr '' i- rnet ,., fir: Ct, A. r. 42. Backflow Prev@rater �' �LL C 7 * N Q t-- �; ri i tZI W '� `'� `'' M O rli Cl p + H �. w 4 3 43. Backflow Irrigation Ir>i M ; - C Q Landscapiuirr . tion ystem `s=� M. el' `� � � _ t:1 Gr � C+y � � - 45. sound Attenyation y- * wrr -T1 r- �+ :' < :-•' ,e 46. Mdndicap ReguTation*t ru : C +7. FTN4 STRUE`,'TUR& & BUIC61NG * L I j.-:1 u � 1 r .r- �•3: r4 % r 48. F-Tq 'PLANNING y: I 1 T : 49.. E=1ecI it Release to EcDsort ; j1K L mss. 5P. Gas RAlease to $aoutlTrn Califdrrt7a`pas Co �' ' -4: `�' 5-1. CERTIFICATE OF GCCUPANCY t� " No. Date �- PROJECT ADDRESS: 3333 BRISTOL ST UNIT: 1500 OWNER'S NAME: ADDRESS: C . J . S EGERSTROM & SONS 3315 FAIRVIEW RD COSTA MESA CA 92626 ARCHIENGINEER: ( 714 ) 5 4 6 —0110 REG.N0.: ADDRESS: UNIT: PERMITTEE: C . J . SEGERSTROM & SONS (714)546-0110 ADDRESS: 3 315 FAIRVIEW RD (' n � F LICENSED CONTRACTOR QR RAIOW� �nMy alfirm that I am licensed under pivvisions a pier 9 (commencing wish Section 7000) of Division 3 at the Business and Professions Code. and my license is in full force and effect. CITY LIC.: STATE LIC.: CLASS: Date: Signature: WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure or a certificate of Workers' Compensation Insurance. or a Certified copy thereof (Section 3800, Lab. C). POLICY ND.: EXP. DATE: COMPANY: t❑ Certified copy is hereby furnished, ❑ Certified Copy is tiled with the city Building Division. —Oase: Applicant: EKEMPTION FROM WORKERS' COMPENSATION DECLARATION: (This section need not be completed if the permit is for one hundred ($100) or less}. I certify that in the performance of the work tar which this permit is issued, I shall:not employ any person in any manner so as to become subject to the Workers- Compensation Laws of California. Date: Signature: NOTICE: ll, after making this declaration, you should become subject to the Workers' Compensation provisions of the Labor Code. you must Iorlhwilh comply with such provisions or INS permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Section 3097. Civ, C), LENDER: ADDRESS: OWNER BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractors' State License Law for the following reason (Section 7031,5 Business and Professional Code: Any city of county which requires a permit to construct, alter, improve. demolish, or repair any structure. prior to its issuance. also requires the applicant for such permit 10 file a signed Statement that tietshe is licensed pursuant to the provisions of the Contractors' Slate License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Prolessions Code) or that he/she is oxompt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant lar a permit subjects the applicant 10 a civil penalty of not more than live hundred dollars (3500). I, as owner of the property or my employeeswith wages as their sole compensation, will do the work, and the El structure is not intended or offered for sate (Section 7D44, Business and Professional Code: The Contractors' State License Law does not apply to an owner of a property who buildg or improves thereon, and who does such work himselllherself or through his or her own employees. provided that Such improvements are not intended or offered lot sate. If, however the building or improvement is sold within one year of completion, the owner will have the burden of proving helshe did not build or improve for the purpose of sale). i I, as owner o1 the property, am exclusively contracting with licensed contractors to construct the project (Section 7044, Business and Professions Code: The Contractors' State License Law does not apply t0 an owner of property who builds or improves thereon and who contracts tar such projects with a contractur(S) license pursuant to the Contractors' State License Law). I am aware that proof of their Worker's Compensation insurance should be provided to me. ❑ 1 am exempt under Section: B. g P. C. for this reason: zzz_ Date: A? Owner: f do hereby certify that I am aware of and understand the requirements of California Neallh an afety Code Sections 255D5, 2 ond 25534 and that I or any future building occupant willlwili not (circle one) need to comply with said slate codes and the requirem nls lar a permit for construction or modification from the Air Quality Management District. Residential construction applications are I. from these provisions. Dale: _P_ Applicant: I hereby certify that I have read this application and state that the above information is correct. I agree to comply with a�,ye-menloioned nd cunty ordinances and slate laws relating to building construction and hereby authorize representatives of this city to enter upon [ property tar inspection purposes. 6 1 Date: Signalur Driver's License or Social Secunty N: 1641.46 While—Budding: Pink—Revenue; Goldenrod—Assessor CITY OF COSTA MESA — SIGN PERMIT PERM NO: SB 05322 PERMIT NO: SB 053226 PLAN CHECK NO: 02896-91 L GOVT: N SUPP: N CONSTRUCTION TYPE: 1FR SP PERMIT TYPE: STR SIG PURPOSE: 0TH JOB DESCRIPTION ; EXTERIOR NON—ILLUMINATED ACRYLIC LETTERS SQ FT: CLAIM VALUE: 500.00 CALC--VALUE: .,`,00,00 GROUP OCC; B-2 / COMMEN'T'S: THE "CHANEL" STORE $E T(• # -}F TE •YR -3E •)E . .. •!4 fE ii• # -If• • •K• # •If # •!f k •iE aE # ?E •1 _X 3E * -M * * * * * * * -)C S I G N I N F O R M A T .1 U N DISTRICT: i TYPE: WALL CHANNEL LETTERS ILLUMINATION: NON CATEGORY: NEW DIMENSIONS: 3FT 03IN X OFT 06IN AREA: 1.60SQFT LETTER HT: 6 STREET FRONTAGE 1: 2151.00 STREET 1: SUNFLOWER AV STREET FRONTAGE 2: 0.00 STREET 2: PARCEL: 41.250102 ZONE: CI—S LOCATION > FRONT: REAR: BUSINESS NAME: CHANEL > REFI'; RIGHT: K O T H E R T O T A L S G R O U N D S I G N THIS ACTIVITY 1.60SQF,r OVERALL HEIGHT: OFT OIN THIS SITE 1.605 FT GROUND CLEARANCE: OFT OIN ITEMS OF INFO : 1 PLANTER AREA: 0,00SQFT ITEMS FOR ACTIVITY: 1 BLDG SET BACK: 50'OFT ,^ COPY VERBIAGE : CHANEL PLANNING NOTES: iF iF 3F 9E �{• � iE # # ie ih �E• ie # if * * #s TF # # 3f• �- # iF• if• �F 9r iE * jE 3E iF if iE 1E• it * ii• iE 3F• iE lf• iE iF # * # !6 iE fE 1E ?t iE # •ik if• # iF 3E•)E• 3rr Tin �i• 1C• # i(• 3F TE #:7E 3E # iE 3(• �i• 4(• # �• D E V E L O P M E N T S E R V I C E S R E Q U I R E M E N' -T-S ZONING APPROVED BY DATE:� BUILDING APPROVED BY ; DATE: 1� APPLICATION ISSUED BY: ` DATE: if •!� # 3E }F si• # 1E !Y �E i'E -1F •!E d( !E )F �f• * it- # # # x :: '1r iF IE• +E 3>F #t• +E # :i #• # >r iC iE LEGALIZATION:N F E E S U M M R Y STRUCTURAL SEGMENT:Y BLDG PMT PLUMBING ELECTRIC MECHANIC SIGN SMTP/RES GRADING PERMIT 15.00 1.60 SMTP /NON --RES PLAN 9.75 .50 ISSUE FEE BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE TOTALS ---- > 17.10 0.00 9.75 26.85 26.85 .00 REVENUE DIVISION TOTALS--> COLLECTED: 26.85 OVER/SHORT: .00 BLDG PMT PLUMBING ELECTRIC MECHANIC SIGN SMIP/TOT GRADING PLAN --CHECK 15.00 1.60 .50 9.75 fE � # 3E # * K• #r iF af• # •1F 9!• •1f TE �E #F iF if• 3F !{• +F i(• #F �E 1E # ik iE #� it 3i: -1'• �(• iF # # # 1E � iF 3E �( �(• #'}F # # tf # •?(# ��i• � •>tF iF �F iF 34 #F � iF # ;'E Tf •IE * tic #F ai 9E �F)E 9E i4• yk # it• I N D I V I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST NO FEES WERE SELECTED FOR THIS PERMIT it IT C3� 451 : CONSTRUCTION AND PLANNING APPROVALS Permit # Date Inspector POOL .PA APPROVALS Permit # Date Inspector 1. Temporary Electrical Service or Pole 52, Pool & Equipment Location • _ 2, Soil Pipe•Undrgrnd, 53. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. 54. Forms �- 4. Electrical Conduit-Undrgrnd, 55. Electrical Bonding 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6, Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE 7. Footings 58, Electrical Conduit-Undrgrnd. 8. Foundation 59. Gas Pipe, © Undrgrnd., Test 9. Water Pipe-Undrgrnd, 60. Backwash Lines, P -Trap, © Undrgrnd. f 10. Structural Floor System 61. APPROVAL TO DECK �r 11. Property Sewer Line & House Connection 62. Backwash & 'Receptor -Final 12. Sewer Cap 63, Heater & Vent -Final 13. Roof Drains 64. Plumbing System - Final 'x 14, Rough Plumbing 65. ElectricakFinal 15. Rough Electrical -Conduit 66. Solar System -Final 16. Rough Electric Wiring 67. Fencing & Access Approval �' � � IV �Jr 17. Rough Wiring Sign 68. APPROVED FOR PLASTERINGL/+ 18. Rough Electrical -T Bar Ceiling 69, POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT / APPROVALS Permit,# 20. Rough Factory Fireplace 21. Ducts, in Structure 70. Underground Hydro 22. Ducts, Ventilating 71. Product Piping ❑ Gas 0 Oil' 23. Gas Pipe -Rough & Test 72. Underground Flush 24. Roof. Framing 73. Undergrnd. Storage Tank © Gas 0 Oil 25. Roof Sheathing 74, Overhead Hydra 26. T -Bar Ceiling (Structural) & Monocoat 75. Dry Chemical 27. Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding 77. FIXED SYSTEM FINAL 29. Insulation /%, 78 .-FIRE PREY. FINAL 30. Drywall Nailing .' i +A HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat 11NAL INSPECTION 32. Electrical Power Meter -Final $Q.-y100D CERTIFICATE ISSUED 33. Final Electric 34. Final Heating & Air Conditioning �4 35. Final Gas Pipe -Test fir; 36. Hood or Canopy 37. Final Factory Fireplace r 38. Final Plumbing f 39. Water Service -Final 40. Gas Service -Final 41. Solar Domestic -Final 42. Backflow Preventer 43, Backflow Irrigation 44, Landscape Irrigation System 45. Sound Attenuation 46. Handicap Regulations 47, FINAL STRUCTURE & BUILDING 2 48. FINAL PLANNING { .qi '49. Electric Release to Edison r 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY No. Date City of Costa TO esa Development Services, Division of Building and Safety CERTIFICATE OF OCCUPANCY This certificate is ,issued pursuant to,the requiremenof the Uniform Building Code, Section 308 adopted by the City of Costa Mesa certifies.that ats7 �e R t the tune of its issuance the building structure herein below described was inspected and{appraved�for'occupancy as:fcillows:� Building Address 3333 BgI��Si'OL STREET #1500 /� Bldg. Permit No. B 76526 Use ..NAIL Group A-2 Type of;Construction I—VR Fire Zone Use Zone r -S g C . A SEGERSTROM " + vll Owner of Build' Tenant 1ST �k - ,��„ V/ Address t ,'i - BUILDING OFFICIAL -cony V �Ve By fir. -�•� REQUIRED TO BE uly 27, 1996 NSPICOUS PLACE 0 )°DRESSDFI11111. : 3333 BRISTOL ST DHT., 1500 OWNER'S NAME IFKNO": C.J. SEGERSTROM & SONS FLOOD: AO -38 ✓.T• ADDREss' 3315 FAIRVIEW RD OSTA MESA, CA 92627 546-0110 &PPL. MAIUNG ADDRESS: ARCHITECT ORENOINCM BRAND ALLEN LIC.ND.: C-99999 RCIL OR 0143 ADDRESS: 900 NORTH POINT UNIT: 400 SAN FRANCISCO CA 94109 CONTRACTOf SUK: PLANT CONSTRUCTION (213)629-8380 CONTRACTONS MAIUNO 626 WH I L S H I R E BL 'WREss: L. A. CA uc,tw: 597075 90 17 I,lsr: 925 LICENSED CONTRACTORS DECLARATION: I hereby affirm d perjury I am Tcwnad under provisions d Chapter 4 (commencing with Section 7000) d Division 3 d the Business and Cade, and y liaenae is In tuff kwcs and eMsct. C NO.: LIC. CLASS: B C. NO.: 9 7 7 EXP: ate: Contractor OWN BUILDER DECLARATION: I hereby affirm under peruty d pajuq that 1 am exempt from the Co Tactors License Law For the F reason (Section 7031.5 Business and Prdessim Code: Any city a county which requires a pwmlt to construct, aper, improve, molah, or repel arty strtrdure, prior to is issuance. also requires the sPDfirand is such permit to Be a signed eteement that he o she 'A licensed pursuant to the provisions d the Contractors License Lew [Chapter g (oommendW with Section 70Do) of Division 3 d the u0ness and P. ions Code] or that he or she is exempt therefrom and the basis for tha alleged exemption. Any violation of Section X31.5 by any applicant for a permit subjects the applicant to a d d penalty of not more Than five hundred ddlan ]5500]]. 0 I, as owner of the property or my employees with wages as their sole compenseion, WM do the work, and the structure is rut Werded or offered for sale (Section 70", Business and Professions Code: The Contractors License Law does not apply io an owner d properly who buids or improves thereon. and who does such work himself or herself or through his or her awn employees, provided that such improvements as not (mended or Blared for sale, 9. however. the 6tMing or improvement is sold within one yaw of Completion, the owner-buker willhave the bunion d provvy he or she did not bald or improve for the purposed vale). 1, as owner d the pmperry. am exdusivehy contrediq with licensed contractors to cortstrw the project (Serlion 7011, Business and Prdeasions Code: The Contractors License Law dose not apply to an owner of Property who balls or improves thereon and who contracts for such projects with a mmrador(s) licensed pursuant to the Comrmors License Law), I am exempt under Section: B. A P.C., for this reason: Dave: Owner. I do hereby certify tree t am aware of sad understand the requirements of C"ornia Health and Salary Code Sections 25505. 25533. end 25531, and that I or any future budd'mg omwarrI will I win not (circb one) need 10 comply with said rate codes end the requirements for e P" for construction or modAcalion hon the Air DwrhhY. Residerdid oordarudion applications we exempt from these previsions. Date: Applicant' WORKER'S COMPENSATION DECLARATION: I hereby atlsm under penally d perjury ons d the toUowbm declaratives: 0 1 have and win maintain a certifirae of mraarh to se04rmae for workers' compensation, as provided Ior by Section 3700 d the Lebo Code, for the performance of the work for which this permit is issued. I have and will maintain waksrs' co npersation insurance. as required by section 3700 at the Labor Code, for the performance d the work for which this permit is issued. My workers' compensation 'insurance carrier and policy number are: carrier: REPUBLIC IND, EXPIRES Policy Number. 07/01/96 'ver sealer need not be compMted if rhe parme ea nor are fSloof or Issaj j I c4ay that in the performance d the work for which this IS . I shaA red airy parer in arty manner so as to E ubject to the wwkeW oomperandon laws d C canna. erid the I shaAd become subject ib the workers' tiom Floris d Section 3700 d the Labor I thug loriti comply provisions. Date: Apel' . W leg: FaRure to datura workers' conpsnvation coverage , And shaft "Joct ire errpteyw to crfmind per rldu and v9 Rnaa W to one hundred Mansard dotter f$laaoaok In n to Ma art of coapanaatbr4 danegaa as provfdad for In . Socrion 3706 of oe Libor Cob, Interest, and &homey'& fen. CONSTRUCTION LENDING AGENCY: I hereby affum under penalty d perjury that Una is a construction landing agency for the performance of the work for which this perms u 'need (Section 3097, Civ. Cj. LENDER'S NAM E - LENDER'S ADDRESS: I cart I have read this dpp -soon and state the the above information is coned. I agree to comply with all city and county odiranoss and §fto laws rlar v to bedding OPmVu bm and hereby aedhove representatives of this my Io enter Lim the aE7n4menli wed property '_r7 '�prrpaeae. GRAIQT WILSON (5151-460P) 1 Dae: Z r 2 3 , % Greer�Fde: Canary-Appicant: Pink-Rmanue: Goklanrod-Assessor CITY OF COSTA MESA — BUILDING PERMIT PERM NO: B 076526 PERMIT NO: B 076526 PLAN CHECK NO: 05075-95 A GOVT: N SUPP: N CONSTRUCTION TYPE: I—FR PERMIT TYPE: STA PURPOSE: ALT JOB DESCRIPTION : 18428 SF T.L. FOR RETAIL SPACE SQ FT: 500,000 CLAIM VALUE: 500,000.00 CALC—VALUE: 500,000,00 GROUP OCC: B-2 / COMMENTS: T,I FOR "CHANEL" Z O N I N G R E Q U I R E M E N T S S E T B A C K S ------------ MAIN BUILDING ---------- ------------ ACCESSORY BUILDING---------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN PARKING REQ• PROV: PARCEL: 41249102 ZNE: C1—S REF NO: PLANNING N TES> INTERIOR ALTERATION TO EXPAND THE EXISTING CHANEL SHOP INTO > THE ADJ SUITE. NO ADDIT SQ.FT, PROP; MEZZANINE IS EXISETING. D E V E L O P M E N T S E R V I C E S R E Q U I R E M E N_T. S ZONING APPROVED BY DATE: J BUILDING APPROVED BY : VCA_ ._ _ DATE:q APPLICATION ISSUED BY: DATE: 14 IE � d4 lE 1t 14 �E #!• �4 �E �E iF lE lE dE ilifr �4 �E �E �E it• iE iF �E iE iE �E �E iE * ori LEGALIZATION:N F E E S U M M A R Y STRUCTURAL SEGMENT:Y BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMTP/RES GRADING PERMIT 2,039,50 SMIP/NON—RES PLAN ISSUE FEE 331.42 f 105.00 BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE TOTALS ---- > 2144.50 0.00 331.42 2475.92 2475.92 ,00 REVENUE DIVISION TOTALS--> COLLECTED: 2144.50 OVER/SHORT: .00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK 2039,50 105,00 *�i(-iF'IFiEiEiFiE*�IfriE�iEi[-iE�1E*aFiFaEiEiE�EiF*if1E�#Ei<•iE�*�*ulEaEirt*1E�E**iEiElFlfdEaE'IE****�♦ElEdfr�E�E;rtif4*IE***�lE***aEiF9E* I N D I V I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST SFC 500000 ALTER BY VALUE COMMERCIAL NOZONE 1.00 500,000.00 END OF FEES • CONSTRUCTION AND PLANNING .APPROVALS Permit # Date Inspector . POOL A APPROVALS Permit #`' Date Inspector 1 . Temporary Electrical Service or Pole 52. Pool & Equipment Location 2, Sol) Pipe•Undrgrnd. 53, Steel Reinforcement 37 Electrical Conduit Utility-Undrgrnd. 54. Forms 4; Efetrical Condvi--Undrgrnd. 55. Efectr'scal Bonding - 5.. Steel Reinforcement 56.' Rough Plumbing & Pressure Test `-6, Electrlca0k-tJFER=Gr3'ed. 57. APPROVAL TO COVER-GUNITE 3,,.Fo6tings ' - -� 58. Electrical Conduit-Undr9rnd. 03. f=oundation = = 59. Gas Pipe, ❑ Undrgrnd., Test 9- Water Pipe-Vpdrgrnd. ' 60, Backwash Lines, P.Trap, ❑ Undrgrnd. 10. Structural Floor System 61- APPROVAL TO DECK }1, Property Sewer (wine & House Connection 62. Backwash & Reeeptor•Final 12. Sewer Cap • 63. Heater & Vent -Final 13. Roof Drains 64, Plumbing System - Final 14, Rough Plumbing- - 65• Electrical -Final 15. Rough Electrical -Conduit 66. Solar System -Final 16, Rough El2ctric Wirirtc 67. Fencing & Access Approval 17. Rough Wiring Sign 68. APPROVED FOFR PLASTERING 18. Rough Electrical:T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning _ F19gEPT,.REQUIREMENT APPROVALS 'r Permit # 20. Rough. Factory: Fireplace _ `-� 21. Ducts, in Structure' - f ` .70. Underground Hydro 22. Ducts; Ventilating : r .,. 71. Product Piping ❑ 6as 00d 23, Gas Pipe Rough &Test 72. Underground Flush - 24. Roof -Framing " - _ _ 73_ Undergrnd. Storage Tank ❑ Gas 0 Oil 25. Roof Sheathing - 74. Overhead Hydro: _ - 26. T -Bar Ceiling (Structdral) & Monocoai 7 757, Ory Chemical _ 27. Frarne,and. Flashing _ _ 76. Dry Stando;pe - 28. Lathing &-Siding 777 FIXED SYSTEM,FINAL' 29. Insulation ! - - 7T� FIRE PREV. FINAL 30. Drywall Nailing :,' :� HEALTA'DEPT. REQUIREMENT 31, Plaster Brown Coat t 7: - ac ' 79, FINAL IISPECTION -. r 32, Electrical Power Meter -Final r ' Bd!FOOD CERTIFICATE ISSUED 33. Final Eiectric - - Ndtes: 34. Finai'Heating & Air Conditioning 35. Final Gas'�ipetest 36. Hood or Canopy 37, Final Factory Fireplace - r -38. Final Pfumbing 39. Water Service -Final 40, Gas Service -Final Y ' 41, Solar Domestic -Final. = 42. Backflow Preventer 43. Backflow lrrig�tion , 44, Landscape Irrigation' System 45. Sound Attenuation 46. Handicap Regulations - 47. FINAL STRUCTURE & BUILDING 48. FINAL PLANNING - �'• 49, Electric Release to Edison 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY No, Date ADDRESS OFIMLD1NG: 3333 BRISTOL ST' UNT: 1500 OWER'SNAMEIFMOn: C.J. SEGERSTROM & SONS FLOOD: AO -38 r"" ADOREss: 3315 FAIRVIEW RD COSTA MESA, CA 92627 546--0110 APPL. SWUNG ADDRESS: ARCHITECT OR ENGINEER; UC. ND.; ARCR. OR ENQ'S ADDRESS: UNT ! cDNTRACTOfismo: PLANT CONSTRUCTION (213)629-8380 CONTRACTOR'S VAluNG 626 WH I L S H I R E BL ADDREs& L. A. CA c. ND.: 597075 9091_7 UNIT: 925 LICENSED CONTRACTORS DECLARATION: I hereby alfim u y rjury Hutt l am under provisions d Chapter 9 (commencing with Section 7006) of Division 3 of the Business endFfollessions Opdo, Apd my We is in full force and affect. C97r%C. NO.: LIC. CLASS: $ �uc.&O... 0 75 EXP:e: �� Contractora=te EA BUILDER DECLARATION: I hereby .1. under penalty of perjury that I am exempt from the Contractors Llowme Law for the following reason (Section 7031.5 Business and Professions Code: Any city or county which requires a permit to constnwt, after, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to his a signed statement that he or she licensed pursuant to the provisions of the Contractors License Law Chapter 9 (commencing with Section 7000) of Division 3 of the eines and Professions Coda) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section ,31:5 by any applicant for a permit subjects the applicard to a eW penalty of not mon than five hundred dopers (.5003. 1. as owner of the property or my employees with wages as their sols compensation, will do the work, and the structure is not intended or offered for sale (Section 7044. Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offend for sale. lf, however, the building or improvement is sold within one year of completion. the owner -builder will have the burden of proving he or she did not build or improve for IM purpose of salej. ❑ I, as owner of the property, am exclusively contracting with licensed *woadnn to wmtrua the project (Section 7044, Business and Professitms Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon and who contracts for such projects with a oodractor(s) licensed pursuam to the Comrectoa License Law). ❑ I am exempt under Settlor: B. 8 P.C„ for this reason; Date: Owner. I do hereby certify that I am aware of and urdentand the requinmens of Caflfornia Health and Safety Code Sections 25505, 25533, and 25534, and that I or any future building occupant will I win not (Circe one) need to comply with said stale codas and the requirements for a permit for oa»tnrction or ffKxkkation from the Air District. Residential oonstruction appiratma aro exempt from Ihess provisions. Dais: Applicant: WORKER'S COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the fo0owkV declarations: ❑ I have and will maintain a certilicate of consent to selfNnsure for workers' uwmDensMicn. as provided la by Section 3700 of the labor Codc for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance. as required by Section 3700 of the Labor Code. for the performance of the work for which this pamul is issued. My workan' Condon insurance carrier and policy number are: Caner: REPUBLIC IND, EXPIRES Policy Number. 07/01/96 tis sectmm need nor be completed r the parmt is for no hundred (S1001 or AM,) L] I certify that in the performance of the work for which this perm ed, I "not ploy any person in any manner so as to boom* subject to the workers' oompensation laws d Calif u+a. that d should became subject to the workers' proovisions off Section 3700 of the Labor Code, I I Orth pity WDVW ro. ,compensation /(AppliraN:ing. Failure to sscurs woman' corgoartsadon coverage Is unLiterM and shaff subjat f an smptoyar to erfrminaf penaillu and civil fines up to orm hundred thousand dollen (SIKO I In addidorr to the cost of ton{oenaaf1or4 damages ea provided for In Secflon 3706 of the Labor Code, fnterrs4 and anomer's face. CONSTRUCTION LENDING AGENCY: I hereby affirm under penalty of perjury that there is a construction landsg agency, for the \performance Of the work for which this permit is issued ($action 30®7, civ. C). LENDER'S NAME: LENDER'S ADDRESS: Y7' 1 have reed Ibis ration end state that Ura above intornhetion a correct. I agree to comply with all city and county ordinances acs ralal'eg !o bnri ig wnatruction end hereby autharixa reprsaenta6ves of Ihia city to star upon the ebovs•rnentloned papery G ANT WILSON Date: 2 — 5 -9 '4" whcs-Building d Safety: Green-Sle: Canary-ApgFcant; Pink -Revenue: Goldenrod-Assesanr CITY OF COSTA MESA — BUILDING PERMIT PERM NO: B 0762$1 PERMIT NO: B 076281 PLAN CHECK NO: N GOVT: N SUPP: N CONSTRUCTION TYPE: I—FR PERMIT TYPE: STR PURPOSE: OTH JOB DESCRIPTION INTERIOR DEMOLITION SQ FT: 20,000 CLAIM VALUE: 20,000.00 CALC—VALUE: 20,000.00 GROUP OCC: M / COMMENTS: DEMOLISH PARTIONS & CEILING FOR CHANEL STORE Z 0 N I N G R E Q U I R E M E N T S S E T B A C K S — MAIN BUILDING ---------- ---------- ACCESSORY BUILDING --------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN PARKING REQ: PROV: PARCEL: 41249102 ZNE: REF NO: PLANNING NOTES> iE dE iE iE iE �E iE 3E iE �E �E iE � * * * * * * 9E dE'aE ;rt � iE iE iF � �E �E �E iE iE frt �F �E �E �E dE dE 9E * dE iE ?tE iE �E �E iF ?✓E � iE iE iE � iE 1E iE }E 1E � �E -IF -IF -IE -IE iE aF i(-� 9E �E �E iE iE �(- iE * iE D E V E L O P M E N T S E R V I C E S R E Q U I R E M E N rT—S v ZONING APPROVED BY DATE: BUILDING APPROVED BY : DATE: APPLICATION ISSUED BY: �c�_ DATE: S p iE��EiEiE�E*�*��*iFiFiEiFiEiEiEiE•*iE � ifdEdE�1E?rtiE*!(* *jF ' LEGALIZATION:N F E E S U M M A R Y STRUCTURAL SEGMEN :Y BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT 207.00 PLAN SMIP4/NOa—RES ISSUE FEE BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE TOTALS ---- > 211.20 0.00 0.00 211,20 211.20 .00 REVENUE DIVISION TOTALS--> COLLECTED: 211.20 OVER/SHORT: ,00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN -CHECK 207,00 4.20 iE iF iE iE iE iE IE iE iE ih iE �E If iF iC• iE iE iE if if iE iE iE iE 1E iE if• 1E * * it * * iE df irk °IE iE iE �E �E #E �E � * >� * lE iE )E •lE')E � �f iF'1F �F �E *'1E 4E 1E #E �E iE ♦'F �E � dE �lE'lE')E �E # � * � dE �E I N D I V I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST SFC 20000 ALTER BY VALUE COMMERCIAL NOZONE 1.00 20,000,00 END OF FEES Oct": il7r.r.. �tONSTRUCTION AND PLANNING 01APPROVALS Permit # Data Inspector POOL ?A J APPROVALS Permit # Date !nspedtor 1. Temporary Electrical Service or,Pole 52. Pool & Equipment Locatioh; 2. Soil Pipe-Undrgrnd. rJ 53. Steel Reinforcement 3. Electrical Conduit Utility -Undfgrpd. 54. Forms A. Electrical Conduit-Undrgrnd. 55. Electrical Bonding -5. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6. Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE 7. Footings _ 58. Electrical Conduit-Undrgrnd. 8. Foundation 59. Gas Pipe, © Undrgrnd., Test 9-. Water Pipe-Undrgrnd. 60. Backwash Lines, P -Trap, O_Undrgrrid. 10. Structural Floor System 61. APPROVAL TO DECK -11. Property Sewer Dine & House Connection 62. Backwash & Receptor -Final 12. Sewer Cap 63. Heater & Vent -Finial - 13. Roof Drains _ 64. Plumbing System - Final 14. Rough Plumbing 65. Electrical -Final 15. Rough Electrical -Conduit 66. Solar System -Final 16. Rough Electric Wiring 67. Fencing & Access Approval 17. Rough Wiring Sign 68. APPROVED FOR PLASTERING 18. Rough Eiectrical•T Bar Ceiling 69, POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning ' FIRE,DEPT„REQUIf EMENT APPROVALS Permit #_ 20. Rough Factory Fireplace `. 21, Ducts•, in'Structure =F 70. Underground Hydro 22. Ducts, Ventilating -. 71. Product Piping © Gas ©Oil 23. Gas Pipe -Rough & Test 72. Underground Flush 24. Roof Framing' 73. Undergrnd. Storage Wank O Gas © Oil 25. Roof Sheathing 74, Overhead Hydro 26, T•Baf Ceiling (Structural) & Nlonocoat 75. Dry Chemical - 27. Frame and Flashing . - _' 76, Dry Stagdplpe _ 28. Lathing Siding , , 77. FIXED SYSTEM FINAL - 29, insulation _ 78. FIRE PREY. FINAL 30. Drywall Nailing HEALTH DEPT, REQUIREMENT 31. Plaster Brown Coat 79. FINAL INSPECTION "' i 32. EiectricaLPosuer Meter -Final 86' FOOD CERTIFICATE ISSUED 33. Finat-Electric Nates: 34. Final HeatingA Air Conditioning• 35, Final Gas Pipe -Test :f 36. Hood or Canopy t 37. Final.Factory Fireplace 38. Final Plumbing 39. Water Service -Final 40. Gas Service -Final 41. Solar Domestic -Final 42. Backflow Preventer 43. Backf tow Irrigation 44. Landscape Irrigation System 45. Sound Attenuation. 46. Handicap Regutations 47. FINAL STRUCTURE & BUILDING 7a� 48. FINAL PLANNING _ 49. Electric Release to Edison _ 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY NQ Date - 'jl71 INSPECTI01 INC. E" '21615 BRISBANE WAY YORBA LINDA, CA 92687 (714) 779-0987 FAX (714) 779-9364 PAG 68-4555 SPECIAL DEPUTY INSPECTORS REPORT Department of Building & Safety City of: 010 T= MESp' Building Permit No. -6n L950-Ao Permit Date Welder Certification No. Job Number Job Identification l —w STFtli7- �Z_ _� _ Addresses 33 %1.S7\-QL <' 1GCA--> General Contractor Rr] 0-rz, i ►2 Uk�1 Address Sub Contractor ►Act-RT\6 iVgg-.l - Address Engineer Address Type of Work: Reinforced Concrete ❑ Masonry ❑ Hi -Tensile Bolting @110"/ Ultrasonic Testing ❑ Fireproofing Welding V Other]NED[,C- ALt Y- R9� Welder Certification No. Welder Certification No. STE - ks-9s Date of Description.•--• Inspection AV -1 L, ]�!in G Q► — . ► • Ms t. , t. r i11 1 BOLTS A1 INIMERRIMAET& "T M .. a L� • l ' _: 11 itW11�a r19 kill DAILY HOURS WORKED Monday Tuesday Wednesday Thursday Friday Saturda Sunday Straight Time Time & Half Double Time All inspection is based on a 4 hour minimum, over 4 hours is an 8 hour minimum. All lab work necessary to complete inspections will be paid by owner, engineer or contractor. CERTIFICATE COMP CE dJy✓`T49a .3W-J-),2Registered Deputy Building InVocibes Certificate Signed by ' I.D. ,o. L-A ,h9 J zA�( has been filed and itstates that the above work was inspected him and complies with the provisions of the Building Code applicable thereto. Approved by: Company: )INSPECTI01 INC. '21615 BRISBANE WAY YORBA LINDA, CA 92687 (714) 779-0987 FAX (714) 779-9364 PAG 168-4555 SPECIAL DEPUTY INSPECTORS REPORT Department of Building & Safety City of: 0-0S '1 MR,sa Building Permit No. 1, 1 LoSd�o� Permit Date Job Number Job Identification 1'1'F—w Sl'R1SL LZ.T1 Address 3 3 3A S;"-6 QHRmFsL General Contractor T�FtN CC�N,5i t2 u C_TI(�4.1 Address Sub Contractor kkL)Eg.T\ 6 -Z Address Engineer _ _Address -- // Type of Work: Reinforced Concrete (3 Masonry ❑_ / Hi -Tensile Bolting @, Ultrasonic Testing ❑ Fireproofing 911,Welding Ind' OtherW�n(-,C- A,L Welder Certification No. Welder Certification No. . Inspected Date of E- ■!Inspection 1 a i)Ct C .1 1 i t i l tS PrT SMIL fig LAODWO 65► a _ i 1 ► r t} 61 a1.- mss. . DAILY HOURS WORKED Monday --Tu—esday Wednesday Thursday Frtda aturdaSunday Straight Time Time & Half Double Time All inspection is based on a 4 hour minimum, over 4 hours is an 8 hour minimum. All lab work necessary to complete inspections will be paid by owner, engineer or contractor. CERTIFICATE COMP CE c�t✓ ��d 3b�Ua Registered Deputy Building BWectot's Certificate Signed by 1 I.D . No. has been filed and it.states that the above work was inspectedIcy him and complies with the provisions of the Building Code applicable thereto. Approved by: Company: ADDREss aF AUILDING: 3333 BRISTOL ST UNIT: 1500 01 wr9NAMEIFm":C.J. SEGERSTROM & SONS FLOOD: AO -38 ADDREss:3315 FAIRVIEW RD OSTA MESA, CA 92627 546-0110 APPL.iWUNG ADDRESS: ARCHITECT OR BmEER:B RAND ALLEN UC. NO: C-99999 ARCH. OR ENG.'S ADDRESS: 900 NORTH POINT UNIT: 400 SAN FRANCISCO CA 94109 COMACTOWSNAME:WILPAC PLUMBING INC (310)523-9300 calmAcrorrsuAiLING14 2 2 5 S HALLDALE AV ADams:GARDENA CA mw: 193129 90249 UNIT: LICENSED CONTRACTORS DECLARATION: I hereby aff irm realty of perjury that am licensed under pravbions d Chapter 9 ( e with Section 7000) d Division 3 of the BusiCade, and Goensa is in butt force and affect. C 0.06547 UC.Cu+ss:C c•N•:1931 9 EXP: 07/96 C O ER BUILDER DECLARATION: l hereby affirm under penely of perjury that i am exempt from the Contractors License Law for the dlowinp reason (Sedicn 7., r. Business and Profeasiom Cods: Arry Wy or county which requires a perms to construct. alter, improve, demolish, or repair any structure, prior to its issuance. also requires the appficant for such permit to file a signed statement that he or she s boomed pursuant to the provisions of the Contractors license law (Chapter 9 (cammancing with Section 7000) of Division 3 of the ursiness and Professiom Code] or that he or she is exempt therefrom and the basis for the alteQed exemption. Any violation of Section 031,5 by any applicant for a permit subjects the applicant m a civil penalty of nol mora than Five hundred dollars [5500]). ❑ I, as owner of the property or my employees with wages as their sob compensation, will do the work, aid the structure is riot intended or offered for sale (Section 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees. provided that such improvements are ria intended or altered for sale, 9, however, the building or impruvamem is sold within one year of oomplation, the owner -builder will have the burden of proving he or she did not build or improve for the purpose of sale). ❑ I. as owner of the property. am exclusively nontrading with licensed contractors to conatrud the project (Section 7044, l3usirrms and Professions Code: The Contractors License Law does not appy to an owner of property who builds or improves thereon and who such contracts for projeds with a contrador(s) licensed puauard Io the Contractors License Law). , I am exempt under Section: B. d P.C.. for this reason: Date: Owner: I do hereby certify that I am aware of and understand the requirements of Cal7onnia Health and Safety Code Sedum 25505, 25533. and 255534, and that I or any future buildup occupant will l wit not (circle ane) need to comply with said state codes and the requirements for a permit for construction or modification frau the Air anagemera District. Reaidentiel axwnswon appicstiom am exempt from these provislom. Date: Applicant: WORKER'S COMPENSATION DECLARATION: I hereby affirm under penuetty of perjury one of the following ded"lons: Q I have and will maintain a certificate d consent to saMtinsuhe for workers' compensation, as provided for by Section 3700 of the labor Code, for the pedomw" of the work for which this parmd is issued. _ n I have and writ maintain workers' compensation insurance, as required by Section 3700 d the Labor Code, for the performance of the )[ work for which this permit is issued. My workers' oompensetion insurance Tamer and policy number are: carrier. CALIF IND EXPIRES Policy Number: N_. Ids section need not be compered i rte permit a for are hundred dafens [S Pool or ess.f h L] I candy that in the performance d the work for which this rt issued. I shall rid ern cry parson in any manner so as to became subject to the workers' compensation laws ol agree the Q became subject to the worlmrs' canpensation p ions o So cion 3700 d the Labor , I f ' h campy t prwisians. Appi ate: r 7+ Lug: Failure to secure worlrers' compansatfon coverve Is unlawful, and shells an errtplgrr to crlmfnar panatdes end vl! lfries up to oris hundred peusand dollars W010WA ler addition to the cwt of comperlsafbR demaPse es pmvldsd for In Sactlon 3706 of tM Lsbor Curds, lrtenest, and artomey'a lass. CONSTRUCTION LENDING AGENCY: I hereby affirm under penally of perjury that there is a aauuudion larding agency for the performama of the wok for which this permit is issued (Section 3097, Civ. C)• LENDER'S NAM E_ - LENDER'S LENDER'S ADDRESS: I candy that I have read this apps cs0on and stale that the above information is correct. I agree to comply with an city and axway ordinances and Stade laws relating to building construction and hereby authorize representatives of this cityrto enter upon the above-mentioned property for inspection purposes. l'\ L?�sN NAVARRO Date: %1 7 (5151-46.WP) White -Building L Safety; Green -File; Cenarp4pplcaa; Pink -Revenue; Goldenrod-Asaeaaor F L P P Z B A •1f L CITY OF COSTA MESA — BUILDING PERMIT PERM NO: P 077243 ERMIT NO: P 077243 PLAN CHECK NO: N GOVT: N SUPP: Y ONSTRUCTION TYPE: I—FR PERMIT TYPE: PLU PURPOSE: ALT OB DESCRIPTION SUPPLEMENTAL TO P-76602 SQ FT: LAIM VALUE: CALC—VALUE: GROUP OCC: M / OMMENTS: T.I FOR "CHANEL" / REF B-76526 Z O N I N G R E Q U I R E M E N T S S E T B A C K S -------------MAIN BUILDING ---------- --------- ACCESSORY BUILDING--------- RNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN EFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN ARKING REQQ• PROV: PARCEL: 41249102 ZNE: REF NO: LANNING NOTES> **iEiEiEiE��3EiEiEiiiE**•1E•1EiEiEiFfEiEif•iF**iEiFiE��iEiEiE•1EiFiFfEfEiF**•}EiEiEiEiFil iEiEiEie**�iEiF9E���(•�iE*iEiE*�*iE�iE9E�iE��� D E V E L O P M E N T S E R V I C E S' R E Q U I R E M E N T S ONING APPROVED BY F' DATE: UILDING APPROVED BY DATE: PPLICATION ISSUED BY: r DATE: •IF iF iF iE iE * iE'E 44.1E iF �E iE * * * � fE * � if• ii'r�� * * �(• * •IE �E �E � •IE �E 1E �F EGALIZATION:N F E E S U M M A R Y STRUCTURAL S GMEN :N BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING ERMIT 7.00 rl• 25% SMIP/NON—RES LAN SSUE FEE 10.00 -, UILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE OTALS ---- > 7.00 10.00 0,00 17.00 17.00 .00 EVENUE DIVISION TOTALS--> COLLECTED: 17.00 OVER/SHORT: ,00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK 17.00 4 i4*iEdUiEiEfEiF**•}E•1EjE�EiE�EiEiE�iE�'IE�EiEiElEiEiE*�4*�4�EiEi41E#EriE�E♦fdEiE�E�iE♦4�(•*�**iE�E'IEiE*1F ii i4*iFl4 •KriE*�•1E*�iE**iF*iE�F1E* I N D I V I D U A L,�4 F E E B R E A K D O W N YPE QTY D E S C R I P T I O N UNIT COST TOTAL COST LU 1 SINKS, SERVICE / MOP/_ 7.00 7.00 END _OF FEES r. CONSTRUCTION AND PLANNING APPROVALS Permit # Date Inspector POOL ` A APPROVALS Permit # Date Inspector 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. 54. Forms 4. Electrical • Conduit-Undrgrnd. 55. Electrical Bonding - 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6. Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE 7. Footings 58. Electrical Conduit Undrgrnd. 8. Foundation = = 59. Gas Pipe, 0 Undrgrnd., Test 9. Water Pipe-Undrgrnd. 60. Backwash Lines; P -Trap, Cl Undrgrnd, 10. Structural Floor System 61. APPROVAL TO 6ECK 11. Property Sewer Line & House Connection 62. Backwash & Receptor -Final 12. Sewer Cap - 63. Heater & Vent -Final 13. Roof Drains 64. Plumbing'System - Final 14. Rough Plumbing_ [O 65. Electrical -Final 15. Rough Electrical -Conduit 66. Solar System -Final 16. Rough Electric Wiring 67. Fencing & Access Approval 17. Rough Wiring Sign 68. APPROVED FOR PLASTERING 18, Rough Electrical -T Bar Ceiling 69, POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air, Conditioning - FIRE DEPT. REQUIREMENT APPROVAL'S- Permit # 20. rough Factory Fireplace 21. Ducts, in Structure _ 70. Underground Hydro 22. Ducts, Ventiiatfng. 71. Product Piping O Gas Q OiI 23. Gas Pipe- Rough & Test 72. Underground Flush 24. Roof Framing 73. Undergrnd, Storage Tank © Gas ❑ Oil 25. Roof Sheathing 74. Overhead Hydra 26. T -Bar. Ceiling (Structural) & Monocoat 75. Dry Chemical 27. Frame and Flashing - 76. Dry Standpipe . 28. Lathing & Siding 77, FIXED SYSTEM FINAL 29. Insulation' 78: FIRE PREV. FINAL 30. Drywall Nailing HEALTH DEPT. REOUIREMENT -131. Plaster Brown Coat 79, FINAL INSPECTION - 32. Electrical Power Meter -Final 80: FOOD CERTIFICATE ISSUED - 33. Final Electric•` f, Notes: r T 34. Final_.Heatiog & Air Conditioning 35. Final Gas Pipe -Test t 36. Hood or Canopy ± 37. Final Factory Fireplace 38. Final Plumbing 39. Water Service -Final 40. Gas Service -Final , 41. Solar Domestic -Final 42. Backflow Preventer 43. Backflow Irrigation 44. Landscape Irrigation System 45. Sound Attenuation r' ` - 46. Handicap Regulations 47, FINAL STRUCTURE & BUILDING - 48. FINAL PLANNING - 49. Electric Release to Edison 50.. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY No Date - ADDRESS OFBUILDM; 3333 BRISTOL ST UNIT: 1500 OMFrSN.WEIrKN011ift C.J. SEGERSTROM & SONS FLOOD: AO -38 ADDRESS: 3315 FAIRVIEWRD' - COSTA MESA, CA 92627 546-0110 APDL. MAILING ADDRESS: ARCHITECT ORENGMEER: BRAND ALLEN mw.: C-99999 ARCH, oRENG:sAMSS: 900 NORTH POINT UNIT: 400 SAN FRANCISCO CA 94109 CONTRACTDR'SNAME: WESTERN AIR & REF (714)851-5013 CONTRACTOR'SMAUZ 1821 MC GAW AVENUE ADDMS: IRVINE CA LIGNO.: 433668 92714 UNIT: LICENSED CONTRACTORS DECLARATION: I hereby affirm under penaky of perjury that I am I'x:ensed under provisions of Chapter 9 (commencing with Section 7000 of Division 3 d the Business and Professions Code and my ioense is In full force and effect. Y c. o.: 015 615 uc. cuss: C-20 SSC- No.: 413668 EXP: 00/00 Die : Contractor: - ^� BUILDER DECLARATIDN: I hereby strum under penalty of perjury that f am exampr from the Contractors ilea en3 Law for the - reason (Section 7031.5 Business and Profession Code: Any city a county which requires a permit to construct. alter. improve, olish, or repair any structure, prior to its issuance, also requires the applicant for such permi to file a signed statement that he or she censed pursuant to the provisions d the Contractors License Law [Chapter 9 (commencing with Sedion 7000) of Division 3 d the iriness and Professions Coda] a that he a she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 1.5 by any applicant for a Permit subjects the appticanl to a civil penalty of not more than five hundred dollars [SSGo]). I, as owner of the property or my employees with wages as their sole compensation, will do the work, and the slnwture is not intended or offered fof We SSeUion 7644, Business end Professions Code; The Cantradors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her awn employees, provided that such improvements we not intended or offered for safe. ff, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving he or she did not build or improve for the purpose of sale). 0 I, es owner of the Properly, am exclusively conlractng with licensed contractors to construct the Project (Section 7044. Businms and Profession Code: The Contractors License Law does not apply to an owner of properly who buitCe or improves Iherean and who contracts for such projects with a cauuractor(s) licensed pursuant to the Contractors License Law). I am exempt under Section: B. d P.C., for this reason: Date: Owner: I do hereby certify that I am aware of and understand (fie requirements of California Health and Safety Code Sections 25505, 25533, and 25534, and that I or any future building occupant will! wit no( (circle one) need to comply wkh said state codes and the requiremer>ts for a permit forconstruction or modification frau the A'r�anagemenl Dialrid. Residential construction appitano s are exempt from these provisions. Date: Applicam: WORKER'S COMPENSATION DECLARATION: I hereby aLPom under penalty of perjury one of The following declarations: 1 have and will maintain a cen'dicate d consent to seff-insure for workers' compensation, as provided for by Section 3700 of the labor Cade, for the performance of the work for which this permit is issued. Q I have and will maintain workers' compensation insurance, as required by Section 3700 of the labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance Cartier and policy number ars: Carrier. Policy Number: I. secfiom need no, be completed d the permit is Au one hundred dollars fSi00j cr IBM.) I cantly lhal in the perlamance d the work for which this permit is issued, I shall not employ any person in any manner so as to subject to the workers' oompenazion laws of Caldomis, and agree that if I should became subied to the workers' r Pensatias pravisi0ns of Section 3700 of the Labor Code. I hwtth oompfy with hese proviaicns. App. t: —Q �Waminp: Falfure to secure Ivonters' companse8on revenge Is unlawful, and shalr subject an employer to crfmfnal a and Ivft Rnu up to ons hundred thousand da/firs ($104000), In addltlon to the cost of compsnsaHor4 4orrines as pmvldsd for In Socdon 3706 of the Labor Code, Interest, and etfofney's fess. CONSTRUCTION LENDING AGENCY: I hereby affirm under penalty of perjury that there is a construction landing agency for the performance of the work for which this permk is issued (Section 3097, Civ. C). LENDER'S NAME: LENDER'S ADDRESS: I oenify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction and thereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. NINA S EL L EC K (5157-46.WP) Whda-8hOeg ; OrserrFile; Canary -Applicant; Pink -Revenue; Goldenrod -Assessor CITY OF COSTA MESA - BUILDING PERMIT PERMIT NO: M 077016 PLAN CHECK NO: N CONSTRUCTION TYPE: I -FR PERMIT TYPE: MEC JOB DESCRIPTION : 18428 SF T.I. FOR RETAIL SPACE CLAIM VALUE: CALC--VALUE : PERM NO: M 077016 GOVT: N SUPP: N PURPOSE: ALT SQ FT: GROUP OCC: B / COMMENTS: T.I FOR "CHANEL" REF: B-76526 Z O N I N G R E Q U I R E M E N T S S E T B A C K S ---------------- MAIN BUILDING ---------- --------- ACCESSORY BUILDING---------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN PARKING REQ• PROV: PARCEL: 41249102 ZNE: REF NO: PLANNING N TES> � iE iF � aE � iE � iE )E IF � iE iE iE * 1E iE lE iF ?'E � iE � dE � � i(''lE'1E �E iE'1E �E iE iE-IE lE iF * �E if iF iE dE � iE iE iE iE IE iE if; iF i(- iE �E -iE iE dF iF -1F iF -1F * iE iE * � iE iE 9E iF iE �E �E � * iE D E V E L O P M E N T' S E R+V I C E S R E Q U I R E M E N T S ZONING APPROVED BY �� DATE: BUILDING APPROVED BY : r DATE:/ APPLICATION ISSUED BY: �� DATE: C/ LEGALIZATION:N F E E S U M M A R Y STRUCTURAL SE.MENT:N ,0 ", BLDG PMT PLUMBING ELECTRsIC MECHANIC FIRE SMIP/RES GRADING PERMIT Y 5`3:50 {a 25% SMIP/NON-RES PLAN+ r �� - ISSUE FEE " 1.5 .Z0 BUILDING -DIV-> PERMIT ISSUE PLAN -CHECK' TOTAL PAID DUE TOTALS ---- > 53,50 15.00 '„ 0.00 68.50 68.50 .00 t J REVENUE DIVISION TOTALS--> COLLECTrED: . 'V 68.50 OVER/SHORT: .00 BLDG PMT PLUMBING ELECTRIC MECHANIC !` FIRE SMIP/TOT GRADING PLAN—CHECK 8% 5 0 BE iE- iE iE 9E * * * * ii 1F 9F 1E iF ;E � i6 -hE iE * * � 3E )F iE it• iE * � iF iF 1E iE i6 t4 iE �E IE !E iE iE"1E �')E'K-')F 3E iE fE iE �(• iE � � �E i'F � BE iF "lE iE IE f# iE iE iE iE if• ii iE � it• * * iE i� iF � I N D I V I D U A L-� .r F E E' 1 B R E A K D O W N r 1/ TYPE QTY D E S C R I P T I ON { UNIT COST TOTAL COST MEC 3 REPAIR/ALT COOLINGn.UNIIT/SYS W/CNTLS 9.00 27.00 MEC 2 VAV BOX i` 1,1 (4 r', 6.50 13.00 MEC 1 VENTILATION FAN CONN --T`6 SINGLE DUCT 4.50 4.50 MEC 2 FIRE DAMPERS I., 'It/ �_ % 4.50 9.00 END OF FRE-9- o RE-9-• J ?CONSTRUCTION AND PLANNING '� �' APPROVALS Permit#. Date Inspector POOL "r - 4 r rA., APPROVALS Permit #-` Date Enspector vi. Temporary Electrical Service dr i? !e 52. Pool & Equipment Location :� - 2. Soil Pipe-Undrgrnd. �� 53, Steel Reinforcement 3. Electrical Conduit ULilitV-U dr r • 54. Forms •} 4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test , 6• Electrical LIFER Grnd. 57. APPROVAL TO COVER-GUNITE 'I 7. Footings 58. Electrical Conduit-Undrgrnd. r 1 8, Foundation 59. Gas Pipe, ❑ Undrgrnd., Test A . Water Pipe-Undrgrnd. 60, Backwash Lines, P -Trap, 0-6ndrgrnd. 1f1. Structural Floor System 61. APPROVAL TO DECK 11, Property Sewer Line & House Connection 62, Backwash & Receptor -Final 12. Sewer Cap ! '; 63. Heater & Vent -Final 13. Roof Drains �� 64, Plumbing System - Final ; 14. Rough Plumbing-Final65. Electrical 15. Rough Electrical -Conduit 66. Solar System -Final i 16, Rough Electric Wiring 67. Fencing & Access Approval \ _' 17. Rough Wiring Sign 68, APPROVED FOR PLASTERING 18. Rough Electrical -T Bar Ceiling 69, POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit # 20. Rough Factory Fireplace 21. Ducts, in Structure 70. Underground Hydro 22. Ducts, Ventilating 71, Product Piping ❑ Gas ©Oil 23, Gas Pipe -Rough & Test 72, Underground Flush 24. Roof Framing 73. Undergrnd. Storage Tank 0 Gas 0 Oil 25. Roof Sheathing 74. Overhead Hydro 26, T -Bar Ceiling (Structural► & Monocoat 75. Dry Chemical 27. Frame and Flashing 76. Dry Standpipe , 28. Lathing & Siding 77, FIXED SYSTEM FINAL 29. Insulation 78. FIRE PREY. FINAL 30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat 79. FINAL INSPECTION 32. Electrical Power Meter -Final 80, FOOD CERTIFICATE ISSUED 33. Final Electric Notes: 0_2M_12S 161- 34. Final Heating & Air Conditioning 35. Final Gas Pipe -Test 36. Hood or Canopy 37• Final Factory Fireplace ' 36. Final Plumbing 39. Water Service -Final 40. Gas Service -Final 41. Solar Domestic -Final 42. Backflow Preventer 43. Backflow Irrigation 44. Landscape Irrigation System - 45. Sound Attenuation 46. Handicap Regulations 47. FINAL STRUCTURE & BUILDING 48. FINAL PLANNING 49, Electric Release to Edison 50. Gas Release to Southern California Gas Co - �- 51. CERTIFICATE OF OCCUPANCY No Date . ADDRESS OF BUILOM; 3333 BRISTOL ST' OwNEFrS�&MEIF.yX"; C ,,J, S£GERSTROK� fir,, SONS ADUREss:3315 FAIRVIEW RD :OSTA MESA, CA 92627 546-0110 ADPL. IWUNli ADDRESS: War: 1500 FLOOD: AO -38 ARChrTECT OR ENGINEER: BRAND ALLEN UC. No.: C-99999 ARCH. OR M's ADDRESS: 900 NORTH POINT UNIT: 400 SAN FRANCISCO CA 94109 CONRACTOR'SNAME:WILPAC PLUMBING INC (310)523-9300 coKmACTDR'SYUUND 14225 S HALLDALE AV ADDREss:GARDENA CA ucNo: 193129 90249 UNT: LICENSED CONTRACTORS DECLARATION: I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 70130[ of Division 3 of the Business and Professions Code. and my Rceme is in full force and affect. CITY UC. NO.• 0 C 4p�719 L1c. cuss: C 36 UC. NO.• 19 3 EXP: 07/96 Dale: .Z IJ ! Contractor —19 C14111-1 OWNER BUILDER DECLARATION: I hereby affirm under penalty of [het I am exempt lrom the Contractors License Law for the following reason (Section 7031.5 Business and Professions Code: Arty city «oounly which requires a permit to oonstnut, after, improve, demolish, or repair any alrumure, prior to its issuance, also requires the applicant for such permit to file a signed statement Ihat he or she is licensed pursuant to the provisions ol the Contractors License Law [Chapter 9 (commencing with Section 7000) of Division 3 of the lusiness and Professions Code] or that he or she is exempt therefrom snd the bass for the alleged exemption. Any violation of Sedion 'W1.3 by arty applicant for a permit subjects the applicant to a civil penalty of not more than five hundred ddfaro (Mi). I, as owner of the properly or my employees with wages as their sok compensation, will do the work, and the structure is not intended or offered for sale (Section 7D44, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees. provided that such improvements ate nal intended or offered for sale, a, however, the building or improvement is sold within one year of oompWion, tiro owner -builder will have the burden of proving he or she did not build or improve for the purpose of said). I, as owner of the properly, am exclusively contracting with licensed contractors to construct the project (Section 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves. thereon and who contracts for such projects with a oomractor(s) licensed pursuant to the Contractors License Law), l am exempt under Section: B. E P.C., for this reason: Date: Owner. I do hereby certify that 1 am aware of and understand the requirements of Cal'loms Health and Safety Cade Sedicm 25505.25533. and 25534, and that f or any future building ooxtperrt will I will ns. (circle one) need to comply with said state coda and the requirements for apermit (Or 0onehuctionormodificalionfromlheAir agement District. Residential construction applicetionaareexemptfromthese provisions. Dale: Applicant: WORKER'S COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following deckmions: I have and will maintain a certitica a of consent to aeltminaure for workers oomponswion, as provided for by Section 3700 of the Labor Code, for the performance of Bre work for which this permit is issued. I he" and will maintain workers' oompensation insurance, as required by Sedion 3700 of the Labor Code, for the performanos of the work for which this penmh s issued. My workers' compensation Insurance carrier and policy number are: Carrier:EXPIRES Policy Number: 05/01/96 his section treed nor be completed Y the permit is for one hundmil dollars (S100) or Jess.) I.J I certify that in the performance of the work for Llwch this permit is iss , I shell mol any person in any manner so ea to become subject to the workers' compensation fewe of Caiiloms, agree that H I b become ntbject ro the wodrers' coon ion�ilons/d Section 3700 of [hs Lab« Cade. I shall! h cion[yM.wit/h� provislom. Date: ! `� Applicant: �� 1 Warnings: Fe lust to secure woman' compensadon coverspe is unhwhd, and shall subjscf fn sntployer M crltrstrre7 pensfdas and civil Ones uP to arta hundred lhouasnd dothm (S1040D4 to adldldon to the Cost of cornpensatlon, darnapas as pmvtdsd for In Section 3706 of the Labor Loot, Intarau, and artomay's fess. CONSTRUCTION LENDING AGENCY: I hereby affirm under penalty of perjury that there is a Construction lending agency for the performance of the work for which this permit is issued (Section 3097, Civ. C). LENDER'S NAME: LENDER'S ADDRESS: I cerlily, that I have read this application and state that the above information is correct. F agree to comply with all dry and county ordinenan and state laws relating to bWding oxm uction end hereby authorize representatives of this city to enter upon the above•menliorrod property for inspection purposes. S EN PACINI / Print Name q � L_ Date: 7& Signature of OwnerlAgentlApphcantlContraetor (515148.WP) Whits -Building & Safety; Careen -Fila; Conary -Applicant; Pink -Revenue; Gddentod-Assessor CITY OF COSTA MESA — BUILDING PERMIT PERMIT NO: P 076602 PLAN CHECK NO: N CONSTRUCTION TYPE: I—FR PERMIT TYPE: PLU JOB DESCRIPTION : 18428 SF T.I. FOR RETAIL SPACE CLAIM VALUE: CALC—VALUE: PERM NO: P 076602 GOVT: N SUPP: N PURPOSE: ALT SQ FT: GROUP OCC: M / COMMENTS: T.I FOR "CHANEL" I REF B-76526 Z O N I N G` R E Q U I R E M E N T S S E T B A C K S ------------ MAIN BUILDING ---------- --------- ACCESSORY BUILDING---------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN PARKING REQ: PROV: PARCEL: 41249102 ZNE: REF NO: PLANNING NOTES> > NEiFiFiFiENF9EiFiFiEiEiEiE*�1E*ii•*iEiEiE)E�1EiE�*jEiE�iEiF****1E*?✓E*�E�E♦Fi6if�*iFiEiE�iFiEiFiElFiFiEi4iE*bE*iE*�E�E�fi��****�EiE*iE y D E V E L O P M E N T S E R V I C E S R E Q U I R E M E N T S ZONING APPROVED BY 1' DATE: BUILDING APPROVED BY : 1 DATE: APPLICATION ISSUED BY: DATE: `243-5 �E �E fE iE iE• � �E i6 iF iF IE ?aF ♦E >�'!E'!F iF NE iE � t>E iF * if � iE iE iE )E * NE iE iE � LEGALIZATION:N F E E S U_ M M A R Y STRUCTURAL SEGMENT:N 4. - BLDG PMT PLUMBING ELECTRIC .MECHANIC FIRE SMIP/RES GRADING PERMIT 21.00 25% SMIP/NON—RES PLAN '"71 ( '� ISSU£ FEE 20.00 BUILDING—DIV—> PERMIT ISSUE PLAN -CHECK TOTAL PAID DUE TOTALS ---- > 21.00 20,00 '0.00 41.00 41.00 .00 REVENUE DIVISION TOTALS--> COLLECTED':- 41.00 OVER/SHORT: .00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK 41.00 r.' .4'"!E iF iE NE iE iE iE iE * 1E'lE � iE i[• iE 9E !F iE iE !E iE iE � 9E iE'ltF ii iE iE iE ;>E iE iE it• dE(9E * �ELif * � * fE 1E * iE !E if• �E iE iF � i(• iE'lE;>F iE iE'lE it• iF if• iE iE * iE * iE � cit iE iE f E iE jE �E 1E �E iE I N D I V I D U A LA. F E£ B R E A K D O W N r TYPE QTY D E S C R I P T I O -N UNIT COST TOTAL COST PLU 1 DISHWASHER '� r ' A 7.00 7.00 PLU 1 SINK, KITCHEN ' 7.00 7,00 PLU 1 WATER HEATER AND/OR'•VENT! 7.00 7.00 END OF FEES ' t CONSTRUCTION AND PLANNING ,-APPROVALS Permit # Date Inspector POOL A APPROVALS Permit # Date Inspector 1. Terriporary Electrical Service or Pole ,2, 52. Pool & Equipment Location Soil Pipe-Undrgrnd, 53, Steel Reinforcement 3. Electrical Conduit UjiiitY•Undrgrnd. 54. Forms 4. Electrica! Conduit-Updrgrnd. 55. Electrical Bonding 5- Steel Rei6fdrOjment 56, Rough Plumbing & Pressure Test 6_F Electrical -.LIFER end. 57. APPROVAL TO COVER-GUNITE 7. Footings - 58. Electrical Condti{C Undrgrnd. ;8. Foundation_ 59. Gas Pipe, 0 Urjdrgrnd., Test S. Water Pipe Undrgrnd, 60. Backwash Lines, P -Trap, © Undrgrnd. t-5. Structural Floor System _ 61, APPROVAL TO DECK 11. Property Sewer Line.& House Connection 62. Backwash & Receptor -Final 12. Sewer Cap 63. Heater & Vent -Final ` 13. Roof Drains - 64, Plumbing System -Final 14. Rough Plumbing- 65. Electrical -Final 15. Rough Dectrical-Conduit ., 66. Solar System Final 16. Rough Electric Wiring 67, Fencing & Access Approval 17. Rough Wiring Sign _ 68. APPROVED FOR PLASTERING ' 18. Rough Electrical -T Bar Ceiling 69, POOL/SPA SYSTEMS FINAL 19. Bough Heating & Air Conditioning- _ - FIRE DEPT. REOUIREMENT APPROVALS --4.- Permit # - 20. Rough Factory Fireplace - " 21. Ducts, in Structure 70. lUnderground Hydra 22. Ducts, Ventilating 71. Product- Piping ©'Gas ©Oil 23. Gas PEpe Rough & Te5t - T - 72. Underground Flush 24. Roof Framing 73. Undergrnd. Storage Tank' 0 Gas ❑ Oil 25. Roof Sheathing ,r 74:' Overhead Hydro_ 26_ T-Bar.Ceiling (Structural) & Monocoat 71 Dry Cheirlicai - _ 27. Frame and Flashing } 76. Dry Stan ipe - 28. Lathin 8c Siding 9 g 7n FIXED SYSTEM'FrNAB - . 29. Insulation. s 7$. FIRE RREV. FINAL r 30. Drywall Nailing ' -Hf ALTH DEPT. REQUIREMENT -.31. Plaster Brown -Coat_ ' 79. FINAL INSPECTIQN -32. Electrical Power Meter -Final r 80:'F000 CE RTIFI.CATE ISSUED= 33. FinaFElectric- 34. Final 1leating&Air GonJitioning ^ 35. Final Gas Pipe,Test- +r ` Notes - f/Lt}_ � 7 24- ,tet -lam r rr -36. Hood or Canopy 37. Final Factory Fireplace } 38. Final Plurribing- 39. Water Service -Final 1 4 ? 40. Gas Service -Final -41. Solar Domestic -Final- 42. Backflow Preventer- 43. Backflow Irrigation 44. Landscape',467 atior"system 45. Sound Attenuation 46. Handicap Regulations 47. FINAL STRUCTURE & BUILDING " 48. FINAL PLANNING 49. Electric Release to Edison « 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY No. Date ADDRESS OF aurLDM: 3333 BRISTOL ST OwRI:R'SNAMEIFKNOm C , J , SEGERSTROM & SONS ADDREss: 3 315 FAIRVIEW RD =OSTA MESA, CA 92627 546-0110 APPL.MAIUNG ADDRESS: uNT: 1500 FLOOD: AO -38 AM]TECTORemm: BRAND ALLEN UC.NO_ C-99999 ARCK OR EM'S ADDRESS: 900 NORTH POINT uNT: 400 SAN FRANCISCO CA 94109 oanRawsKAUE: WILPAC PLUMBING INC (310)523-9300 cONTRACT01TSmmm 14225 S HALLDALE AV Am m. GARDENA CA „c,,,o,; 193129 90249 UNT: LICENSED CONTRACTORS DECLARATION: I hereby aff'sm under pendty of perjury that I em licensed under provisions of Chapter a (commencing with Section 7000) of Division 3 of the Business and Prolassions Code. and my Ibsnse Is in full force and gilled. c / m C. NO..: 6 5 4L�7%9� uc. cLAsa: C 3 5 uo.`No.: 193129 EXP: 07/96 e: d `V Contractorwit ) . O 14ER BUILDER DECLARATION: I hereby atflrm under penalty of penury ihC I am exempt from the Contractors License Lew for the tallowing reason (Sedion 7031.5 Susinass and Professions Code: Any city or county which requires a permit to ooneWct, eller, improve, demolish. or repair any structure, prior to ifs issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Conlradors License Law (Chapter 9 (commencing with Section 7000) or Division 3 of the lusiness and Professions Codej or that he or she is exempt therefrom and the bass for the alleged exemption. Any violation of Section '031.5 by any applicant for a Permit subjects the applicant to a civil penalty of not mora than rive hundred dollars (5500]). ❑ I, as owner of the properly or my employees with wages as their sale compensation, will do the work, and the slnrcturs is not intended or offered for site (Section 7044. Business and Professions Cade: The Contradom License Law does not applyto an owner of property who builds or improves theraon, and who does such work himseH or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. lf, however, the building or improvement is sold within one year d completion, the owner -builder will have the burden of proving he or she did not build or improve for the purpose of sake). ❑ I, as owner of the property, am exclusively contracting with licensed contractom to construct the project (Section 7044, Business and Professions Cade: The Contractors license law does not apply to an owner of property who builds or. improves thereon end who contracts fo such projects with a conlradorjs) licensed pursuant to the Contractors License Lawiv ❑ I am exempt under Section: B. 8 P.C.. for this reason: f �: Date: Owner: I do hereby certify that I am aware of end understand the requirements of California Haab and Safety Code Sections 25505, 25533, and 25534. and that I or any future building occupant will I will not (circle one) need to comply with said state codea and the requirements for a permit for construction or modification from the Airu�atyMaanaaernmiDistrict.Residentialmnsirudionapplicoionsamexemptfromthese provisions. Data: Applicant: WORKER'S COMPENSATION DECLARATION: I hereby affirm under penalty of perp" one of the following declaration: ❑ I have and will maintain a olleffnam of consent to seltansure for workers' compensation. as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and wii maintain wodrare'tanpertsation insurance, as required by Seam 3700 of the tabor Code, for the performance of the work for which this permit is issued, My workers' CarriBr. iia V i carrier and puff y member are: " EXPIRES Policy Number; 05/01/97 his section need cwt be crompWad 7 rho permit is kr one hundred doflars jS 1001 or lass.) I cenify that in the performance of the work for which this permit in owed. I shag not employ any person in any manner so as to become subject to the workers' compensation Laws of California. and agree that 4 1 should subject to the workers' rompensa fon q`arvis� ions of Section 3700 of the Labor Code, I shall fonhwdh comply with those provish G'Ing.- !1J 1�! ' Applicant: �i!} i.. �( Fafhrn to secure workers' compsrrsatfon coverage Is usdawful, and sluff sub*1 an !oyer to crfnrfraf Penalties and civil linea tip to one hundred thousand doffiers (!104000); In addfdor to the coat of contperisaWnt, darnagas as prodded for In Section 3706 of the Labor Cools, Interest, end attorney's Isar. CONSTRUCTION LENDING AGENCY: I hereby affirm under penetty of perjury that there is a construction lending agency for the performance of the work for which this permit is issued {Ssdion 3097, Civ. C). LENDER'S NAME: LENDER'S ADDRESS: I certify that I have read this application and stale that the above information is coned. I agree to comply with all city and county ordinances and state laws relating to building construction and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. S T E V W--�2A C I N I Date: 6 b4 9L (5151.48.WP) Whil"uildng d Safety; Groan -File; Canary -Applicant; Pink-Aevenue; Goldenrod -Asses for CITY OF COSTA MESA — BUILDING PERMIT PERMIT NO: P 078085 PLAN CHECK NO: N CONSTRUCTION TYPE: I—FR PERMIT TYPE: PLU JOB DESCRIPTION : 18428 SF T.I. FOR RETAIL SPACE CLAIM VALUE: CALC—VALUE: PERM NO: P 078085 GOVT: N SUPP: N PURPOSE: ALT SQ FT: GROUP OCC: B 1 COMMENTS: T.I FOR "CHANEL" REF:B-76526 Z O N I N G R E Q U I R E M E N T S S E T B A C K S ------------ MAIN BUILDING ---------------------- ACCESSORY BUILDING----------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN PARKING REQ; PROV: PARCEL: 41249102 ZNE: REF NO: PLANNING N TES> fE �E �'lt• -1E �(- iE IE iF iE iE fE * iE iE "1E'lE'lE iF !E iF if" iE iE "IE iE iE iE dE iF iE'!E iE iE iE'�E iE iE iF ifr � � 9E -1F iF iE'f!� � # �E iE 4E * � iE !E iE iE 3F iF �E'lE �E �E !(" iE iE * dE * iE iE dE � � -1E iF � D E V E L O P M E N T S E R V I C E S-0 R E Q U I R E M E N T S ZONING APPROVED BY DATE: BUILDING APPROVED BY ; /.=1 DATE: APPLICATION ISSUED BY: J,y� DATE: jE iE iE if" iF � dE iE � iE iE � iE iF iF iE iE � 9E iE � iE fE iE'1E i(' aE � �(- itch iF � "1E iE LEGALIZATION:N F E E S U M M A R Y STRUCTURAL SEGMENT:N BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT 28.50 25% rd SMIP /NON --RES PLAN ISSUE FEE 22.00 BUILDING—DIV—> PERMIT ISSUE PLAN" -CHECK TOTAL PAID DUE TOTALS ---- > 28.50 22.00 0.00 50.50 50.50 .00 11 REVENUE DIVISION TOTALS--> COLLEGTED: 50.50 OVER/SHORT: ,00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK 50.50 1/ �E 4E !E iE � iE iF jE * 9f'lE -IE IF'1F * iE if iE i(' 4E IE #F 4E � 4E'IE iE"1F iE ii- if .}E * -0E � >ti4 iF" �E.iE iE �E iE iE iE iE dE iF � iE iE �F iE i( -IE 1E iE * IF IE iF dE lE iE i6 3E 3E 3E dE iE iE iE iE iE iE iE dE "1E dE iE I N D I V I D U A j; F E E B R E A K D O W N TYPE QTY D E S C R I P T 10,_N- UNIT COST TOTAL COST PLU 1 WASH BASIN 8.75 8.75 PLU 1 WATER CLOSET (TOILET? 8,75 8.75 PLU 1 WATER HEATER AND/OA VENT 11.00 11.00 END OF FEES 4 17 L r7,". CONSTRUCTION AND PLANNING APPROVALS Permit # - Date InspecEor POOL t i APPROVALS Permit # Date Inspector ' 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location-'. 2. Soil Pipe-Undrgrnd, 53. Steel Reinforcement 3, Electrical Conduit Utility-Undrgrnd, 54. Forms 4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6- Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE 7. Footings 58. Electrical Conduit-Undrgrnd. 8. Foundation 59. Gas Pipe, 0 Undrgrnd., Test 9. Water Pipe-Undrgrnd. 60. Backwash Lines, P -Wrap, ❑ Undrgrnd. 10. Structural Floor System 61, APPROVAL TO DECK 11, Property Sewer Line & House CoAnection 62. Backwash & Receptor-Finat 12, Sewer Cap 63. Heater & Vent -Final 13. Roof Drains 64. Plumbing System - Final 14. Rough Plumbing -1 Sf 65. Electrical -Final 15. Rough Electrical -Conduit 66, Solar System -Final 16. Rough Electric Wiring 67. Fencing & Access Approval 17. Rough Wiring Sign 68. APPROVED FOR PLASTERING 18, Rough Electrical -T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditionin§ FIRE DEPT. REQUIREMENT APPROVALS Permit # 20. Rough Factory Fireplace _ 21. Ducts, in Structure 70. Underground Hydro 22. Ducts, Ventilating 71. Product Piping 0 Gas 00i] 23. Gas Pipe -Rough & Test 72. Underground Flush 24. Roof Framing 73. Undergrnd. Storage Tank 0 Gas 0 Oil 25. Roof Sheathing 74. Overhead Hydro 26. T -Bar Ceiling (Structural) & Monocoat 75. Dry Chemical 27. Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding 77. FIXED SYSTEM FINAL 29. Insulation - 78. FIRE PREV. FINAL 30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat 79. FINAL INSPECTION 32. Electrical Power Meter -Final 33. Final Electric 34. Final Heating & Air Conditioning 80. FOOD CERTIFICATE ISSUED Motes: �•1�+ 35. Final Gas Pipe -Test 36. Hood or Canopy 37. Final Factory Fireplace 38. Final Plumbing 39. Water Service -Final 40. Gas Service -Final 41. Solar Domestic -Final 42. Backflow Preventer 43. Backflow Irrigation 44, Landscape Irrigation System 45, Sound Attenuation 46. Handicap Regulations 47. FINAL STRUCTURE & BUILDING 48. FINAL PLANNING 49, Electric Release to Edison 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY No. Date 1 09W I ,AOoREss OF eawc: 3333 BRISTOL ST UNIT: 15 OWNER'SNAMEIFmwm: C.J. SEGERSTROM & SONS FLOOD: AO— A imm: 331 5 FAIRVIEW RD :OSTA MESA, CA 92627 546-0110 ADPL. NWUND ADDRESS; ARCNrrm OR I7fams: BRAND ALLEN uc. No.: C-99999 ARCN.OR EW'S ADDRfss: 900 NORTH POINT UNIT. 400 SAN FRANCISCO CA 94109 00NTRACTOR'5NHlE: CAUSEY ELECTRIC INCORPORA (714)855-9610 CONTRACTOR'S MRIXI 3 V AND E RB I L T ADOItEss IRVINE CA uc. wo.; 331064 92718 VMT: LICENSED CONTRACTORS DECLARATION: I hereby affirm underMla.m licernssd proviviors d Chapter 9 (Commencing with Section 7000) d Division 3 d the Euairheas anld Pma ' 1 end effect. CITY UC. NO.: O 7 7 5 4 uc. c1 ASs: C 10 1764 P: 02/97 Date: ! C or.OWNER BUILDER DECLARATION: I hereby affirm under penarym the Corhredora License Law for the following mavon (Section 7031.5 Business and Professions Code: Any Cly or ocurd vrkhiat a permit to Construct, alterimprove, demolish, or repair any structure. prior to its issuance, also requires the applicant for wch permit to file a signed statement tst he or she 4 licensed pursuant t0 the provisions of the Conlradrxa License Law (Chapter 9 (Commencing whh Section 7000) of Division 3 of the mness and Professions Code) or that he or she is exempt therefrom and the basis lor the alleged exemption. Any violation of Section' K37.5 by arty applicant for a pennB subjects the applicaN to a aryl penalty of not more than five hundred dollars )5500])' ❑ 1. as owner of the property or my employees with wages as their ads compensation, will do the work, and the structure in not intended m offered for sate (Section 7044. Business and Professions Code: The Contractors Lioerue Law does nd appy to an owner of property who bulds or improves thereon, and who does such work himself or herself or through his or her own employees. provided that such Improvements are not intended or otfeced for sale. lf, however, the building or improvement is void within one year of completion, the ' owner -builder will have the burden of proving he or she did not build or improve for the purpose of sale). ❑1. as owner d the am ex _ B J I>�nY, exclusively Contracting with Iitensed contractors m carutrud ons protect (Section 7044. Business and - PrClessions Code: The Contractors License Law does na apply to an owner of property who builds or improves Iheiaton and who-- contracts homcontracts for such projects with a cdntnactor(s) kersed pursuant to the CordraCEars License Law). / ❑ 1 am exempt under Section: B. d P C.. for this reason: Dale: Owner: r- I I do hereby certify that 1 am aware of requirements end urKkntwA the requiremes California Health and Safety Code Sections 25505, 24533, end 25534. and that I or any future building occupant will I will not (cirds one) need to comply with said stale Codes and the mquirements for a Permit for corsauction or modification from the Air r�ty anagament District. RasideN®I castnudion apgkatio s are exempt from t m provisions. Date: Applicant: WORKER'S COMPENSATION DECLARATION: I hereby affmn oder penalty of perjury one of this billowing declarations: ❑ 1 have and will maintain a certificate d orient to selfAnsum for workers' compensation, as provided for by Section 3700 of the Labor Code. fa the performance of the work for which this permit is issued. I Kava end will maintain wokers'compensation itmraroa, as required by Section 370D of the Labor Code. for the performance of the work for which this permit is issued. My workers LHLcyt0eanpolity number Cartie: ars: EXPIRES Policy Number. 10/01/96 Vs section need rim be completed ! llle permit is for one hundred dollars )5100) or Am) j I carlity thel in the performance of the work for which this petit ' ehdI nd employ any in any manner so as to m becae subject to the woemrs' compensation laws of Cafdorthia agree i I should Subject to the workers' compensationon 'Ana d Section 3700 d the Labor Cade, I shelf I h con ifhoee Date: `EioAppl' Waminy: F.M. t0 secure worker' Compensatlon end vlslf vrb)ect employer for crkWnAl perulpq and ciWl fines up to ane hundred thousand dollars ($104000), An addFNon to the cost of comp tin, damages no provided for In SeC80n 9706 of the labor Gods, lntersal, and aftomey's tato. CONSTRUCTION LENDING AGEm NCY: I hereby affuunder penalty d perjwy that there is a construction landing agency for the performance d the work for which this peri is issued (Section 3097. Civ. C). LENDER'S NAME: LENDER'S ADDRESS: I certify that I have road this application and state that the above information is correct, I agree 10 comply with an city and county ordinances and stale laws relating to building construction and hereby authorize representatives d this city to enter upon the above-mentioned property for inspection pR I C LEWIS _ 11 Date: (5151-46.WP) White-Buidig d Salary: Green -Fie; CenerVAppicanl: Pink -Revenue; Goldenrod-,4ssasaor CITY OF COSTA MESA — BUILDING PERMIT PERM NO: E 0769761 PERMIT NO: E 076976 PLAN CHECK NO: N GOVT: N SUPP: N CONSTRUCTION TYPE: I—FR PERMIT TYPE: ELE PURPOSE: ALT JOB DESCRIPTION : 18428 SF T.I. FOR RETAIL SPACE SQ FT: CLAIM VALUE: ` CALC--VALUE: GROUP OCC: B / COMMENTS: T.I FOR "CHANEL" STORE TI, RE:#B76526 Z O N I N G R E Q U I R E M E N T S `j S E T B A C K S ------------ MAIN BUILDING ---------- --------- ACCESSORY BUILDING--------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN PARKING RE • PROV: PARCEL: 41249102 ZNE: REF NO: PLANNING N TES> > iE')E -lE 9E -!F if iE iF iE ic• iE �(• iE i4 �E * * * iE * * * * * dE * � iE �E •IE 3E Ulf• �E �E'If �E iE �E iE fE iE 9E iE jE i[• iE dE )E '1E �E •IE �E �E• •IF •IE iE •IE iE iE iE •IE iE 9E iE iE iE dE dE � �E iE 9F �E it IE * iE aE iE D E V E L O P M E N T S E"R V I C E S R E Q U I R E M E N T S ZONING APPROVED BY DATE: BUILDING APPROVED BY DATE: APPLICATION ISSUED BY: : DATE: �E � iE lE lE �F lF iE � iE iE iF iE iF * iE iE * 1E -1F iF iE r 1f -)F IE iE )E iE iE � dE iE LEGALIZATION:N F E E/J S U M M A R Y STRUCTURAL SEGMENT:N BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT '232.$0 •.50 SMIP/NON—RES PLAN ISSUE FEE 15.00 BUILDING—DIV—> PERMIT ISSUE PLAN -CHECK TOTAL PAID DUE TOTALS ---- > 232.80 15.00 .' 0.00 247.80 247.80 .00 REVENUE DIVISION TOTALS--> { COLLECTED: 247.80 OVER/SHORT: .00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK 247.80 iE �E 9E �E �F lE -1E't- * � * iE'!E ,tiE iE iE iE iE i6 iE iE iE iE iE iE iE iE � � � � iE if lE dE lE lE iE �E iE'lE iF I(- iE iE if iE iE iE iE iE iE iE iE iE iE 9E lE 9E �E � iE 1E iE iE'lE iE iE jE iE iF iE ?E dE 9E �E d(- if iE I N D I V I D U A L; F E E B R E A K D O W N TYPE QTY D E S C R I P T I OrN UNIT COST TOTAL COST r ELE 20 FIXTURES, LIGHTING:, 1 ST 20 EA. .75 15.00 ELE 464 FIXTURES, LIGHTING oADDITIONAL EA. .45 208.80 ELE 12 RECEPT/OUTLET 1 1 ST 20 EA, .75 9,00 END OF FEES _ -Yy CONSTRUCTION AND PLANNING APPROVALS Permit # Date Inspector POOL i A APPROVALS Permit # -�-- Date lnspettar . 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. 54. Forms 4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding S. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6. Electrical UFER Grnd. 57, APPROVAL TO COVER-GUNITE 7. Footings 56. Electrical Conduit-Undrgrnd. 8, Foundation 59. Gas Pipe, © Undrgrnd., Test 9. Water Pipe-Undrgrnd. 60. Backwash Lines, P -Trap; © Undrgrnd. 10. Structural Floor System 61. APPROVAL TO DECK 11. Property Sewer Line & House Connection 62. Backwash & Receptor -Final 12. Sewer Cap 63. Heater & Vent -Final 13, Roof Drains ' 64. Plumbing System - Final 14. Rough Plumbing 65. Electrical -Final 15, Rough Electrical -Conduit 16. Rough Electric Wiring 71 ! ! T -9z9- 66 Solar System -Final ,,r. Fencing & Access Approval 17. Rough Wiring Sign 18. Rough EI'ectrical•T Bar Ceiling7f 19. Hough Heating & Air Conditioning APPROVED FOR PLASTERING 69. POOL/SPA SYSTEMS FINAL FIRE DEPT. REQUIREMENT APPROVALS Permit # 20. Rough Factory Fireplace 21. Ducts, in Structure 70. Underground Hydro 22. Ducts, Ventilating 71, Product Piping ❑ Gas ©Oil 23. Gas Pipe -Rough & Test 72, Underground Flush 24. Roof Framing 73. Undergrnd, Storage Tank © Gas 0 Oil 25. Roof Sheathing 74. Overhead Hydro 26. T -Bar Ceiling (Structural) & Monocoat 75, Dry Chemical 27. Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding 77. FIXED SYSTEM FINAL 29. Insulation 78, FIRE PREY. FINAL 30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat 79. FINAL INSPECTION 32. Electrical Power Meter -Final OOD CERTIFICATE ISSUED l,1otes:� e2l. 33. Final Electric 34. Final Heating & Air Conditioning % 35. Final Gas Pipe -Test 36. Hood or Canopy 37. Final Factory Fireplace 38, Final Plumbing 39. Water Service -Final 40. Gas Service -Final 41. Solar Domestic -Final 42. Backflow Preventer 43. Backflow Irrigation 44. Landscape Irrigation System 45. Sound Attenuation 46, Handicap Regulations 47. FINAL STRUCTURE & BUILDING 48. FINAL PLANNING 49. Electric Release to Edison �60. Gas Release to Southern California Gas Co 51. -CERTIFICATE OF OCCUPANCY No. w Date ADDRESS OF B1.111.01140; 3333 BRISTOL ST &MEWS NAME IF KNOWN: C. J. SEGERSTROM & SONS ADDRESS:3315 FAIRVIEW RD ' APPLTRE53: , CA 92627 546-0110 ARCHITECT OR ENG WEER: ARCH. OR ENG.'S ADDRESS: UNIT: 1500 FLOOD: AO -38 UC. NO.: UNIT: CONTRACTarsw"EIDSON FIRE PROTECTION ( 310)514-5535 CCNTRACTDR'sIi""N' 1881 N GAFFEY ST ADDI'EM'SAN PEDRO CA Uallo.: 574585 90731 DNIT.- B LICENSED CONTRACTORS DECLARATION: I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (Commencing with Section 7000) of Division 3 of the Business ond Professions Code, and my license is in full force and effect. CITY LIC. N0,:0 5 018 9 UC. CLASS: C16 LIC. NO.: 574585 EXP : 01/97 Date: Coho-aaor: OWNER BUILDER D CLARATI : I hereby affirm under penally of perjury that I am exempt Fran the Co on License Law for the following reason (Section 7031.5 Busihesa end Profehenions Cods: Arty city or county which requires a permit to eofstntel, filer, improve. demolish, a repair any structure, prior toile issuance. also requires the applicant for such permit to file a signed sl t ement that he or she n Iiarnsad pursuant to the provisions of the Contractors License Law (Chapler 9 (oommenoing with Section 7000) of Division 3 of the Business end Professions Code] or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031,5 by any applicant for a permit subjects the applicant to a Civil penalty of not mora than live hundred dollen 11500]). ❑ I, as owner of the property or my employees with wages as Ihei Ida compensation, will do the work, and the structure is not intended of offered for Sale (Section 7044, Business and Professions Code; The Contraaon license Law does not applyto an ownerof property who builds or improves thereon. and who does such work himself or herself or through his or her own employees, provided Thal such improvements are not intended Of otlered for sale, lf. however. the building or improvement is sold within one year of comphstion, the owner -builder will have the burden of proving he or she did not build or improve for the purpose of sale). ❑ I, as owner of the property, am exclusively contracting whh licensed contractor to Construct the project (Section 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon end who contracts lot such projects with a contractor(s) licensed pursuant 10 the Contnw:tors License Law). ❑ 1 am exempt under Section: B. A P.C.. lot this reason; Date: Owner: I do hereby cendy that i am aware of and understand the requirements of California lieahh and Safety Code Sections ?5505.25533, and 25534, and that 1 or any future building occupant will I will not (circle one) need to comply with Said stale codes and the requirements for apenndfaeomtroetionormodiDeationfromtheAir=R-y anagemeniDistrict.Residentiaimmtructionappliowionsweexemptfromthen provisions. Date: Applicant: WORKER'S COMPENSATION DECLARATION: I hereby alOrM under penalty of perjury one of the following declarations: ❑ I have and wAlmaintain a certilicate of consent to self -insure lot workero' compensation, as provided for by Section 3700 of the Labor Code, iso the pedormance d the wok lot which this panrtit is issued. Q I have and will maintain worker' compensation insurance, as required by Section 3700 d the Labor Code, lar the performance d the work for which this permit is issued. My workers' compensation insurance carrier and policy number are: Canter: R'TATF FETW) EXPIRES Policy Number: j 3 d J 4 9898 —9.5 07/01/96 }This seaion need not be completed T the ponnt is for one hutrdred ddlars (f 1001 orless.) Li i certify that in the performance of the work for which INS permit is issued, I shell not employ any person in any manner so as to become subject to the workers' compensation taws d Cafifomia, and agree they it I should become subject to the wofkero' compensation rovisions 4 Sepion 3700 of the Labor C06e, I eha11 I� ty 'Ill the ieiors. . Dale: Applicant: �yC/•' Warning. Fail to 4o secure wo ero'rompenosffon coverage to unfo art hall art *1 an emioloyer to crfminart penald" and civil ftnes up to ono hundred thousand dollars (SIOAMO), In addidon to the coat of Compenssflork danuWs as provided for In section 3706 of the Labor Code, Interest, and &"mays foss. CONSTRUCTION LENDING AGENCY: I hereby affirm undo( penally of perjury that there is a Construction lending agency for the performance of the wank lor which the Parma is issued (Section 3097, Civ. C), LENDER'S NAME: LENDER'S ADDRESS: I certify that I have rad this application and state that the above information is correct. I agree to comply with all city and oounty ordinances and state taws misting to building construction and hereby authorize representatives of this sty to enter upon the above-mentioned property for inspection purposes. STEVE FUC S —Pr'ret Nemo at Signmuralof Owner en1/Ap Iican or (5151.490P) Whse-Building 3 Safely; Green -Fila; Canary -Applicant: Pink-Ravenue; Goldenrod -Assessor CITY OF COSTA MESA — BUILDING PERMIT PERMIT NO: F 076620 PLAN CHECK NO: 00723-96 L CONSTRUCTION TYPE: I—FR PERMIT TYPE: FIR JOB DESCRIPTION : 18428 SF T.I. FOR RETAIL SPACE CLAIM VALUE: 5,000.00 CALL—VALUE: —PERM NO: F 076620 GOVT: N SUPP: N PURPOSE: ALT SQ FT: GROUP OCC: M / COMMENTS: T.I FOR "CHANEL" REF: B-76526 SPRINKLER SYSTEM ALTERATION Z O N I N G R E Q U I R E M E N T S S E T B A C K S ------------ MAIN BUILDING ---------- --------- ACCESSORY BUILDING--------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RIGHT: FT IN LEFT: FT IN RIGHT: FT IN PARKING REQ: PROV: PARCEL: 41249102 ZNE: REF NO: PLANNING NOTES> irk !f 'ff• if')E'If ?tk IE 'Ili �'IE #E Ili � FIE ♦f >fE ♦f iE irk iE irk iE iE �1E �1E iE iE if �k i6 ♦rt * � {E •IE * * •1E' E'1E iE iC' �lE �E iE � �E >tiF 1F jE IF 1E •1E �E !E � IE iE'TE �E iE iE iE iE iE iE iE IE i(• 11(• 3F t1E dE iE'IE 'If •IE -)E D E V E L O P M E N T S E R V I C E S R E Q U I R E M E N T S ZONING APPROVED BY DATE: BUILDING APPROVED BY DATE: APPLICATION ISSUED BY: DATE: Kit, irk � �k �k * 1E !E � !k'E >rt �k dE yak alk * ?✓k * 1E•'If >7E'IEirk * * � * � aE * �k � iE'SE- LEGALIZATION:N F E E S U M A R Y STRUCTURAL SEGMENT:N BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT PLAN ISSUE FEE BUILDING—DIV—> I PERMIT ISSUE PLAN,—!CHECK TOTALS ---- > 72.00 0.00 ,A6.80 REVENUE DIVISION TOTALS--> COLLECTED: BLDG PMT PLUMBING ELECTRIC MECHANIC 72.00 65% SMIP/NON—RES 46.80 TOTAL PAID DUE 118.80 118.80 .00 72.00 OVER/SHORT: .00 FIRE SMIP/TOT GRADING PLAN—CHECK 72.00 irk # tE �lE -)E -)f in •lf- irk alk irk tE irk irk �k � Ik •Ill •Ili •lk •If• •lk dE •lf• •]k � tk �k irk �k Ik -1(- -Ili -Ili iE �k irk iF dk'Tk * *irk * irk � � tk � is •Ili irk iE irk irk iF iF �lk irk irk irk irk if iE irk ilk irk irk •1f• da• alk 9k �1k >'[' irk alk * iE � I N D I V I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST FIR 72 FIRE EQUIP FEE (FROM BLDG VAL TABLE) 1.00 72.00 END, OF FEES 7 ' r i i i1 of CONSTRUCTION AND PLANNING APP90VALS Permit # Date Inspector POOL & APPROVALS Permit # Date Inspector 1, Terriporary Electrical Service or Pole 52. Pool & Equipment Location 2. Soi�•Pipe-Undrgrnd. 53. Steel Reinforcement - 3.'Electrical Conduit Utility-Undrgrnd. 54. Forms 4.' Liect'rical Conduit-Undrgrnd. 55. Electrical Bonding ~ _5.'Steel Reinforcemerit•' 56. Rough Plumbing & Pressure Test .6 -"Electrical UFER Grnd. 57. APPROVAL TO COVER-GU41TE -A. Footings - 58. Electrical Conduit-Undrgrnd. 8, Foundation _ 59. Gas Pipe, 0 Undrgrnd., Test 9. Water Pipe-Undrgrnd. 60, Backwash Lines, P -Trap, 0 Undrgrnd. i 10. Structural Floor System 61, APPROVAL TO DECK j 11. Property Sewer Line & House .Qon l ction 62. Backwash & Receptor -Final 12. Sewer Cap =" 63. Heater &Vent -Final 1,3, Roof Drains 64, Plumbing System - Final 14. Rough Plumbing r 65, Electrical -Final 15, Rough Electrical -Conduit 66. Solar System -Final - 16. Rough Electric Wiring- I 67. Fencing & Access` Approval t 17. Rough Wiring Sign 68, APPROVED FG9 PLASTERING 18. Rough Electrical -T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19, Rough Heating-& Air Conditioning i r ti FIRE DEPT. REQUIREMENT - -APPROVALS=-- Permit _ 20. Rough FaatoryFirepEace ,:. »• , _ 21. Ducts,'in 9.7tructure- , _ + T # .70, Underground Hydro 22, Ducts;•Ventilating '. -.71. Product Piping P Gas 000 23. Gas Pipe Baugh &Testr _ F 72. Underground Flush' ` 24. Roof Frarrung 25. Roof 'Sheaihing17 - •73. Undergrnd. Storage -Tank 0 Gas 0 Oil 74. Overhead .a�r4 &% ,f 26. T -Bar Ceilin (Structural) & Monocoat g - 75. Dry Chemical - 27. Frame -and Flashing •" - ` 76. Dry StandpipeJc 28. Lathing & Siding _ 4 _ y 77.-. FIXED SYSTEM FINAL StX.1 U.) �'�b'9(o 7•�Q'9(I 29. Insulation ;` 78: --FIRE PREY. FINA` 30. Drywall Nailing i HEALTH DEPT, F EOUIRENIENT 31. Plaster Brown Coat- - T 79. FINAL IN5PECTIUN _ X32. Electrical Power Meted Fitaai 80. FOOD CERT11 fCkrE I5SlJED ,-33. Final Electric n K. Notes:= L 34. Final -Heating & Ail Contiitioning 35. FinalGasRipe-Test '36. Hood pr Canopy - - ' r j i1- � (fid - ' ?_LY Y °� s'�U -14- 1Q37. 37.Final Fac€o'ry Fireplace �- ` �}Q,►�S 38. Fihal Plumbing '39. Water -Service -Final 40- Gas Service -Final - 41. Solar Domestic -Final 42. Backflow Preventer 43. Backflow Irrigation 44. Landscape Irrigation System 45. Sound Attenuation_ 46. Handicap Regulations - 47. FINAL STRUCTURE &BUILDING r 48. FINAL'PLANNING +49. Electric Release to Edison 50. Gas Release to Southern California Gas Co y 51, CERTIFICATE OF OCCUPANCY No. Date ' (714) 754-5273 • Fax (714) 754-4856 • www.cl.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 MECHANICAL PERMIT .lob Address: 3333 BRISTOL ST Suite No 1500 Vicinity: SUITE 1500 ISSUED BY: Parcel Number: 41249102 Applicant: SANDERS, BILL Address: 1140 RED GUM ST Phone: (714) 630-3200 ANAHEIM, CA Zip: 92806 Owner: SOUTH COAST PLAZA Address: 3315 FAIRVIEW AVE misc. Phone: COSTA MESA, CA Zip: 92626 Contractor: THERMALAIR INC Address: 1140 RED GUM ST Phone: (714)630-3200 ANAHEIM, CA Zip: 92806 License: 102216 SCOPE OF PERMIT MECHANICAL PERMIT FOR INTERIOR T,I. FOR "CHANEL" (SUITE 1500). INSTALL 5 VAV BOXES 8 ALTERING EXISTING DUCTWORK. REF: B04-01809 Quantity ISSUE FEE $23.50 Inst FAU <100 k BTU $0.00 Inst FAU >100 k BTU $0.00 Repair I Alt Cooling/Heat $13.70 Inst / Rep. Recess Wall Htr $0.00 Refrig Sys <100 k BTU $0.00 Refrig Sys >100 k BTU $0.00 Gas Piping $0.00 . Factory Fireplace $0.00 Hood w/Meth Exhaust $0.00 VAV Box $53.25 Vent Fan 1 Single Duct $0.00 Appliance $0.00 Fire Dampers $0.00 Smoke Dampers $0.00 Inst or Relocate Appi Vent $0.00 Air Handlers < 10000cfm $0.00 Air Handlers > 10000cfm $0.00 Floor Furnace $0.00 Floor or Suspend Heater $0.00 FEE SUMMARY _ Repair / Alt Absorbtion Unit Repair/ Alt Refrigeration Unit Ventiliation System Evaporative Cooler Commercial incinerator Domestic Incinerator Coi?ipressors / Absorption Systems Up to 3 hp / 100k BTU 3To 15hp/500 k BTU 15 To 30 hp / 1,000 k BTU 30 To 50 hp 11,750 k BTU Over 50 hp 1 Over 1,750 BTU Boilers Upto3hp 3To15hp - 15to30hp 30 to 50 hp ' Over 50'hp ' Other Mechanical Fee, Investigation Fee Plan Check Fee Status: ISSUED Applied: 02111/2005 Issued: 02/11/2005 Quantity $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 $0.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void it work is not commenced within 180 days, or if work Is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446.4618!00) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the u� work for which this permit is issued. 2kkhave and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. lam'- y workers' compensation Insurance carrier and policy number are: fCa a ^'�.E.�QQ1C-�1�Z __ _ Poli'cyNu'rttber:,��lO�i02.SS _ `7Tir s section need not he completed 1l rhe permit 15 valued at one hundred doflars ($ t 00) or less.) ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Califomia, and agree that if I should becomo subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with the ions Applioent-S"ture�_ ' L �JLQ, WMWN&-PAnRE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRiMiNAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE (Sl 00.000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SEC1•t0q'370T0FTFIETABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that-LaR licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Coda, and my license Is in full force and effect. be. # A I kD r la�'ss ti _ SaD C 3 2 C- Contractor'e-Blgnalluim. t aD-f= CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lenders Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemptlon. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (See. 7044, Business and Professions Coda: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Ortver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-slx (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title S. California Administrative Code). ❑ As owner-bullder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Data: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the Califomia Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .......................................................................................................................................................................................................................................................................... _........... ......................1.111.......................... 2 Does or will the applicant or present or future building occupant need to fits a registration form for acutely hazardous materials? 0 Yes 0 No (Section 25533 of the Califomia Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight o1 500 pounds, or a volume of 55 gallons, Or 200 cubic feet of compressed gas at standard temperature and pressure). _ .. -- - ...-- --._ _._................._................................................................ _..................... .-... _. 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the Califomia Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required, has Section 25534 of the Califomia Health and Safety Coda been fully Complied with? ❑ Y a s- ❑ No ---1.....1__11.._— ..... --......... _.......................................................................................---....-......---.....—_...-- 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this application aggermlt for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? []Yes LJ No (Section 65850.2 of the Califomia Govamment Code requires that the requested information be furnished on applications for non-residential building permits). ..............................................._ _-._..._............................................................................................................................................................................................................................................. _ _ .. 6 Will any part of the facility to be constructed under this petmii be within 1000 fest from Lha outer boundaries of a school? ❑ Yes ❑ No (If fres", the facility must meet the requirement of Sections 25534 and 42303 of the Califomia Health and Safety Code). ......... ................ ......................................... _...................................................... ,,,,,,.,...................... .............. ............................ ............................................................ ............................ ............ -........................ 7 If a permit from the South Coast Air quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by Califomia Health and Safety Code Section 42303 been made? ❑ Yes ❑ No . .................... .......................................................................................................................................................................................................................... 8 (If yes', attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE=: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. nature Of L I Owner(s) Date Ly -trtdt0r.Authofized.App4icant- -- . _ • _ Date ----�: aL - CODE!INSPECTIOtITYPE f2AIE IfTMALS CODE # INSPECTION TYPE Qaie 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final B1Dck/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Suite No 1500 Vicinity: Parcel Nunmber: 41249102 Applicant: DRECHSLER, DANIEL Address: PLUMBING PERMIT Phone: 626 966-2884 Zip: Owner: SOUTH COAST PLAZA Address 3315 FAIRVIEW AVE MISC. Phone: COSTA MESA, CA Zip: 92526 Contractor: H D PRODUCTION PLUMBING CONTRACTORS INC Address: 846 N DODSWORTH AV Arch / Eng : Address: COVINA, CA Phone: 626-966-2884 Zip: 91724 License: 817184 Phone: Zip:' License: SCOPE OF PERMIT . - REF: 804-01809- INTERIOR 3700 SF STORE TI FOR "CHANEL" 1N SPACE 1500. PLUMBING PERMIT IS FOR: 1 SERVICE SINK &'11 WATER HEATE=R. Status: ISSUED Applied: 01/10/2005 Issued: 01/10/2005 ISSUE=D BI, - QTY AMT FEE SUMMARY 0 AMT CITY 0 AMT ISSUE FEE $23.50 0 Laundry Tub / Washer $0.00 Backflow irrigation $0.00 0 Landscape Irrigation $0.00 Backflow Preventer $0.00 0 P -Trap $0.00 Bathtub $0.00 0 Pressure Regulator $0.00 Clarifier System $0.00 0 Process Piping (per 10 ft) $0.00 Connect (Ice,Soda,etc) $0.00 0 Receptors $0.00 Dental Units $0.00 0 Septic Tank $0.00 Dishwasher $0.00 0 Sewer Cap for Demo 50.00 Drain, Floor $0.00 0 Sewer Connect $0.00 Drain, Rainwater $0.00 0 Sewer Private Line $0.00 Drain, Roof $0.00 0 Shower $0:00 Drinking Fountain $0.00 0 Sink, bar $0.00 Status: ISSUED Applied: 01/10/2005 Issued: 01/10/2005 ISSUE=D BI, - QTY AMT QTY 0 Sump Pump $0.00 0 0 Swimming Pool $0.00 0 0 Trap Primer $0.00 0 0 Urinal $0.00 0 0 Vacuum Brkr Bkflow(1-4) $0.00 0 0 Vacuum Brkr Bkflow(5+) $0.00 0 0 Wash Basin $0.00 0 0 Wash Basin Set $0.00 0 0 Waste and Vent System $0.00 0 0 Water Closet (Toilet) $0.00 0 0 Water Heater 1 vent $12.30 1 0 Water Piping (Inst or Rep.) $0.00 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days, or If work Is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446-46(&00) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. (I have and will maintain workers' compensaUon Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. My woriars, c°� ensati Ins ante carried policy number are: ! Carrier: ��r an Policy Number: (This section need not be competed if rho permit is value f orae h1indrod dollars {$100} or less.) I certify that In the performance of the work for which this permit is Issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of C mia, en gra at If I ould become subject to the workers' compensation provisions of 5e tion 37 0 of the Labor Code, I shall fdrthwlth comply with these pro ' o s. Applicant Signature: Date: WARNING: FAILURE TO SEC E WORKERS COMPENSATION RAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO GRI INAL P ALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE (5100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic. # Class M Contractors Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued, (Sec. 3097, Civil Code). Lenders Name: Lenders Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than lire hundred dollars ❑ 1, as owner of the property, Or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors license Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feel in depth into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, lalsework, or demolition or dismantling thereof, will be more than thlrty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to rolease or threatened release of a hazardous material? ❑ Yes ❑ No (Sectlon 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _ 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the Califomia Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). __ ..._.._ ............... ___.. _.._....._................. ............. _..................._............................................................... ............ _ _ 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 Han RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑Yes ❑ No ......................._............................ ...... _... _ ._..... _—.......... _ ..........._ ..............._.................._....... ................ ._............ ................._.....-----....—_ _ 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a pltostion aPPermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes 19 No (Section 65850.2 of the California Govemment Code requires that the requested information be fumished on applications for non-residential building permits). ................................................................_.__............................................................... ........................................................................................................................... .......................................................................................... 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the Outer boundaries of a school? [:1Yes ❑ No (11 'fres", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ......................................................................11........................................--......••..................................................................................................................................._.............................._—.................... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which Is the subject of this application, have all of the disclosures prescribed by Califomia Health and Safety Code Section 42303 boon made? ❑ Yes ❑ No .............................................---._........ _ ................ _............-.................................................................................................,....................................................................................... 8 (if 'yes", attach certificate of compliance from the appropriate air poliutian control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. l agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for Inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. gnat O Owner(s) ' Data n r Apnzed Applicant Date CODE /• INSPECTION TYPE 2M INTITIA CODE! INSEECTION TYPE Q 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 " Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 BUILDING PERMIT Job Address: 3333 BRISTOL ST Status: ISSUED Suite: 1500 Applied: 09/30/2004 Vicinity: SPACE 1500 (CHANEL) Issued: 09/30/2004 Parcel Number: 41249102 Zoning: PDC PDC Applicant: BARTH, EDDY ISSUED BY: Address: 140 LOMAS SANTA FE - SUITE 200 Phone: (858) 793-9104 SOLANA BEACH, CA Zip: 92075 Owner: SOUTH COAST PLAZA Address 3315'FAIRVIEW'AVE ' /MISC, Phone: COSTAWESA, CA Zip: 92626 Contractor: DICKINSON CAMERON CONSTRUCTION INC Address: 140 LOMAS SANTA FE SUITE 200 Phone: (858) 793-9104 SOLANA BEACH, CA Zip: 92075 License: ' 690239 Ar h c Eng. Address:. -Address: Phone: __ Phone: Zip: License: License: SCOPE OF PERMIT ` INTERIOR 3700 SF STORE DEMOLITION FOR'CHANEL" IN SPACE 1500 IN PREPARATION FORA FUTURE INTERIOR STORE TI. FEE SUMMARY Plan Check: $99.61 Calc Valuation: $8,000.00 , Permit: $153.25 !' Claim Valuation: $8,000.00 SMIP Res: ' $0.00 — = SMIP Corn: $1.68 Other: $0.00 Inspection:. $0.00 ; Total: ' $254.54 - PLANNING & ZONING SETBACKS. '%' , `��' • ' MAIN STRUCTURE Front 0-0 Rear, ' 0-.0' Left, 0-0 Right - " 0--0 '0-0 ACCESSORY Front Rear- 64 Left 0-:0 Right .: d_-0"/ ! . PARKING Existing:. 0 - _ Required: 0 Proposed: 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a perlod of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result In the expiration of this permit. FOR INSPECTIONS CALL: (714) 7S4-5828 2448.48 (6100) WQRKERS' COMPENSATION DECL-ARATION: I hereby affirm under penalty of perjury, one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Cade, for the performance of the work for which this pemilt Is Issued. My workers' compensation Ins rance carrier and policy number are: D Carrier: , _ - __ Policy Number: (This section need not be completed it the permit is valued at one hundred dollars ($100) or less.) ❑ i certify that in the performance o1fJ4 work which thl s d. I shall not employ any person in any manner so as to become subject to the workers' compensation laws of C91ifo a agr if ould b me sub ct to the workers' compensation provisions o1 Sec n 3700 of t Labor Code, I shall forthwith comply with these provision Applicant Signature: Date: WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBIECT AN EMPLOYER TO CRIMAL PENALTIE AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed unclekpnpsiotis of C t 9 (commencing with Section 7000) 01 Division 3 of the Business and Professions Code, and my license Is In full force and effect. Lic. ft CCS Z Class q96 1 Contractor's Signature: 4 Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is issued. (Sec. 3097, Civil Code). Lenders Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the iollowing reason (Sec. 7031.5, Business and Professions Code: Any city of county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a Civil penalty of not more than five hundred dollars (5500).): ❑ I, as owner of the property, or my employees with wages as their solo compensation, WILL 00 THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet In depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high, (Chap. 3.2, Grp 2, Art 2, Sec. 341, 71tle B, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 01 the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet o1 compressed gas at standard temperature and pressure). _................................._ ............... _ _ ................ ...... _........... .........,.......................................... ,......,................................. ...- ............_.....I—-. ...... _..... ­....._....... — ... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater then a weight of 500 pounds, or a volume of 55 gallons. or 200 cubic teat of compressed gas at Standard temperature and pressure). ..... — ............ _ .........._...- ..-...—.................................................................................................. —................_......... ...—.......... _......... .—.......... — 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Seclion 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. —_.......---.._.. —_. __..............._........................................ -_........ .......__... _...................... ---------- 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code boon fully complied with? ❑ Yes ❑ No ...........__........._........._.._—...— ---- ...-- ..................._............----.......—....._._.......-----.. 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication aggermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes LJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residentlal building permits). ..................................................................... -.......... ........................... _ _............................ .................................................................. I ........... ........... .... 6 WIII any pan of the taciltry to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if 'fres", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ............................................................................................_...............--•--..........................---.........----••-................................................................................................................................................ ........................"I', ",............... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which Is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 boon made? ❑Yes ❑ No .......................................................................................I...............---...---......_...................................................................................................................................... ................................ .................... ..... .......... — 8 (I! yos", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and cityordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. g turaOwner{s Da Or r ate CODE P. INSPECTION TYPE QejE, fbIM65 CODE 0 INSPECTION TYPE 2M 1NTITI6L$ 1616 Fixed System Final F e Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final BtocklRetaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition it 250 Final Building/Occupancy V,l - (714) 754-5273 • Fax (714) 754-4856 • www.ci,cosla-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 BUILDING PERMIT Job Address: 3333 BRISTOL ST Suite: 1500 Vicinity: STE 1500 (CHANEL) Parcel Number: `411249102 Zoning: PDC PDC S Applicant: BARTH, EDDY ISSUED BY: Address: Status: ISSUED Applied: 10125/2004 Issued: 11/24/2004 . Arch : BARTELUCE ARCHITECTS AND ASSOCIATES Eng: PEYTON - TOMITA & ASSOCIATES Address: 36 W 25TH ST Address: 954 TOWN & COUNTRY ROAD Phone: 212-691-7200 Phone: 714-245-4931 NEW YORK, NY ORANGE, CA Zip: 10010 License: C26233 92868 License: 3304 SCOPE OF PERMIT INTERIOR 3700 SF STORE TI FOR "CHANEL" IN SPACE 1500, WORK TO INCLUDE FEE SUMMARY Plan Check: Permit: SMIP Res: SMIP Com: Other: Inspection: Total:- $388.99 $2,393.75 $0.00 $73.50 $0.00 $0.00 $2,856.24 Phone: 858-9674325 Zip: Owner: SOUTH COAST PLAZA Address 3315 FAIRVIEW AVE Right 0-0 ACCESSORY Front ' 0-0 -MISC. Phone: PARKING Existing: 0 COSTA MESA, CA, Zip: 92626 Contractor: DICKINSON CAMERON CONSTRUCTION INC Address: 140 LOMAS SANTA FE SUITE 200 Phone: (858) 793-9104 SOLANA BEACH, CA Zip: 92075 License: 690239 . Arch : BARTELUCE ARCHITECTS AND ASSOCIATES Eng: PEYTON - TOMITA & ASSOCIATES Address: 36 W 25TH ST Address: 954 TOWN & COUNTRY ROAD Phone: 212-691-7200 Phone: 714-245-4931 NEW YORK, NY ORANGE, CA Zip: 10010 License: C26233 92868 License: 3304 SCOPE OF PERMIT INTERIOR 3700 SF STORE TI FOR "CHANEL" IN SPACE 1500, WORK TO INCLUDE FEE SUMMARY Plan Check: Permit: SMIP Res: SMIP Com: Other: Inspection: Total:- $388.99 $2,393.75 $0.00 $73.50 $0.00 $0.00 $2,856.24 Calc Valuation: $350,000.00 Claim Valuation: $350,000.00 PLANNING & ZONING SETBACKS MAIN STRUCTURE Front 0-0 Rear 0-0 Left 0-0 Right 0-0 ACCESSORY Front ' 0-0 Rear 0-0 Left 0-0 Right 0-0 PARKING Existing: 0 Required: 0 ProoQosed: 0 NOTES: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void it work Is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result In the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 ?446.48 (eros) ROM DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure frsr workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ( eve and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compen-s['atiiioo-n IIInntsurance carrier and policy number are: PdicyNurnber r .(MISS -Ce� !on need completed it the permit Is valued atone hundred dollars ($100) or less.) zcqA-�� ❑ I certify that in the performance of thew rk for whi it is Issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of C. and ea that ould be 9 subject to the workers' compensation provisions of Secil 3 100 of he Labor Code, I shall forthwith comply with these provis C 1/ .App rs►gnflate �l l , WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CAVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LA80R CODE, INTEREST, AND AT'TORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am lice ad dor provisions of hapter 9 (commencing with Section 7000) of Division.3.flfjhe Business d Professions Code, and my license Is in full ft e arld"_ e�cCflLTC. Cowr tgnature: ale: O CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is Issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Dale: OWNER-13UILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031 .5, Business and Professions Code: Any city or county which requires a permit to construct, atter, improve, demolish, or repair any structure, prior to Its Issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement Is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or Improve for purpose of sale.). - ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sac. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more toot in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) toot high. (Chap. 3.2, Grp 2, Art 2, Sec, 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Sefety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to fila and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard t( mporaturo and pressure). _Y_76 or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic toot of compressed gas at standard temperature and pressure). ........................................._....................................... __.......................................................................................................................... _............ —............. __........ —............. ... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No tSeclion 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an Aiv P' is presently required, has Section 25534 of the Cal€fornie Health and Safety Code been fully complied with? ❑ Yes ❑ No ........ ............................ _................... __............ _—.............................. ......................... ..... .._................ ................................................................................................ .................................... ........... _......................... -- ......... _.......... 5 does or will the applicant or present or future building occupant require for the work which is the subject of this application a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ................................................._...... .............................................. _............. ............................................................................................................................................................................................................................ , B WIII any pert of the faCll€ty to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). if a permi.................................................. ...w ..._................................................................................................................................................... •----............_........................ .......... __.... _..... _ 7 t from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescdbed by California Health and Safety Code Section 42303 been made? [:]Yes ❑ No 8 (If fres", attach certtf€cafe of compliance from the appropriate air poilutton wntrol officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given Is Correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree n copy or allow occupancy of any building authorized by this permit until final inspection. gn lure O er( at e � Ap Oates Q901 J. INSEECTION TYPE 2A19 lIfTmaL$ CODE t INSPECTION TYPE E Jam¢ INTITIAL,q 1616 Fixed System Final Fir Preventlon 206 Final Mechanical 1288 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wali 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy d Ia (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT .lob Address: 3333 BRISTOL ST Suite No 1500 Vicinity: Parcel Nunmber: 41249102 Applicant: KEVIN SCHELIN Address: 136 E GARRY Phone: (714)556-8591 SANTA ANA, CA Zip 92707 Owner: SOUTH COAST PLAZA Address 3315 FAIRVIEW AVE MISC. Phone: COSTA MESA, CA Zip: 92626 Contractor: SMALLCOMB WIRING CORPORATION Address: 136 E GARRY Phone: (714) 556-8591 SANTA ANA, CA Zip: 92707 License: 145961 SCOPE OF PERMIT INTERIOR 3700 SF STORE TI FOR'CHANEL' IN SPACE 1500. REF.: B04-01809 Status: ISSUED Applied: 02/07/2005 Issued: 02/07/2005 21 ISSUED BY: ELECTRICAL TO INCLUDE: 692 LIGHT FIXTURES, 31 OUTLETS, 8 SWITCHES AND 3 SUS PANELS TO 200 AMPS. NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes andWated regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or If work Is suspend/codes, andoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicabland all required inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result In the expiration,of this permit. FOR INSPECTIONS CALL. (714) 754-5626 2448-48 (W) FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 Temp Dist System 1 Lighting $0.00 0 Temp service test $0.00 Busway 1100 It $0.00 0 Res. a/c package $0.00 Standing Section $0.00 0 New Res (1-2 units) $0.00 0 Misc Electrical Equipment MOO 0 New Res (3+units) $0.00 0 Transformers up to 1 kvalkw $0.00 0 Pool / Spa $0.00 0 ................up to 10 kvalkw $0.00 0 Lighting Fixts $512.56 692 ........,.........up to 50 kvalkw $0.00 0 Recept Outlets $30.03 31 .................up to 100 kvalkw $0.00 0 Switches $8.80 8 ..................over 100 kvalkw $0.00 0 Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0 Res Appl $0.00 0 Low Volt Wiring System 1 Ckt $0.00 0 Service to 200a $0.00 0 Misc. Conduit $0.00 0 Service to 1000a $0.00 0 Misc. Conductor $0.00 0 Service over 1000a $0.00 0 Circus ( gen or ride) $0.00 0 Motors to 1hp $0.00 0 Circus (meth ride or lights) $0.00 0 Motors to 10hp $0.00 0 Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 0 Fireworks Stand $0.00 0 Motors to 100hp $0.00 0 Other Electrical Fee $0.00 Motors over 100hp $0.00 0 -, Communication drops $0.00 0 Investigation Fee $0.00 Sub panel to 200a $91.50 3 Plan Check Fee $0.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes andWated regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or If work Is suspend/codes, andoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicabland all required inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result In the expiration,of this permit. FOR INSPECTIONS CALL. (714) 754-5626 2448-48 (W) DECLARATIONS WORKERS' COMPENSATION DECLARATION: hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of constant to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the hw rk for which this permit is issued. ave and will maintain workers' compensaticpn insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. My workers' compensation insurance carrier and policy. number are: eMT r�-G Policy Nuttiber: -TTF—ssactlan rtes n t be completed f1 the permit is valued at one hundred doflars (S100) or loss.) ❑ I certify that in the performance of the work f r which this permit is issued, I shall not employ any person In any manner so as to become subject to the workers' compensation laws of California, an� rae a I1 I should becomo subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those pr sions: Ap�Plicat]t5lgsreture.----� �• --� offs a -w .2 Q� 10ARNI4p F�URE TO SECURE WORKERS' COMPENSATION 00VERAGE IS UNLAWFUL AND SHALL. SUBJECT AN EMPt.OYE CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED LiCDSAND DOLLARE (S100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I herebfjlEmjb i(.1 -am ilcenspd under provisions of Chapter 9 (Commencing with Section 7000) of DivisiSR2,ofthe.Business andProfessions Code, and my license is In full r ores�e and a Le.,Nr r G7' 4 tir _ f�-tr CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is Issued. (Sec. 3097, Civil Code). Lender's Name: _ Lender's Address: Signature: _ _ _ Date: OWNER -BUILDER DECLARATIONS: hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct. alter, improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my emplcyee8 with wages as their sole compensation, WILL DO THE WORK, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ' ❑ 1, as owner of the property, am EXCLUSf VELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ i am exempt under sec. _ _ Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's license No. Expires: Verification of Ownership by (type of document, i.(i. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT C! RTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth Into which a person is required to descend, will be made In connection with work authorized by this permit, and that no building structure, scaffolding, fafsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec, 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: _ HAZARDOUS MATERIALS AND EMISSIONS CeRTIFICATION: I Will the applicant or present or future building occupant need to fife and certify a Business Plan for emergency response to refease or threatened refease of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous matarials7 ❑ Yes ❑ No (Section 25533 of the California Health and Safety Cade, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to Cr greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic foot of compressed gas at standard temperature and pressure). _..... ___._...—_..... _—.... _........ _...................... 3 Does or will the applicant or present or future building occupant need to prepare an RM PP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. _ ......................_.. _..._. .........._. _. _ ....._. _................................ .........._._...... 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Coda been fully complied with? ❑ Yes ❑ No --- _...._.. ... ... _....... —... .. _ .... ............ ............... ..... ............ ........_ _r _.... _.. 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agoncyr LJ Yes j� No (Section 65850.2 of the California Govemmegt Code requires that the requested information be furnished on applications for nun -residential building permits). ....... ........_........ ............._..... .............. ............ _... - �...._...........-- - ........._.............._....................................................... ...... _....._... 8 Wii1 any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yos ❑ No (If 'fres", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). __................._.......__ ............--........._..............-----......... ......_..................... _....................................................... ......................................................... .._.............. ........ ...... .............. ......................... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which Is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ....._................................---------................._.c'e, ....._..................---- -- po'l.."it'i'................o"T •---er')*.................................................................................................�................................._..................__.._................. 8 (If 'j�es", attach certificate of compliance from the appropriate Bir pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature 01 Legal Owner(s) r �Q Data L==== 1 41 AgdlOr Authorized.Appljcanl _ Date CODE !. INSPECTION TYPE Q f1T19L$ CODE ILf,5PECT10N TYPE PdiE flfTITIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final _ 208 Final Plumbing 200 Final Re -Root 210 Final Electricals 201 Final Block/Retaining Well _ 212 Final Fire Prevention 202 Final Factory Fire Place _ 220 Final Planning Approval 203 Final Sign _ 222 Final Site 2D4 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 FIRE SUPRESSION PERMIT Job Address: 3333 BRISTOL ST Suite: 1500 Vicinity: 1500 Parcel Number: 41249102 Zoning: PDC PDC Applicant: RANDY MANCINO Address: 818 N GRAND AVE Phone: (626) 913-6720 COVINA, CA Zip: 91724 Owner: SOUTH COAST PLAZA Address 3315 FAIRVIEW AVE MISC. Phone: COSTA MESA, CA Zip: 92626 Cohtractor: ALLREADY FIRE SPRINKLER CO Address: 818 N GRAND AVE SPRINKLER HEADS. REF: B04-01809 Phone: (626)913-6720 Status: ISSUED Applied: 12/07/2004 Issued: 02118!2005 ISSUED BY: COVINA, CA Zip: 91724 License: 358795 SCOPE OF PERMIT FIRE SPRINKLER PERMIT FOR INTERIOR T.I. FOR "CHANEL" (SUITE 1500). RELOCATE 48 FEE SUMMARY Plan Check: $99.61 Calc Valuation: $7,500.00 Permit: $153.25 Claimed Valuation: $7,500.00 Other: $0.00 Total: $252.86 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or it work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 t44s.46 (6=) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. ❑ I have and will maintain workers' Compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' cope satlo Insurance terrier and policy number are: �1 [� / Carrier. �� f1 K L A? S �c e2 _ Policy Number: _1 .. L) /LI;Eo � (This section need no be completed it the parmif Is valued at one hundred dollars ($10-0) or less.) ❑ I certify that in the performance of the workfor which th rmit is issued, I shall not employ any person In any manner so as to become subject to the workers' compensation laws of Callfom€ nd agree that if I ld become.subject to the workers' compensation provisions o1 Section 3700 of the labor Code. I shall forthwith comply with the �^ Applicant Signature. _ __._� --`-' ---- Date: WARNING: FAILURE TO SECURE WORKERS' PENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE (5700.000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under pr°�visions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Prof ess€ons ode, and my license Is in full force and effect. L€c. q :3 �i 7 7. , Class k G Contractor's Signature: r r dq Data: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this perm€i is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the lollowing reason (Sec. 7031.5, Business and Professions Code: Any city or county which requiros a permit to construct, alter, Improve, demolish, or repair any structure, prior to Its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (Commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner o1 the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professions Coda: The Contractors License Law does not apply 10 an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or site did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Data: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type o1 document, Le. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet In depth Into which a person is required to descend, will be made In connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec, 341, Title 6, California Administrative Code). ❑ As owner-bullder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: i Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ NO (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Caste Mesa Fire Department by every business which has at any one lime during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .............. .......................................................................................................................................... _............. _............................................... ...,,,.,.,.......................................... ........ "".,................._................................................... 2 Doas or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). -----.._.._.....-----._............_.._...............................—...........�................—...........__................_........................... .............. ....._.............................................. ......_._......................................................... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP {Risk Managomeni and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. _......._.........._....�._..__......... _.. ..............._ ........................ — ....._— ...... _.....__ .............., ................_.�....._..... .............._......... nd .........................................._....... 4 If an RMPP is presently required, has Sectlon 25534 of the California Health eSafety Code been fully complied with? ❑ Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a pllcatlon aggarm€t for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes LJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ............................._...._._......................................._._................—.._....---............. �._.............. ............................................................. ....._........_........................ ._....................................... .......... 6 Will any pert of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 a1 the California Health and Safety Code). _ _._.. ---............—............—..........__._................._................................................... _......_._.._..-...................................................................................... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No .. _(If_..........__.._. ............e appropriate --.._..... ..... ............ ...... .............. ----... _..._-.._............................. ..... 8 (lf des', attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I conity under penalty of perjury that I have read this application and state that the information given is correct. I agre to comply with al .state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-dasc ' ed ro arty lar•' peCliompurposas..l.agre�not to occupy or allow occupancy of any building authorized by this permit until final Inspection. —5ighatura-Of Legal Owner(s) Date And/Or Authorized Applicant Dale CODE f. INS,PECj]ON TYPE 2M RMALS CODE INSPECTION TYPE INTMALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Stock/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Silo 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 www.ci.costa-mesa.ca:us 77 FAIR DRIVE:.COSTA MESA, CA 92626 ELECTRICAL PERMIT Job Address: 3333 BRISTOL ST Status: ISSUED Suite No 1500 Applied: 04/26/2005 Vicinity: BACK OF HOUSE AT LOWER LEVEL Issued: 04/26/2005 Parcel Nunmber: 41249102 Applicant: FRANK NALIBOFF Address: 140 LOMAS SANTA FE,-" $23.50 SUITE 200 I Temp service test SOLANA BEACH, CA Busway 1100 K' Res. a/c package Owner: SOUTH COAST PLAZA .. _ New Res (1-2 units) $0.00 Address 3315 FAIRVIEW AVE ,' $0.00 , Pool 1 Spa MISC. ' 0 COSTA MESA, CA Phone: (858)793-9104 ; Zip 92075 Phone: Zip: 92626 ISSUED BY: Contractor: DICKINSON CAMERON CONSTRUCTION INC Address:. 140 LOMAS SANTA FE _ SUITE 200 rPhone: (858) 793-9104 SOLANA BEACH, CA-, - Zip: 92075 License: 690239 SCOPE OF PI=RMIT REMOVE AND SECURE EXISTING LOW VOLTAGE EQUIPMENT AT BACK OF HOUSE AREA ON LOWER LEVEL FOR "CHANEL" SPACE 1500 REF.: B04-01809 AND E05-00086 FEE SUMMARY Quantity ISSUE FEF $23.50 Temp Dist System / Lighting Temp service test $0.00 Busway 1100 K' Res. a/c package $0.00 Standing Section New Res (1-2 units) $0.00 0 New Res (3+units) $0.00 0 Pool 1 Spa 30.00 0 Lighting Fixts $0.00 0 Recept Outlets., '$0.00 0 Switches $0.00. ;; r 0.' Non Res Appl' �. $0.00 ;� ,� '0 Res Appl ,� $0.00 : �0 l Service to 200a $0.00 ti 0 Service to 1000a SOHO 0 ; Service over 1000a $0.00 , , 0 Motors to 1hp $0.00 "o . . Motors to 10hp $0.00, 0 Motors to 50hp $0.00 0 Motors to 100hp $0.00. 0 Motors over 1 00h $0.00 0 Communication drops $0.00 0 Sub panel to 200a $0.00 0 Pole Light Pkg $0.00 0 Sign Circuits $0.00 0 FEE SUMMARY Quantity Temp Dist System / Lighting 50.00 0 Busway 1100 K' $0.00 0 Standing Section $0.00 0 Misc Electrical Equipment $0.00 0 .-Transformers up to 1 kvalkw $0.00 0 .....up to 10 kvalkw $0.00 0 ..................up to 50 kvalkw $0.00 0 ...............up to 100 kvafkw $0.00. 0 .....over 100 kvafkw ; " $0.00 ' 0 Low Voltage Equipment '518.20 - %1 Low Volt Wiring System / CkC•, - $0.00 0 Misc. Conduit , $0.00 � 0 Misc. Conductor- $0.00 0 Circus (gen or.ride) $0.00 ,0 Circus (mech ride or lights) .$0,00 0 ChristmasTree'Stand'. $0.00 '0 Fireworks Stand' ,, $0.00 0 Other Electrical Fee • .$0.00 Investigation Fee, '% $0.00 "Plan Check Fee $0.00 Reinspection Fee $0.00 NOTICE:. The.work authodzed.by•this permit shalllcomply with all applicable handicap -access. requirements. under Califomia statutes and related regulations., (Ord. No: 92-28, § 1, 12-21-92)' -EXPIRATIONr-This.permit -shall automatically expire and.become.void.lf work isnot commenced.within 180 days; or if work is suspended or abandoned -for a.pedod of 180•days. INSPECTIONS:, in -order for, the !work.authorized : under, this permit ito•be considered.legal; such Iwork, must; comply with -all applicable codes, and alP .required,Inepections•andfinal:approval•must be obtained - Failure :to obtaiminspeclions and.final approval will result In.the expiration of.this pe t. 'FOA INSPECTIONS'CALL:. (714) 7546626=_ 2+n54e (SW) •, r DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the r_1 rk for which this permit is issued. ve and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the pedomranco of the work for which this permit is Ir -sued. workers' co ensat!on Insuran a arrier aln�d oil cnu�mb0 r QP) _1 . RUC �V'� PolrcyNumtijr:�Zo-1 2 1,.fes tion need not be completed if the permit is valued atone hundred dollars ($100) or less.) Ice" that in tha perfo ante of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' ompensation laws o Iltomta, and agree that I[ I s ou�bePidbct to the workers compensation provisions of Section 3700 of the labor Code, I shag forthwith comply with these Bions. r� ADpfiraniSignaturw— ,W URE -TO 5 E WORKERS' OOMPENSATI ERAOE U WFUL AND SHALL SUBJECT AN EMkOVEWTO CRIMINAL PENALTIES AND CML FINES UP TOONE HUNDRED �DOLLARE !fol iN ADDMON TO THE COST OF ON, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTArTORS DECLARATION: I hereby affirm that I am licens er rev' ' hapter 9 (commencing with Section 7000) of Division 3 of the Busin and P%o�fe�sslo,�ssC�ode, and my license Is In full n effect. Lic. ti v Class 1r _: � `+�` n rector. s•5lgaatare:: Data: CONSTRUCTION ODING AGENCY: ❑ 1 hereby aff that there Is a construction Lng agency for the performance of the work for which this permit Is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who Contracts for such project with a contractors) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner TO verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, I.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet In depth into which a person Is required to descend, will be made in connection with work authorized by this pemnit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and cenity a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? [:]Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal 10 or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ......................................................................................................................................................................................................................_......M............................1._.....__...._._................................. ........ ......» 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No DSection 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire epartment of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. _.._...... ....................»..»..............................._...................................... _ __....................—..----....--....................—.__...................... __ ._............ 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? El Yes ❑ No ». ..... _ _......._. _ ................ _._._._._....—._.._............. _................... _.—............... — 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this gigplication afermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes LJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). —_ ..................... ....................... ..._.....�_ »».......... ............._............... »» ..............—._....._........__.._.....................................—_...----........- ........................... 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a School? ❑Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). _ .......................... ........................».............._..... ....................... ................................................... ...................................................... ......-...................................................................................-...................—....................................__._. 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes [3 NO _.. _............ ............. ................................. _... _...................................... ..._........ --•--............................................ 8 (If "yes", attach certificate of compliance from the appropriate air pollution control officer}. CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the Information given above is correct. I agree to comply with all state laws and cityordinances regarding Hazardous Matertals and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of pedury that I have read this application and state that the information given is correct. I agree to comply with all state taws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Date AndlQr horized A is _YA r5," Vii, t�Dai`. - If ° I - • 2&g INTMAL CODE 1 INSPECTION TYPE ' Q&U 1NTITIA' 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical $ 201 Final Block/Retaining Wall 212 Final Fire Prevention iP 202 Final Factory Fire Place 220 Final Alarming Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy M CITY OF COSTA MESA BUILDING DIVISION DEVELOPMENT SERVICES DEPARTMENT PERMIT I PERMITINUMBER B05-00341 (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 BUILDING PERMIT .lob Address: 3333 BRISTOL ST Suite: 1500 Vicinity: SPACE 1500 Parcel Number: 41249102 Applicant: GUS MOHLER Address: FOVELL ENTERPRISES INC CORONA, CA 1540 COMMERCE ST Address: UNIT G Owner: SOUTH COAST PLAZA Address 3315 FAIRVIEW AVE Phone: MISC. COSTA MESA, CA Contractor: SOUTHWEST SIGN CO Address: FOVELL ENTERPRISES INC CORONA, CA 1540 COMMERCE ST Zip: 92880 Zoning: PDC PDC ISSUED BY: Phone: 909-734-6275 Zip: 92880 Phone: Zip: 92626 Phone: 909-734-6275 License. 724929 Status: ISSUED Applied: 03/02/2005 Issued: 03/02/2005 Arch : Eng: Address: Address: Phone: Phone: Zip: License: License: SCOPE OF PERMIT INSTALL 1 NON -ILLUMINATED FOR'CHANEL' IN SPACE 1500 FEE SUMMARY Plan Check: $35.10 Calc Valuation: $1,500.00 Permit: $54.00 Claim Valuation: $1,500.00 SMIP Res: $0.00 SMTP Com: $0.50 Other: $0.00 Inspection: $0.00 Total: $89.60 PLANNING & ZONING SETBACKS MAIN STRUCTURE Front 0-0 Rear 0-0 Left 0-0 Right 0-0 ACCESSORY Front 0-0 Rear 0-0 Left 0-0 Right 0-0 PARKING Existing: 0 Required: 0 Proposed: 0 NOTES: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result In the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 !446.46 (61001 WORKERS' C MPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers' componsation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ( !I ave and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. 41y workers' co`mpgnation Insurance car or and policy number are: / I - n CaTr a""�+ 7�7>~�e Er IA Pbncy N r: ! CP r t D 7 �., _.0 section need not be completed if the permit is valued at one hundred dollars ($140) or lass.) ❑ I certify that in the performance of the work for which this permit is Issued, I shall not employ any person In any manner so as to become subject to the workers' compensation laws o1 California, and agree that It I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provi ,Appittrnrsat�tt"ra:F EDate:+ _• 3 �--%C� 1�MNtNQ: FAILURE TO SECURE WORK?Pd- COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN E�R TO'CRIMINAL PENAL IES AND CAVIL FINES UP TO ONE HUNDRED OUSAND DOLLARE ($100,000), IN ADDRION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I _ _y.Aftfrm.that.lt, m.11ceonsed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the•Bu� s� s and Professions Code, and my license is in full force and Contractor Signature:_., _ r tD ate;, CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there Is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty o1 perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption, Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sac. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. 11, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, talsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 W III the applicant or present or future building occupant need to file and cenity a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 01 the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet a1 compressed gas at standard temperature and pressure). _............................__....................---._.._....._........_ _......... .......... _ ...........,,................................................................. ..._...— ......... . 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materIats7 ❑ Yes ❑ No (Section 25533 of the California Heahh and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ................................._ __..............................__.................._........................... .........._.................................. ......,............................................................................. _.................... _..................... -......... I.......... .... 3 Does or will the applicant or present Or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. —__.._........................................_.._.................................. __..............................................................................................................................................................._...........m......................_................._....... 4 If an RMPP is prey required, has Section 25534 of the California Health and S sentlafety Code been fully complied with? ❑ Yes ❑ No _ _ ................................_._............................. .................. ............................................................ __................................................... ............... _.......................... ........... __................... _.................. — 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this application a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes No (Section 65850.2 of the California Government Code requires that the requested Information be fumished on applications for non-residential building permits). ................_...... ................. .. -.......... - ----.........._—...._.. .........,............ __.................. ..._........................-----------....... ... ----- t3 will any pan of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if 'fres", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). If .. -i.......... ••-----•--.._...-- -- ----......_— ........ ......... . � .................. _............................ __ __. 7 a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the Subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ..._.............. _._..__............ ................................................. ...__..................-................ ................................. ..................... ........................_._...................... _........................... 8 pf yes', attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the Information given above Is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. t agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Legal Owner(s) Data DdLOc-4a hwzed•AppUoent-------,-,•,,- CODE P. INSPECTION TYPE )Aja INTITIALS CODE INSPECTIONTYPE 1NTITA4 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site r� 204 Final Demolition 250 Final Building/Occupancy r7 rr — CITY OF COSTA MESA BUILDING DIVISION s FOB -00101 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us r FOR INSPECTIONS CALL: (714) 754-5626 FIRE SUPRESSION PERMIT Job Address: 3333 BRISTOL. ST Status: ISSUED Suite: 1410 Applied: 05/06/2008 Vicinity: Issued: 05/06/2008 Parcel Nunmber: 41250107 Zoning: PDC .PDC * Applicant: PULIDO,,DANIEL • .•; :F, ,� Address: 818 N GRAND AVE Phone: 626-913-6720 COVINA, CA 1;, r Zip: 91724 - - A Owner: SOUTH COAST PLAZA_ Address 3315 FAIRVIEW RD Phone: COSTA MESA,,CA Zip: 92626 Contractor: ALLREADY FIRE SPRINKLER - - Address: 818 N,,GRAND;AVE ? Phone: 626-913-8720 COVINA,,CA ,,li. Zip: 91724, License: 358795 SCOPE OF PERMIT FIRE SUPPRESSION PERMIT TO RELOCATE 2 SPRINKLER HEADS FOR AN_ 1TNERIOR T.I. TO "VAN CLEEF & ARPELS,,, SUITE,1410. REF#: BC08-00045 FEE SUMMARY - Plan Check: $21.22 Calc Valuation: $800.00 Permit: $32.65 Claimed Valuation: $800.00 Other: $0.00 Total: $53.87 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the worts authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE t. INSPECTION iYpE DATE INTMALS CODE 1 INSPECTION TYPEflAj N� 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof _ 210 Final Electrical (� 201 Final Block/Retaining Wall 212 Final Fire Prevention2 202 Final Factory Fire Place _ 220 Final Planning Approval 203 Final Sign _ _ 222 Final Site 204 Final Demolition _ 250 Final Building/Occupancy WORKERS' COMPENSATION DECLARATION: 1 hereby affirm under penally of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by action 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy numberare: (Carrier; &/'YA P"r ll Ll�r ll_ (This ZiRim need not be completed ff The perrmt is valued at are hundred dollars ($100) or fess.) Policy Number: //V�y ��� 7,17a W ❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should becom sub) o the workers' compensation provisions of Section 3700 of th or C de, I all forthwith comply with these provisions. Applipn['s Signature Date ; WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL. AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force/and effect. / Class # r-Contrattor's Signature Date CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that then; is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code), Lenders Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of -perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale., If. however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ f, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature Date 3057-46 (3ro7) Owner ID verified by driver's lict ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or mon: feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division, Applicant's Signature Division of Industrial Safety Permit Number: Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be flied with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution Control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (if 'yes'. attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state taws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. S ria:ure of L al 0%vrier(s) Date ndlar Authorized Applicant—,Date (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT Job Address: 3333 BRISTOL ST Suite No 1410 Vicinity: SPACE 1410 (VAN CLEEF AND ARPELS) Status: ISSUED Applied: 02/1512002 Issued: 02/1512002 Parcel Nunmber: 41250107 Applicant: SCHELIN, KEVIN ISSUED BY: Address: 136 E GARRY - 'r Phone: (714) 556-8591 - SANTA ANA; CA Zip: 92707 Owner: SOUTH COAST PLAZAS Address i i' • - COSTA MESA CAS Phone: 3315 FA[RVIEW-ROAD Zip: 9262$ Contractor: SMALLCOMB WIRING CORPORATION Address: 136 E GARRY _ Phone: (714)556-8591.' SANTA ANA,•CA Zip:- 92707 . �• License: 145961 ,.. SCOPE OF PERMIT ELEC PERMIT FORINT'STORE.TI FOR ".VAN CLEEF 8 ARPELS"; IN,SPACE 1410. 94 LIGHT FIXTURES, 28 OUTLETS, 14 SWITCHES; 1 SERVICE TO 200A, 1 SUB PANEL TO 200A. REF: B02-00111 ` FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 Temp Dist System / Lighting $0.00 0 Temp service test $0.00 Busway 1100 ft $0.00 0 Res. a/c package. $0.00 Standing Section $0.00 0 New Res (1-2 units) $0.00 0 Misc Electrical Equipment $0.00 ', 0 New Res (3+units) $0.00 0 - ='' Transformers up to 1 kvalkw $0.00 , 0 Pool I Spay $0.00 0 ..up to ,10 kvalkw $0.00/ • 0 , Lighting Fixts '$76.02 94 up to 50 kvalkw :, ;,L_ .,$0.00 ; 0- Recept Outlets ; $27.84 28 ........ .....up to 100 kvalkw; s $0.00` 0 Switches =,$15.40::;' , 14 ,, % ...........:......over 100 kvalkw ' ' $0.00,- 0 Non Res Appl $0.0D =.� 0 Low Voltage Equipment, "' _ $0.00 0 Res Appl $0.00-0�� . Low Volt Wiring System I Clef $0"00%,-,.0 Service l0 200a �� $30.50 1 : I Misc. Conduit $0.00 0, Service to 1000a $0.00 0 Misc. Conductor $0.00 r 0 Service over 1000a $0.00 , 0 Circus (gen or ride) $0.00 - % 0' Motors to 1hp $0.00 -0- i Circus (meth ride,or lights) Motors to 10hp "$0.00 0 Christmas Tree Stand �- $0.00- 0 (' Motors to 50hp $0.00 - 0 Fireworks Stand /.- 50.00 0 Motors to 100hp $0.00 .0;-- �_ Other Electrical Fee ____S0.00 Motors over 100hp $0.00 Communication drops $0.00 0 " ' Investigation Fee " $0.00 Sub panel to 200a $30.50 1 Plan Check Fee $0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $0.00 0 Temp Pwr Pale $0.00 0 TOTAL CALCULATED FEES $203.76 Intermed Pole $0.00 0 COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void It work Is not commenced within 180 days, or it work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 2"6-+e (ts+oo) N DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of polury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the for which this permit is issued. EY't have and will malntgin workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this penult is Issued. My workers' comPansatio nsurance carrier and policy number are: Carrier: _ _ i Pi �f r , �z- Policy Number. (This section need not he completed i1 ftpermit& valued atone hundred dollars ($100) or lass.) ❑ I certify that In the performance of the work for which this permit is Issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws c California, ag a that If I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these p tions. _ Applicant Signature: - Date: WARNING: FAILURE T- S ECtRE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUB.IECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE {$100,0001, IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3705 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am lice under provisions of Chapter 9 (commencing with Section 7000) o1 Division 3 of the Business of d Professions Code, and my license Is in full force and effect. Lic, a Class A C f (D Contractors Signature: Date: S — 0')L— CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is issued. (Sec. 3097, Civil Code). Lenders Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-buildor will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Profasslons Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or dead): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsawork, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 6, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Data: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _...................................................................................................................................................................... .......................................................... _................ 2 Does or wit! the applicant or present or future building 000upant need to [Ile a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight o1 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ........................... ........................... ................................................ ...................................................................................................... ....................................................... ...................... ....................,...-""................. ................ —............ 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the l=ire Department. 4 If an RMPP Is presently required, has Section 25534 of the California Health and Safety Cade been fully complied with? ❑Yes ❑ No _ .....................—..._...---.._ _...................._.............. ...................... __.._.........................---................._..... ........ _. �...... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication agermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes [ J No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any pan of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑-Yes ❑ No (1f "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 11 a permit from the South Coast Air Oualq. Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑Yes ❑ No ....................._ ._........................_................................... _—._.....................—...._................................ __. .... ............. _.�--- 8 (If jres', attach certitlCate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Dale: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given Is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. L= V.Signature Of Legal Owner(s) Date AndlOr Authorized Applicant Date CODE f, INSPEUQN TYPE Q,,jE j1 SAODE! INSPECTION TYPE fiAiE I TTTLA1a9 1616 Fixed System Final Fire Prevention 206 Final Mechanical 126$ Pool Spa Final 208 Final Plumbing , 1 200 Final Re -Root 210 Final Electrical rl 201 Final Block/Retaining Well 212 Final Fire Prevention 202 Final Factory Fire Place .220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy a (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 PLUMBING PERMIT Job Address: 3333 BRISTOL ST Status: ISSUED Suite No 1410 Applied: 02!1912002 Issued: 02/1912002 Vicinity: SPACE 1410 (VAN CLEEF AND ARPELS) Parcel Nunmber: 41250107 ISSUED BY: Applicant: GRIMM, DAVID Address: 387 SMOKERIDGE-TERRACE Phone: ,(714) 283-1586 ANAHEIM; CA = ; , .Zip: 92807_, Owner: /SOUTH COAST PLAZA Address�� COSTA MESA CA Phone: X�`� 3315 FAIRVIEW ROAD Zip. 92626 �•, Contractor: J E D S PLUMBING `Address: 387 SMOKERIDGE-TERRACE- �< Phone: -(714) 283 -1586 - ANAHEIM, CA Zip: 92807 ' License: 547467 Arch l Eng Address: Phone: :- Zip r- 1' i _ \ .w License:- SCOPE OF PERMIT` PLUMBING PERMIT FOR INTERIOR STORE TI FOR "VAN CLEEF & ARPELS' IN STE 1410.2 FLOOR DRAINS, 1 KITCHEN SINK, 1 WASH BASIN, 1; WATER CLOSET, 1 WATER HEATER/VENT.. REF: -1302-00111 1 FEESUMMARY AMT QTY AMT QTY AMT QTY ISSUE FEE \ .1$23.50. ` Laundry Tub 1 Washer $0.00 0 Sump Pump ' : $0.00 0 Backflow irrigation, $0.00/ _0 ` .' `\ Landscape krigation . $0.00 0 - Swimming Pool �; �' $0.00 0 Backflow Preventers x$0.00' , ,0 -P-Trap $0.00 -: 0 _, -- Trap POmer$0.00 0 Bathtub $0.00 0 'Pressure Regulator. $0.00 0 Urinal'i�%/� $0.00 0 Clarifier System $0.00 0` Process Piping (per 10 ft) $0.00 r 0 Vacuum Brkr Bkffow(1-4) $0.00 0 Connect (Ice,Soda,etc) $0.00. `0, Receptors $0.00 `0~ '1 V -Vacuum Brkr-Bkftow(5+) $0.00 0 Dental Units $0.00 0 Septic Tank $0.00 0 Wash.Basin $9.80 1 Dishwasher $0.00', -0-' Sewer Cap for Demo $0.00 0 -Wash Basin Set S0.00 0 Drain, Floor $19.60 2, ` Sewer Connect, \'--, s ; , , $0.00 0 Waste and Vent System $0.00 0 Drain, Rainwater $0.00 0 Sewer Private Line $0.00 '0 Water Closet (Toilet) $9.80 1 Drain, Roof $0.00 0 Shotier ",,- $0.00 ' 6- Water Heater/ vent $12.30 1 Drinking Fountain $0.00 0 Sink, bar $0.00 0 Water Piping (Inst or Rep.) $0.00 0 Expansion Tank $0.00 0 Sink, commercial $0.00 0 Water Re -pipe $0.00 0 Gas Earthquake Valve $0.00 0 Sink, Floor $0.00 0 Water Service $0.00 0 Gas (1-4 outlets) $0.00 0 Sink, kitchen $9.80 1 Water Softener $0.00 0 Gas (Over 4 outlets) $0.00 0 Sink, service/mop $0.00 0 OTHER $0.00 Gas Repipe $0.00 0 Spa (private) $0.00 0 VIOLATION $0.00 Gas Service $0.00 0 Spa (public) $0.00 0 PLAN CHECK $0.00 Interceptors (Grease, Oil) $0.00 0 REINSPECTION $0.00 0 Interceptors (Sand Auto ) $0.00 0 TOTAL CALCULATED FEES: $84.80 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, g 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or If work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2448.46 (M) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. MJ—_L have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. My workers' compensation Insurance carrier and policy number are: Carrier. — = , Policy Number: �±.'9 3 c9 tl / Cao 9 ..7 (This section need not bm completed if the permit is valued at one hundred dollars ($104) or less.) ❑ I certify that in the.performance of the work for which this permit Is Issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that If I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these pr ions. Applicant Signature: Date: 2-14A4/0 :2 WARNING: FAILURE TO SECU SATION COV GE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($1 ADDITION TO THE OOST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and affect. Lic. f1 C --c/ % Class N C-7 Contractor's Signature: Date: CONSTRUCTION Lfiff6rNG AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, atter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) o1 Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds Or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Drivers License No, Expires: Verification Of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant of present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity o1 hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). �-�..... -..................................................................................................................................•-•--.......................................................................................................................................................................... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). -•------................................................................................. ....................................................................................................................... ......................................................................................................... 3 Does or wiIi tho applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ................................. .15,......................y, r'..........e"d, ................ct'i............................................'o,r'"i'a.............................. f-e-t-y"'................................................................................................................................................................................. 4 If a.. Pispresently required, has Section 25534 of the California Health and safety Coda been fully compiled with? ❑Yes ❑ No ............................................................................................................................................................................................................................................................................................................................................................................................ 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ........................................................................................................................................................................................................•----•---..................................................................................................................._..---............................................._. 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? []Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). T­--if- ........................................................................................................................................................................................•---.................................................................................................................................................................I.......... If a permit from the South Coast Air quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ..................................................................................................................................................................................................................................................................................................................................................................... 8 {If yes", attaoh certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described properly for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. SignatureI Legal Owner(s) Date r uthorized Applicant Date CODE L INSPECTION TYPE INTRIALS CODE f INSPECTION TYPE j&,U„ INTITIAL$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical L p� 1266 Pool Spa Final 208 Final Plumbing 'T •a i _ o� 200 Final Re -Roof 210 Final Electrical 201 Final Block/Refaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/OccupanW . `I (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 MECHANICAL PERMIT .lob Address: 3333 BRISTOL ST Status: ISSUED Suite No 1410 Applied: 03122!2002 issued: 03122!2002 Vicinity: :SPACE,1410 (VAN CLEEF AND ARPELS) Parcel Number: 41250107 - - ISSUED BY: Applicant: SANDERS, BILL Address: 1140 RED GUM'S? /i Phone: (714)630-3200 ANAHEIM, CA Zip: 92806 Owner: SOUTH COAST PLAZA, Address: " COSTA MESA CA Phone: 3315 FAIRVIEW ROAD Zip: 92626 �\ " Contractor: 7THERMALAIR INC Address: 1140 RED GUM ST t�Phone: (714) 6343200 ANAHEIM, CA Zip: �� 92806 - License: 102216 ' SCOPE OF PERMIT ` MECH PERMIT FOR.INTERIOR STORE TI FOR "VAN CLEEF & ARPELS" IN SPACE 1410. 1 REPAIPJALT COOLING/HEAT; 1 `VAV BOX;,1 VENT FANISINGL E DUCT.'REF: B02-00111 FEE SUMMARY Quantity, y � Quantity ISSUE FEE $23.50 _ Repair I Alt A6sorbtion Unit $0.00 "0" Inst FAU <100 k BTU $0.00 C Repair I Alt Refrigeration Unit $0.00 0, Inst FAU >100 k BTU $0.00 0 Ventillation.System $0.00 0 Repair l Alt Cooling/Heat $13.70 1 Evaporative Cooler $D.00- 0 Inst I Rep. Recess Wall Htr $0.00 0 Commercial Incinerator $0.00 0 - Refrig Sys <100 k BTU $0.00 0 Domestic Incinerator $0.00- 0; ,- Refrig Sys >100 k BTU $0.00 0 Compressors ! Absorption Systems Gas Pipind , $0.00 0 ,' -Up to 3 hp / 100 k BTU $0.00" 0 Factory' Fireplace ,> $0.00 0 '" ' 3 To 15 hp/500k BTU $0.00 0 Hood w/MecbrExhaust" \' - ' . $0.00 0 15 To 30 hp !.1,000 k BTU ' ; . ' $0.00' 0 VAV Box 30 To 50 hp L 1,750 k BTU / ' $0.00 0 Vent Fan 1 Single Duct $7.25 1 Over 50 hp 1 Over 1,750 BTU " , ' $0,00/ 0 Appliance'���� $0'.00 -0 Boilers Fire Dampers' � Up to 3 hp $0.00 0 Smoke Dampers v, x$0.00 �`0 ;� 3 To 15 hp $0.04 0 Inst or Relocate App] Vent $0.00 , . 0 15 to 30 hp $0.00 0 Air Handlers < 10000cfm . ` -$0.00 D 30 to 50 hp $0.00 0 Air Handlers > 10000cfm $0.00,,,-'0 Over 50 hp,, j' $0.00 0 Floor Furnace $0.00- 0 Other Mechanical Fee Floor or Suspend Heater .,50.00. 0 Investigatiori Fee ' $0.00 Plan Check Feer $0.00 _Reinspection.Fee= $0.00 TOTAL CALCULATED FEES $55.10 COMMENTS/ SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 2"6-46 (SM), DECLARAMNS WORKERS' COMPpNSATION DECLARATION: hereby affirm under penalty of perjury one of the following declarations: ❑ i have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 1 have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this {hermit is issued. My workers' cgmpensailon Insurance carrier and policy number are: Carrier. t L O' - V Y Policy Number.e. - _O 1 (This section need not be cbmpleted it the permit is valued atone hundred dollars ($100) or less.) ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that 111 should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith Comply with these rovis.ions. Applicant Signature: -is uL � AI> _ Date:�- WARNING: FAILURE Tb SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($1 OD,DDO), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Coda, an�dlicense is In full force and effect. UC. # Class # C !09AC-7-0�C.S� Contractors Signature: Zoo 4Q _ Qu Date: 3 - 22 CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: _ Lender's Address: Signature: _ Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that Under penally of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professlons Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner o1 property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for safe. If, however, the building or Improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Seo. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: © I hereby Certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in Connection with work authorized by this permit, and that no building Structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feel high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title S. Califomia Administrative Code). ❑ As owner-builrlor, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do Such work from the division. Signature: _ Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic foot of compressed gas at standard temperature and pressure). ....................................................................................................................................................................................................................................................................................................... _...... .............................. . .................. _ 2 Does or wyl the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ................ ......................... ............................................ ...._............................. _................................................................. ...............................�.................................................... ................................ __............... .................. ................... �. 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the Califomia Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. .................................................................................................................................................................................................--................,.......................................................................................... . .................. _...... 4 I! an RMPP is presently required, has Section 25534 of the Califomia Health and Safety Code been fully complied with? ❑ Yes ❑ No — ---.._............................................... _ .........'­ ... ---.......................__.._.......... _...... _....................... ....._............,..__.................... ._................ — 5 Dass Or wiff fhb applicant or present or future building occupant require for the work which is the subject of this a plication apparmit for such construction or modification from the South Coast Air Quality Management District or from any other air pcilution control district or agency? U Yes LJ No (Section 65850,2 of the California Government Code requires that the requested information be furnished on applications for non-residenlial building permits). —.........._..._._�__.................. ......................._._�._. ...._.._............... _ .....................••.............. -- .................... __....,.._ ___...... _................... T .............. _—...._. 6 Will any part of the iacifity to be constructed under this permit be within 1000 foot from the outer boundaries of a school? ❑ Yes ❑ No (It -/es", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ........._._.................••-----_..................................._----.,...............-----------.............._...................................................-------.._..............................._._............................._.._.....,.......---..._.—._.....---.. 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by Califomia Health and Safety Code Section 42303 been made? ❑ Yas ❑ No __................................................ _............................. _..................................... ............................... ........-----................ -----.................................................................. _.—._............ __.................. __............. __..... B (If bras", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signalure: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signet a Of Legal Owner(s) D@te And/Or Authorized Applicant Date CODE;. INSPLGII211-11PE 2M I�IAL�4 QgDE INSPECTION TYPE 2&UlINTr ASL$ 1816 Fixed System Final Fire Prevention 206 Final Mechanical - ! 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Blook/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 BUILDING PERMIT Job Address: 3333 BRISTOL ST Status: ISSUED Suite: 1410 Applied: 01/23/2002 Vicinity: STE 1410 (VAN CLEEF AND ARPELS) Issued: 02!1112002 Parcel Number: 41250107 Zoning: PDC PDC Applicant: WATSON, DUSTY ISSUED BY: Address: Phone: 714-662-7933 - /,,!% ' 4' Zip: Owner: CMF,INC:%oWESTFIELD CORP Address ATiTN RORY PACKER.ESQ./ LOS ANGELES; -CAS Phone: x,11601 WILSHIREBL.I2TH FL. ` Zip: 90025 Contractor: '-WATSON�CONSTRUCTION INC. Address: 1260LOGAN "AVE UNIT 6002 Phone:,' (714) 662-7933 COSTA MESA, CA Zip: 92626 License:; 705797 i Arch : INTERIOR SPACE INTERNATIONAUFRANK LIMAHELUEng: Address: 10960 WILSHIRE BL Address:, ` STE 900 l" Phone: -310-473-5358 Phone: LOS ANGELES, CA Zip: 90024 "-License: C14425 v' License: - SCOPE OF PERMIT 1250 SF INTERIOR STORE TI FOR "VAN CL'EEF &-ARPELS" IN.ST9.1410.` ` �r,'.' i FEE SUMMARY Plan Check: $269.77 ` ,� i' Calc Valuation: r $218;750.00 Permit: $1,660.15- 4 �; Claim Valuation: $218,750.00 SMIP Res: $0.00 / ;SMIP Com: $45.94 Other: $0.00 Inspection: ..$0.00 `,Total: $1,975.86 PLANNING & ZONING SETBACKS,-_;� MAIN STRUCTURES Front %.0- 0 �= Rear`s z,0- 0 Left 0- 0 " =_. `Right _ v\0 "0 , ACCESSORY 'Front �,-0- 0 Rear_ 0- 0 Left 0-0 Right- • 0-0 - PARKING Existing:,�- 0 Required: ` 0 Proposed: 0 ` NOTES: ' r NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 244646 {6+00) DECLARATiONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: [��My I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ave and will main "n workers' COm nsation insurance, as required by section 3700 of the Labor Code, for the performance at the work for which this perm€tis €sued, workers co t€on��[,is(ur ce rrier and number ere: Policy Carrier: Poli Number: (This section need not be completed ff the permit is vale at one hundred dollars ($100) or lass.) ❑ I certify that in the performan o the work far hich thi ermit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Califo € an agree ih iI I sh be ome subject to the workers' compensation provisions of Sectio 3700 of the Labor Code, I shall forthwith comply with these provisio Applicant S€gnature: l Date: u WARNING: FAILURE TO SECURE WORKERVOOMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUB.jECT AN EMPLOYER TO CRIMINAL PAN TIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($t 00.0130 , IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLA TION: I hereby affirm that I am licensed un pro isions of C pter 9 mm npi0 i tiop�000) of Division 3 of the Business and Prof e s C e - license is in full force and effect. Lia ft (� t Class # Contractors Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance at the work for which this permit is issued. (Sec. 3097, Civil Code). Lenders Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Coda: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) o1 Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant t4 a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and tate structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the properly, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contracto(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Cade requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ..............._...................................... -.... ........ ................................................................................. ........ -....................... _............................ _............... .............................. __.................. _... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 o1 the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity Of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). -—._._.......................... --- _..............................................•....................... --...................... ---..................... —...................... —................ —................... —............... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the Cal€Tom€a Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, Certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ................................................................................ ct.......................................................................n. d'........."it,y"....'o"d..................................... tie,.............................................................. .......... ................................................. 4 War RMPP €s presently required, has 5oction 25534 of the California Health and Safety Code been fully complied with? ❑Yes ❑ No ..............","..."......................-..........................----__.....................................................................................................................---•-•--------..................................................................................................................................................... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification from the South Coast Air Quality Management District or trom any other air pollution control district or agency? LJ Yes E No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). _ ..... .................. .._..._..- - _ _ _ ..................... --..............._.—_................................................................ .... .... _ ............._ ..... 6 Will any pari of tha facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? []Yes ❑ No (If 'yes', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ................................................................................................................................................................................................................................................................................................................................................................... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency Is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No .............................................................................................................................................................................................................................................................................. 8 (If "yes", attach ceriiiicate of compliance from the approprfate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree IA comply with all Aisle laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above -describe operty for inspe tion ries. I agree not 10 occupy or allow occupancy of any building authorized by this permit until final inspection. Si a egalOwner(s) Date And/or Authorized Applicant Date CODE i, INSPECTION TYPE pINTITIA CQDE # INSPECTION TTP E Qdg 11 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Root 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site r 204 Final Demolition 250 Final Building/Occupancy 7 rev.�.�.-..-..--..^-.++Wv..w•'-t-. ..�� .�--r-r— „-.- - --.. -T. f �— _ . _ -.—� f CAT of Costa Ne5a Development Services, Division of Building and Safety N'110�f CERTIFICATE OF OCCUPANCY This .certificate,ris issued pursuant to�the�requirements of�the Uniform Building Code, Section 308 Ir:� adop�ed by t ie�City of Costa Mesa cerrifies,that_at the time of its.issuance the building structure herein below described was inspected and$a 'ri oved,for-occuparicy"as>foliaws: Building Address 3333 BRISTOL STESET UNTT 1403 Bldg. Pernut No. B 82170 Use //� Group B Type of Goitr�ction IFR SP +Fire Zone ` ' }` Use Zone CiS J�-")i, �errH "-';;'MRr'F Owner of Building C.J. Seger�troms`& SbnsJ"` Tenant n'10AL .� Address By BUILDING OFFICIAL- COWP C }�'6 Date" J ne 2 199 REQUIRED TO BE POSTED -IN A CONSPICOUS PLACE UILDINO: 3333 BRISTOL ST UNIT: 1403 fr' '_ EIF*1OWN: C , J , SEGERSTROM & SONS FLOOD: AH -38 `� ADDREss: 3315 FAIRVIEW RD COSTA MESA :P_ y:.r626 (714)546-0110 APDL. kWUNQ ADMn ARCtilTECTOREIMEER: JOEL BRAND Lic.NO: C011791 ARcN oR ENa.'s ADDREss: 1400 POST OAK BLVD. UNIT: 200 HOUSTON TX 77056 CMMACTarSmmF- ANDERSON, WALTER M (714)839-1646 coFmAcwnMAula 10572 BARBETTE AVE Awfl : GARDEN GROVE CA uc NO: 301942 92643 UNIT: LICENSED CONTRACTORS DECLARATION: I hereby affirm under penally of perjury that I am licensed under provisions of Charter 9 (oommenciM with Section 7000) of Division 3 of the Business and Professions Code. and my license is in full force and effact. qR[7:0 0 9 361 NIC. CLASS: B LtC. O.: 301942 P: 0 2/ 9 8 Contractor. LDER DECLARATION: 1 hereby affirm under penalty of perjury that I am exempt Tram the Contradors License Law la the on (Section 74315 Business and Professions Code: Any city a County which requires a permit to construct. after. improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement the he or she is iioersed pursuant to the Provisions d the Conlradors License Lew [Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code] or that he or she is exempt therefrunn and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of not more than We hundred dollars [4500]). 1, as owner of the property or my employeas with wages as their sole compensation, will do the wale, and IM structure is not intended or offered for sale (Section 7044, Business and Professions Code: The Contractors License law does not applyloan ownerof property who builds or improves thereon. and who does such wok himself or herself or through his or her own employees. Provided that such improvements are not intended or offered for sale. 9. however, the building or improvement is cold within one year of aomplelion, the owner -builder will have the burden of proving be or she did not build or improve fa the purpose of sale). © 1. as owner of the property. am exclusively nontrading with licensed Contractors to construct the project (Section 7044. Business and Professions Code: The Contractors license Law does not appy to an owner of property who builds at improves thereon and who contracts for such projects with a contrador(s) licensed pursuant to IM Contractors License Law). I am exempt under Section: B. A P,C.. for this reason: Date: 6cmer. I do hereby codify that I am aware of and understand The requirements of California Health and Safety Code Sections 25505. 25533, and 25534, and that 1 or any future building occutwl will I will not (arcls one) need to comply with said stele codes and IM requirements for a permit for conslrucrionormodificationfrom the Air Quality anagemorsDistrict. Residential construction applications weexempt from these provisions. Date: Applicant: WORKER'S COMPENSATION DECLARATION: I hereby affirm under penalty d perjury one of the following dedsrstims: © I have and will maintain a oonificate of consent to seg -insure for workers' compeleation, as provided for by Sedion 3700 of the Labor Code, for the performance of the work fa which this permit is issued. �] I have and will maintain workers' compensation insurance, as required by Sedion 3700 of the Labor Code. for the performance d the f[— work for which this permit is issued. My workers' compensation insurance carrier and policy number are: Carrier: STATE FUND EXPIRES Pricy Number: RC2432317 05/21 /97 (This section freed nwr be completed i the permit a for one hundred dollars [V ool or leas.) I certify thm in the performance of the work for which this permit is issued. I shall not employ any in m nor so as to became subject to IM workers' compensation laws d should California, end agree that lf I shoub lime su act the workers' nom anion `Wsionsof_Apdion 3700 of the Labe Code, I shyr9thwith comply those 'alas p Applicant: emM Failure to secure workers' Oonpeneadon coverage 1s unlawful, and shall "Joel an employer to Criminal penaldes and up to we hendrod thousand dollars J$IOAOWJ, A7 addldon to the Cost Of Comp whom, damages as provided for In Section 3706 of the Labor Cods, lntuest, and Affomsyi fess. CONSTRUCTION LENDING AGENCY: I hereby affirm under penalty of perjury that there is a construction landing agency for On performance of the work for which this permit is issued (Section 3097. Civ. C). LENDER'S NAME: LENDER'S ADDRESS: I codify this 1 have read this application and state that the above information is cored, i agree to comply with all city and county Ordinances and state laws relating to building construction and hereby authorize representatives ofthis city to amor upon the above-mentioned property for inspection purposes. BRUCE ANQERSON Date: zc� 4515146.WPI White-BuiWirw & Safety; Greer -Fila; -Applicant; Pink -Revenue; Goldenrod -Assessor CITY OF' COSTA MESA - BUILDING PERMIT PERM NO: B 082170 PERMIT NO: B 082170 PLAN CHECK NO: 00622-97 A GOVT: N SUPP: N CONSTRUCTION TYPE: 1FR SP PERMIT TYPE; STR PURPOSE: ALT JOB DESCRIPTION : COMMERCIAL T,I, STORE INTERIOR SQ FT: 1,794 CLAIM VALUE: CALC-VALUE: 27,699.36 GROUP OCC: B / COMMENTS; THE "FRED JOAILLIER" JEWELERY STORE Z O N I N G R E Q U I R E M E N T S S E T B A C K S ------------- MAIN BUILDING ------------ --------- ACCESSORY BUILDING--------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN PARKING REQ: PROV: PARCEL; 41249207 ZNE: C1S REF NO: PLANNING NOTES> EXPANSION OF EX. TENANT (FRED JOAILLIER JEWELERS) INTO > ADJOINING VACATED SUITE AT SC PLAZA, f"r' if•iEiEil##1[if##iI-#iEif-IE#�EiEiEiEiE�f'�i'�EdElE�EiEdE##141Ei4'lE#iEiFiFiE#�E#######irF#�f�E�f##L-]E####iF-IEiE#iFiEiE#.####!F##### D E V E L O P M E N T S E R V I C E S R E Q U I R E M E N`T,.'S 'r f ZONING APPROVED BY DATE; Z, BUILDING APPROVED BY _ DATE: APPLICATION ISSUED BY: n/,l DATE: �44 _ LEGALIZATION:N F E E S U M M A R Y STRUCTURAL`�'SEGMENT:Y BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMTP/RES GRADING PERMIT 376.75 SMTP/NON-RES PLAN 61,22 5.82 ISSUE FEE BUILDING -DIV-> ' PERMIT.' ISSUE PLAN -CHECK TOTAL PAID DUE TOTALS ------ > 382.57 0.00 61.22 443.79 443,79 .00 REVENUE DIVISION TOTALS--> COLLECTED: 382.57 OVER/SHORT: ,00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN -CHECK 376.75 5,82 ###iE#)f-###iEiEiEiE####tF####lEiEil-#i(-iEiEdE'iEifiFiEIE##jE1EiE�E?tElEfIFt1F#i[•�EiEiE�h###3Ei(•IEIfieiF#####illiFirk�EiE##�E�EiE#### I N D I V I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST SFC 1794 STO-INT, ALTER TYPE I II F.R. -AVER 14.36 25,761.84 SFC 1794 EQU-ALT COMM, SPRINKUR SYS --AVER ,36 645.8'4 SFC 1'794 EQU--ALT COMM, AIR COND -AVER ,72 1,291.68 END OF FEES 03-25-1997/11:01 ANA382.57 R04:01-0003928 PERMIT -.082170 I" CONSTRUCTIpN AND PLANNING APPROVALS permit #. T Daie Inspector OOL & SPA' APPROVALS Permit # . Date Inspector 1. Temporary Electrical Service or Pole- 52. Pooi & Equipment Location 2 Soil Pipe-Undrgrnd. „ 53. Steel Reinforcement ; •3. Electrical Conduit Utility-Undrgrnd. 54. Forms 4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding 5; Steel Reinforcement ,56.' Rough Plumbing & Pressure Test _ �• Electrical LIFER Gritti. y r - 57. APPROVAL TO COVER _GUNITE ; -T Footings - - 58. Electrical Conduit--Undrgrnd. 8. Foundation' 7 59, Gas Pipe, ❑ Undrgrnd., Test 9. Water Pipe-Undrgrnd. .60. Backwash Lines, P -.Trap, 0 Undrgrnd. 10. Structural Floor System 61. APPROVAL TO DECK 11. Property Sewer Line.& House Connection 62. Backwash & Receptor -Final 12. Sewer Cap r .63. Heater & Vent -Final 13. Roof Drains .64. Plumbing System -Final 14. Rough Plumbing 65: Electrical -Final ` 15. Rough Electrical -Conduit ' 66. Solar System -Final , 16. Rough Electric Wiring 67. Fencing &Access Approval 17, Rough Wiring Sign I 68. APPROVED FOR PLASTERING 18, Rough Electrical -T Bar Ceiling '69, POOL/SPA SYSTEMS FINAL 19.- Rough Heating & Air Conditioning - FIRE DEPT. REQUIREMENT APPROVALS Permit # 20• Rough f=actory Fireplace _ r 21. Ducts, in Structure 70. Underground Hydro 22. Ducts, Ventilating - 71. Product Piping © Gas © Oil 23, Gas Pipe -Rough & Test 72. Underground Flush 24. Roof Framing _ 73. Undergrnd, Storage Tank © Gas C Oil 25. Roof Sheathing 74. Overhead Hydro 26. T -Bar Ceiling (Structural) & Monocoat 75. Dry Chemical 27, Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding _ 77. FIXED SYSTEM FINAL 29. Insulation _ - 78. FIRE PREV. FINAL 30, Drywall Nailing _ - HEALTH DEPT: REQUIREMENT 31. Plaster Brown Coat 79, FINAL INSPECTION 32.`Electrical Power Meier -Final 80. FOOL? CERTIFICATE ISSUED _ 33. Final Electric - Notes: 34. Final Heating-& Air Conditioning,'_ - 35. Final'Gas Pipe -Test _ 36. Hood or Canopy 37. Final Factory Fireplace 38. Final Plumbing _ _ - 39. Water Service -Final 40, Gas Service -Final 41, Solar Domestic -Final .. 42. Backflow Preventer • - 43. Backflow Irrigation 44. Landscape Irriqation System 45. -Sound Attenuation -46. Handicap Regulations 47. FINAL STRUCTURE & BUILDING 48. FINAL PLANNING 7 " - 49. Etecthc Release to Edison 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY No. Date - —ADDRESS OF 61dlDDi6: 3333 BRISTOL ST UNIT` 1403 OWNER'S NAME IfKN WN: C . J . SEGERSTROM & SONS FLOOD: AH -38 ADDRESS: 3315 FAIRVIEW RD COSTA MESA (7141546-0110 ARCNITECTORf]WEIER: JOEL BRAND m"D- C011791 ARCH. OR ENG.'S ADDRESS: 1400 POST OAK BLVD. UNIT: 200 HOUSTON TX 77056 Co"""CTO"s "F` TRI COUNTY FIRE (714)589-4207 CONTRACTOR'S "AII410 23052 AL I C I A PKWY AD RM' MISSION VIEJO CA MND_ 659326 92692 UNIT. 333 LICENSED CONTRACTORS DECLARATION: 1 hereby affirm under penalty of penury that 1 am licensed under provisions of Chapter 9 (Commencing with Section 7900) d Division 3 of the Business end Professions Code, and my license is in full force end eHed. CITY LIC. NO.: 058754 LIC.CLMS: C 16 uC..NO.:: 659326EXP: 03/98 Date: .41— Contractor: ! !C / — rQuA fE-^�,1 a K r1 OWNER BUILDER DECLARATION: I hereby affirm under penally d perjury that I am exempt hen the CCntracom Lipase Law for the following reason (Section 7031.5 Business and Professions Code; Any city or county which requires a permit to construct. t. after, improve, demolish. or repair any stneeture. Prior to ifs issuance. also requires the applicant for such permit to We a signed statrierwit Ohat he or she is licensed pursuant to the provisions of the Ccrracor License Law (Chapter 9 (commencing with Section 7000) d D"lon 3 d the Business and Professions Code] or that he or she is w4mpl therefrom and the basis for the alleged exemption. Arty violation of Section 7031.5 by arrf applicant for a permit subjects the applicant to a civil penally of not mora than fire hundred dolten [S500U. ❑ 1, as owner of the property or my employees with wages as their sale campensanion. will do the work, and the structure is not intended or offered for safe (Section 7044, Business and Professions Cada: The Contractors Lkwap Law does not apply to an owner of properly who builds or improves thereon. and who does such work hissed or herself or through has or bar ohm employees, provided that such Improve menle are nor imerded or offered for sale. If. however, the buil ld"ung or improvement is add within one yew of cmnpladlon. the owner—builder will have the burden of proving he or she did not build or improve for the purpose of sale). ❑ I, as owner of the property. am exclusively ocntrraing with Iirxased contractors b construct the projed (Section 7044. Business and Professions Code: The Contractors License Law does not apply to an owner of property also Minds or improves thereon end who contracts for such projects with a owdraclor(s) licensed pursuant to the Conlredors Uosnse Law). ❑ 1 am exmnpt under Section: B. if P.C.. Icr this reason: Date: Owner I do hereby cw* that I am aware d and understand tie requrtemems of California FIaafdh and Safety Cade Setioro 25.506.45533. and 25534, and that I or any Mute building occupant will I will not (circle one) new to comply wah said slate codes and the requirements for a p" for oats Wtion or modification from the Air cn�ty anagemerd District. Residerdiel construction appkatiom we swamp from Ilona Prwlsans. Dade: Applicant; wORKER'S COMPENSATION DECLARATION: I hereby afrmm under penalty of perjury one of the IoGowiry dodo ions: ❑ I have end will maintain a eeriffnate of consent to self•nsure for worker' compensation, n provided for by Section 3700 of the Labor Cods. for dye performance of the work for which this Pwmi is issued. I have and will maiman wedrare' compensation insurance. as required by Section 3700 of the labor Code. for the parlarmanoe d the work fa which this pwmid is issued. My workers' Compensation insurance carrier and policy number are: carrier: rjy.T71N,11 x'ArJ.F' EXPIRES Poky Number ,hIT�.Ta _ A 1 �. c>! ��p 10/01/97 (This section reed nal be complefed ff fire perms is for one Ixahcivd dollars 1$100) or Am) Q I certify that in the performance d the work far which this pernha is issued, I shell nd employ any parson in any manner so as to become subject to the wodras' oompmsetion Paws of California, arid agate that ' I tlhordd became subject to the worker' compensation provisions of Section 3700 of the Lubar Code. I shad forthhvah campy esepltliTiteoru. Oats: 4-14 io — r'l Applicwd: Wemfng: F'aNum to seams waters' cortipernuBon coverage Is unlawhrl, and SWI 4. an employer to cr/mheal pwtio" and civil Ones rq to one hundred O virsand dafWo f$104000A 4n addition to fie cwt of coapwuador, derrapes n provklad Nr In Secdon 3706 of the Labor Cods, fsteresf, Sud stesnar's fans. CONSTRUCT10N LENDING AGENCY: I hereby affirm urdw penehy of perjury [hat them is e constnxtion lem&g agency for the performance of the work For which this perms to issued (Seton 3097. Civ. C). LENDER'S NAME' LENDER'S ADDRESS: I cenify that I have read this application and state that the above information is correct. I agree to comply with ad coy and omM ordinances and state Paws relating to building construction and hereby akalwize represwaafives of this city to enter upon the above-merdiored property for inspection Purposes. CRATG R Dae: (515146.WP) Whaa49urTding 8 Safety, Green -We: CenegrAppicara; Pink -Revenue: Goldenrod-Assencr CITY OF COSTA MESA — BUILDING PERMIT PERM NO: F 082427 PERMIT NO: F 082427 PLAN CHECK NO: 00861--97 L GOVT: N SUPP: N CONSTRUCTION TYPE: IFR SP PERMIT TYPE: FIR PURPOSE: ALT JOB DESCRIPTION ; COMMERCIAL T.I. STORE INTERIOR SQ FT: CLAIM VALUE: 2,200.00 CALC--VALUE: GROUP OCC: B / COMMENTS: THE "FRED JOAILLIER" JEWELERY STORE FIRE SPRINKLER ALT #B8 Z 0 N I N G R E Q U I R E M E N T S S E T B A C K S ------------- MAIN BUILDING---_--------- FRNT: FT IN REAR: FT IN LEFT: FT IN RIGHT: FT IN --------- ACCESSORY BUILDING ------------- FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN PARKING R28(�: PROV: PARCEL: 41249207 ZNE: REF NO: PLANNING NCSTES> iF * � iE �E iE i6 * iE � � # if• iE iF iE ki- * � !E iE !(�E � iE if!E !E iE iE iF tE � * iE iE 3E itiE iE iF iF -IE iF * 1E 1E 1E �E � �E 3F iE ? E iE # jE iE iE 3E 1t 9E iE iE -1E'lt 3E iF iE jE iE i4 aE If �E dE lE �F �E D E V E L O P M E N T S E R V I C E S R E Q U I R E M E N T S ZONING APPROVED BY DATE: BUILDING APPROVED BY DATE: APPLICATION ISSUED BY: DATE: 7 9E 3F iE !E iE � dE 3E �F iE 3E r1E iE iF � iE 9E iF �E 9E it 1E , LEGALIZATION:N F E E S U M M R Y STRUCTURAL SEGMENT:N BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT 75.00 65% SMIP/NON—RES PLAN 48.75 ISSUE FEE BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE TOTALS ---- > 1 75.00 0.00 48.75 123.75 123,75 .00 REVENUE DIVISION TOTALS--> COLLECTED: 75.00 OVER/SHORT: ,00 BLDG PMT -PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK 75.00 jf -)i• � aE � # �E iE iE !t• iE * K !f i(' -K jt iE iE .N. cit iE fF #.� � * iE iE iE iE iE iE 3E iE iE iE fF � iF iE ?•E # 4F iP iE �I- * iE � * 9E iE iI-?E'16 � � !(iF iE # � �E iE St ->F 9E � iE iE iE if!E ib � iE• 3F iE I N D I V I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N FIR 75 FIRE EQUIP FEE (FROM BLDG VAL 'TABLE) END OF FEES "r UNIT COST TOTAL COST 1.00 75.00 04-14-1997/122:32 PM375.08 RM0:01-0804796 PERMIT. -082427 CONSTRUCTION AND PLANNING APPROVALS Permit # Date - inspector JDL &SPA APPROVALS Permit # ©ate Inspector 1. Terr,porary Electrical Service or Pole 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. 54- Forms. 4. Electrical Conduit-Undrgrnd, 55. Electrical Bonding 5. Steel Reinforcement 56- Rough Plumbing & Pressure Test 6- Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE 7. Footings 58, Electrical Conduit-Undrgrnd. 8. Foundation 59. Gas Pipe, © Undrgrnd., Test 9. Water Pipe-Undrgrnd, 60. Backwash Lines, P -Trap, ❑ Undrgrnd. 10. Structural Floor System 61, APPROVAL TO DECK 11. Property Sewer Line & House Connection 62, Backwash & Receptor -Final , 12. Sewer Cap 63, Heater & Vent -Final 13. Roof Drains 64. Plumbing System • Final 14, Rough Plumbing 65. Electrical -Final I 15. Rough Electricat-Conddit 66. Solar System -Final 16, Rough Electric Wiring 67. Fencing & Access Approval ' 17, Rough Wiring Sign 68. APPROVED FOR PLASTERING 18. Rough Electrical -T Bar Ceiling .69. POOLISPA SYSTEMS FINAL 19, Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit # 20. Rough Factory Fireplace 21. Ducts, in Structure 70. Underground Hydro 22. Ducts, Ventilating 71. Product Piping © Gas © Oil 23. Gas Pipe -Rough & Test 72. Underground Flush 24. Roof Framing 73. Undergrnd. Storage Tank ❑ Gas 0 Oil 25- Roof Sheathing 26. T -Bar Ceiling (Structural) & Monocoat 74. Overhead �:»-s-(2sr�� 75. Dry Chemical ) /,� 7 27. Frame and Flashing 28. Lathing & Siding 76. Dry Standpipe 77. FIXED SYSTEM FINAL % 29. Insulation 78. FIRE PREV. FINAL Sao 97 30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat 79. FINAL INSPECTION 32. Electrical Power Meter -Final 80. FOOD CERTIFICATE ISSUED 33. Final Electric Notes: 34. Final Heating-& Air Conditioning 35. Final Gas Pipe -Test 36. Hood or Canopy 37. Final Factory Fireplace 38. Final Plumbing 39. Water Service -Final 40. Gas Service -Final 41. Solar Domestic -Final 42. Backflow Preventer 43. Backflow Irrigation 44. Landscape Irrigation System 45, Sound Attenuation 46. Handicap Regulations 47. FINAL STRUCTURE & BUILDING '. 48, FINAL PLANNING 49. Electric Release to Edison 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY No�_ ,.-•_-- Date ADDRESS OF SUIL1)M0: 3333 BRISTOL ST UNIT: 1.403 OWNER'S KNE IFKNOW' C.O. SEGERSTROM & SONS FLOOD: AH -38 "DOE": 3315 FAIRVIEW RD COSTA MESA (714)546-0110 AIMITECT OR EIMEER: JOEL BRAND •N0•` C011791 ARM OREla'S"DORM: 1400 POST OAK BLVD. UNIT: 200 HOUSTON TX 77056 C0HiNACT0R'S NAGE: WEST RAY CO (714)854-7127 CONTRACMA'S MMLMG 132 E GARRY AV • ADDREss: S. A. CA "r - ND-: 237876 92707 UNIT: LICENSED CONTRACTORS DECLARATION: I hereby affirm wider penalty of perjury that I am lieaneed under provisions d Chapter 9 ( with Section 7000) d Division 3 d the BusneSb and Profeeaknns Cods, and my license is in full Face and effect. rTY ucV:ER o.: 06134 LIC. CLASS. B uc. No.: & EXP: 07/97 �! Cuxwador. ILDER DECLARATION: I hereby dkm under penalty d perjury thal 1 am exempt from the Contractors Licenser Lew fa the son (Section 7031.5 Business and Professions Cada: Any cs7r or county which requerm a permit to wmtrurct, ager. improve, ufemoleh, or repair any stnrctwe, prior b is issuance, also n xp m the applicant for such perms to file a signed statement that he or she e licensed pursuer t to the provisions of the Contractors License Lew [Chapter 9 (oommancirm with Section 7000) of Division 3 of the Business and Professions Coda) or that he or she is exempt therefrom and the bass for the alleged exemption. Any violation of Section 70:71.5 by arty applicant la a permit subpcts the applicant to a civil penalty of not mons than tive hundred dollars PMD. I, as owner of the propenyor my employees with wages as their tole oompersatlon, will do the wok, and the structure end imended or offered for sale (Section 7044, Business and Prdmsions Code: The Contraclon License Law does not apply to an owner d property who bolds or inpnwes thereon. and who does such work himself or hersell or through his or her own employees. provided that such improvwer" are not intaded or offered for sale. i, however, the building or improvement is sold within one year of dehlplelion, the ow 4xi lder will have the burden of provng he or she did nil build or improve for the Purpose d sale). , ❑ 1, as owner of the properly. am exclusively, nontrading with lirwrsed oontracfors to consoucl the project (Section 704/!Bus'ehaes and Profsasiors Code: The Cauradas License Law does nil apply to an owner of property who bwlds or npro as thereon and who contras for such projects with a odtrador(s) Gcsnsed ptasuara to the Caron i ctas License taw). ❑ I am exampt under Section: 0. 5 P.C.. for this reason: Date: Owner. I do hereby certify that I am aware of and understand the re0mmerts of Caltomia Health and Safety Cods Sections 25505, 25533. and 25534, and that I o any future building ooarpud will! wit not (circle one) need to comply with said stats codes and the rworemems for a Perms for wmlruction or modifimlion from the Ai=l yreiPanegemenl District. Residential oondruction appiodiars aro exempt from Uhese Provisions. Date: Applicant: woRKER'S COMPENSATION DECLARATION: I hereby affirm under penalty d pi rpay one of the }a0owag declarations; ❑ I have and will meitan a dntifi als d cones to seMrasune for workers' comparutlion, as provided for by Section 3700 of the Labor Cads, for the performance of the work la which this perm's is issued. ❑ 1 have and will maintain wodur,'compensation irnurance. as required by Section 3700 of the Labor Cods. for the performance of Iles work to which thea psnms is issued. My workers• comp wmtion Insurance nrriw and policy number aro: Cartier: Policy Number: ( section need nor be completed M the parmY is for one hundred dolkrs ($ FOO) or Asssj I centy that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to bacoms subject to the workers' mmpsmation Lowe of Celifamie, and agree that d 1 should become subject to the workers' pensatbon provisions of Section 3700 of the Labor Code. I shall forthwith oompty wth those provisions. D Applicant: WaMing: FrNraa to sacra■ workers' Compenreadon COVWVS IS unlnMrf, aril SWI sublsec an imiplo yah to afnafrW penstittise and vIf f7rw up to ora hundred Nauaand dollars f$104000A In sddidon to dw cast of canpsnsaWn, damages as pr*vM*d for In Soctlon 97W of ilea Labor Coda, Intw ul, and st ormy s fess. CONSTRUCTION LENDING AGENCY: I hereby affirm under Penalty of perjury that Ihem is a owslrudion knd4v agency for the performance of the work for which the permit is issued (Sadion 3097. Civ. C), LENDER'S NAME: LENDER'S ADDRESS: I camiy, that I have read this application and state that the above Information is coned. I agree to comply with all city and county ordinances and stale laws relating to buildig consinxtion and hereby authorize representatives of this city to enter upon the above~toned property for inspection Pwpoaes. DAVID HREHA Date: 4 i (5151.46,WPI Whh"uikting 4 Safety: Pink -Revenue: Goldenrod -Assessor CITY OF COSTA MESA — BUILDING PERMIT PERM NO: E 082489 PERMIT NO: E 082489 PLAN CHECK NO: N GOVT: N SUPP: N CONSTRUCTION TYPE: IFR SP PERMIT TYPE: ELE PURPOSE: ALT JOB DESCRIPTION : COMMERCIAL T.I. STORE INTERIOR SQ FT: CLAIM VALUE: CALC—VALUE: GROUP OCC: B / COMMENTS: REF:B-82170 * * iE iF � iE it- � -YE � iE � � � if iE if � �F iF ib � �- * � iE iE iE iE � >� � � -YE iE iF � iE iE �t � iE -1E iE• * 3E it -1E 1E ->E �E iE � �(- * � iE iE � iF at- iF iE iE iF it iE iE• � if• jE � * � � � iE iE � Z O N I N G R E Q U I R E M E N T S S E T B A C K S MAIN BUILDING ------------- ISSUE PLAN -CHECK ----------- ACCESSORY BUILDING — — FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RIGHT: FT IN PARKING REQ: PROV; PARCEL; 41249207 ZNE: REF NO: if- iE 1F if aE * if- iE -7F iE iE 3E � iE iE iE iE �E dE iE dE dE iE iF iE'iE �E iE )E'1F'lF iF -YE i'F iE iE iE'1F iE ii iE iE iE * PLANNING NOTES> I N D I V I D U A L F E E B R E A K D O W N > dE * t� iE !f3E iE AE iE 3E � 3E � * �F � � !E � iE � � SE ff iE �f r1F lilt iE � irk !E -1F iE � #E• iE iE• iE � Bf- � �E'lE �E �E iF iE 1E'lE 3E 7E fE * iE �E iE iF iE iE iE � � )F �F dF >� if it iE iE # 3E 3E iE i'E #irk of D E V E L O P M E N T S E:'R V I C E S R E Q U I R E M E N T S ZONING APPROVED BY DATE: BUILDING APPROVED BY : 14 DATE: APPLICATION ISSUED BY: DATE: LEGALIZATION:N F:E E S U M M A R Y STRUCTURAL SEGMENT:N BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT PLAN ISSUE FEE 81.90 22.00 SMIP /NON --RES BUILDING -DIV-> PERMIT ISSUE PLAN -CHECK TOTAL PAID DUE TOTALS ---- > 81.90 22.00 0,00 107.90 103.90 ,00 REVENUE DIVISION TOTALS--> COLLECTED: 103.90 OVER/SHORT; .00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK 103.90 if- iE 1F if aE * if- iE -7F iE iE 3E � iE iE iE iE �E dE iE dE dE iE iF iE'iE �E iE )E'1F'lF iF -YE i'F iE iE iE'1F iE ii iE iE iE * if � iE dE jE iE iE !E iE * i(- iE iF �E if- iE 1E iE iE iF iE jE * * iE iE jE AF �E iF dE �E # �k !E I N D I V I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST ELE 20 FIXTURES, LIGHTING 1 ST 20 EA. 1.00 20.00 ELE 61 FIXTURES, LIGHTING ADDITIONAL EA, .65 39,65 ELI' 3 RECEPT/OUTLET I. ST 20 EA, 9.. 3.00 ELI' 3 RECEPT/SWIT'CI1 The worklau�T.20 EA. ,(�.a � 3.00 ELE I SUB -PANEL COM ! 0rr1e11j5 this(� 16.25 ri64 o appE.0 a Permit aha!! V awe. s requjrernen +dicap g 1997 Kites and relate nderCalit APR 1 (Ord. No. fla.�'8, 7, 2 greulWjon) ' omra p� CCSTA MESA Y Cin. 4- '-% -.-%- dt CONSTRUCTION AND PLANNING - APPF;OVALS Permit z# Date Inspector SOL &SPA APPROVALS Permit Date Inspector 1. Ter-%porary Electrical Service or Pole, 52. Pool & Equipment Location 2. Soil Pipe•Undrgrnd. ; 53. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. -. 54; Forms 4. Electrical Conduit-Undrgrnd. •55. Electrical Bonding 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test fi. Electrics! LIFER Grnd. _ 57. APPROVAL TO COVER-GUNITE 7. Footings 58. Electrical Conduit-Undrgrnd, 8. Foundation 59. Gas Pipe, 0 Undrgrnd., Test 9. Water Pipe-Undrgrnd. ,60. Backwash Lines, P -Trap, 0 Undrgrnd. 14, Structural Floor System 4 61. APPROVAL TO DECK 11. Property Sewer Line &!-louse Connection 62. Backwash & Receptor -Final ` 12. Sewer Cap i 63, Heater & Vent -Final 13. Roof Drains �' 64, Plumbing Sysiern -Final 14, Rough Plumbing 65. Electrical -Final 15. Rough Electricai-Conduit 16. Rough Electric Wiring 17. Rough Wiring Sign I Solar System -Final 7. Fencing & Access Approval 68. APPROVED FOR PLASTERING 18. Rough Electrical -T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19, Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit # 20. Rough Factory Fireplace 21, Ducts, in Structure 70, Underground Hydro 22. Ducts, Ventilating 71. Product Piping © Gas ❑ Oil 23. Gas Pipe -Rough & Test 72. Underground Flush 24. Roof Framing 73. Undergrnd, Storage Tank © Gas ©Oil 25, Roof Sheathing 74. Overhead Hydro 26. T -Bar Ceiling (Structural) & Monocoat 75. Dry Chemical 27. Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding 77. FIXED SYSTEM FINAL 29. Insulation 78. FIRE PREV. FINAL 30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat 79. FINAL INSPECTION 32. Electrical Power Meter -Final 80. FOOD CERTIFICATE ISSUED 33. Final Electric 34. Final Heating & Air Conditioning Notes ` 35. Final Gas Pipe -Test '. 36. Hood or Canopy 37. Final Factory Fireplace _ 38. Final Plumbing c 39. Water Service -Final 40. Gas Service -Final 41. Solar Domestic -Final 42. Backflow Preventer 43. Backflow Irrigation 44. Landscape Irrigation SystemC'D 45. Sound Attenuation `"f ~- c_ 46. Handicap Regulations r= 47. FINAL STRUCTURE & BUILDING 1 48. FINAL PLANNING 49. Electric Release to Edison�,.�7 50. Gas Release to Southern California Gas Co 51, CERTIFICATE OF OCCUPANCY No. _. Date _ BUILDING PERMIT LOG ' EMPLOYEE: ADDRESS: 33rc3 PERMIT NUMBER: TYPE OF PERMIT: VALUATION: ff 7-�4 SQUARE FOOTAGE: PERMIT FEES: DATE: TIME IN TIME OUT ACTIVITY �lw ONLY ONE ADDRESS PER SHEET- TIME IS TO BE CACULATED TO THE NEAREST 15 MINUTES PLEASE BE AS SPECIFIC AS POSSIBLE IN RECORDING ACTIVITIES. ADORE" OF BUILDING: 3333 BRISTOL ST LINT. 14 0 3 OwNaEWSNAMEIFRT10M: J. SEGERSTROM & SUNS FLOOD: AH -38 3315 FAIRVIEW,-RD, COSTA MESA E aL. � nD fEsS, (714)546-011.0 AR"T"TORENEi": JOEL BRAND LIO'ND.: C011791 MM OR EM'S ADORM: 1400 POST OAK BLVD. UM, 200 HOUSTON TX 77056 00Hf"ACTOR''""w— THERMALAIR INCORPORATED (818)442-3341 caNTRACTOnMiNum 1140 N RED GUM ST ADmm ANAHEIM CA LIG110, 102216 92806 UNIT: LICENSED CONTRACTORS DECLARATION: I hereby dfim under Panay d perjury aw I am Grxnssd under PIMWOs otChapter9 (commencim with Section 7000) d Division 3 of the Business and Professions Code, and my license is in full krce and effect. CTTY LIC. No.: 0 Ofi 0 6 uC. cuss: C 2 0 LIC. ND.: �k2d6 EXP • 03/98 } Dale: Y-7 Contractor. f OWNER BUILDER DECLf ATION: I hereby affirm urdar penaty I am exommpt from t Contractors Lioense or the following reason (Section 70.5 Business end asei Prafons Code: Any or county which regimes permit to oomancf, eher, Improve, dsmofLsh, or repel any structure, prior to as issuance, ako requires the applicant for such Permit Io a signed statement Gnat he or she e ticersed praeueru so lM provision of IM Contrectoru License Law [Chapter 9 (oommencinp with Section 7000) of Division 3 of the Business and Professions Codal or that he or she is exempt therstram and the basis for the alleged examplion. Any violation of Section 7031.5 by any applicant for a permit subjects the eppliceni to a civil penalty d not more then five hundred dollars [5500]). ❑ t, as owner of IM property or my employees with wages as their sole compensation, wi ldo the work, and tM structure is nit intended or offered for sale (Section 7044, Business and Profgssions Code: The Contractors License Law does not apply to an owner of property who buddy or improves thereon. and who does such work himself or hers" or drough his or her own employees. provided that such improvements are not intended or offered for sale. k, however, IM building or improvement is sold within one year of completion, the ownw-builder will have the burden of proving M or she did not build or improve for the purpose of sale). ❑ I, as owner of the property, am exclusively cemrer„ng with kensed contractor, to construct the project (Section 7044, Business and Prdession. Code: The Contractors License Law does not appy to an owner d Properly who builds or Improves thereon and who contracts for such projects with a oorrector(s) lioegsed pursuant to the Contractors License Law). ❑ I am exempl under Section: B. 5 P.C., for this reason: 1 Date: Owner, I do hereby cw* that I am aware of and understand thq requirements of California Health and Safety Code Sections 25505.25533. and 25534, and that I or any future building occupant will�l not (circle one) need to comply with said state codes and therequirements for a permit fa oonsirucdon or modification from the Airp ~- mem District. Residential construction applications are exempt from these pro"sions. Gare: AppticvWf WORKIER'S COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following dedaralkme: ❑ 1 hews and will maintain a certificate of oonsent to 80 -insure for workan' comparsation, as provided for by Section 3700 of the Labor Code, for 1M performance of the work lur which this pend is Issued. I have and will maintain wokers'rampnnsatton insurance, as required by Section 3700 of the Labor Code, for 1M performance of the work for which this permit is issued. My workers' oDmpensafion insurance carrier and policy number are: Carrier QT,T(_r) rAgTjA.r.TV EXPIRES Policy Number: rte-- n e n a n A n. 03/31/98 (Ines sedan need n« be complerad I rhe perm,t a nor one hrmdred dollars ($tool or Lits.) ❑ I certify that in IM performance of the work for which Ihis permit Is issued, I aha5 not employ arty person in arty manner so as to become subject to the workers' compensation Lewy of California, and m l I ouk b come subject to the walurs' eompensation T7Askxu c Section 3700 of the LAbor Cade, I �hh comp veil ffi s ' 'ons. Data: �Y App[icam: Warnfing: Fafnir to secdre workers' co"Wer a tdon cewnaQ, is Nur, .oro, ecf .nip ro plmfrtaf p aril crvff ons � to one hundred thousand dollen (41111 oA M ire turf or ronperaatb dar u pro rn $action 3706 of rhe Labor Cods, Interest, and attorney's leu. CONSTRUCTION LENDING AGENCY: I hereby alfimh under penally of perjury that throe is a mrslnrction lending agency for the performance of the work for which Ins parmil 1s Owned (Section 3097, Civ. CI. LENDER'S NAME: LENDER'S ADDRESS: 1 certify that I have read this application and state that 1M above i formetion is correct, I epee to comply with all city and county ordinances and stats laws relating to building tonsguol on and hereby au "ize repesaretives of the city to enter upon the above-mentioned property for inspection purposes. JOW PUENTE JR N IVBrq Data: Z oar re IAgamlApplioanUCoM or fFlmt Wpl White-RiAkiinn k Sefaty: Graer-Ml- r:wn»v_1r 16i m- Pink -411 m- rkAe& rod-.larraxur CITY OF COSTA MESA — BUILDING PERMIT PERM NO: M 082298 PERMIT NO: M 082298 PLAN CHECK NO; 1.1 GOVT: N SUPP: N CONSTRUCTION TYPE: IFR SP PERMIT TYPE: MEC PURPOSE: ALT JOB DESCRIPTION COMMERCIAL T.I. STORE INTERIOR SQ FT: CLAIM VALUE: CALC—VALUE: GROUP OCC: B / COMMENTS: THE "FRED JOAILLIER" JEWELERY STORE, MECHANICAL RE:#B82170 Z 0 N I N G R E Q U I R E M E N T S S E T B A C K S -------------------- MAIN BUILDING ------------ --------- ACCESSORY BUILDING --------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RIGHT: FT IN PARKING REQ: PROV: PARCEL: 41249207 ZNE: REF NO: PLANNING NOTES> iEiE�***���*iEiFiE*�(•jEt4iFiEic iEiEiEiEiEiEiEaF�iE�)EiF�3FiE'1E*iEik*�iEiEiEiEiEiFiEiEifiE3E9EiFiF�EiFiEiE*iE�EiEiEiEf4��E��iEiE�#*�iE3E D E V E L O P M E N T S E R V I C E S R E Q U I R E M E N T S ZONING APPROVED BY DATE: WILDING APPROVED BY DATE: APPLICATION ISSUED BY: DATE: �E iE iE 1E � iE lE iE iE iE iE iE it- iE iE iE iE iE iE +E iE iE iE fE iE * jE iE * 9E � it� � LEGALIZATION:N F E E S U M M A R Y STRUCTURAL SEGMENT:N BLDG PMT PLUMBING ELECTRIC' MECHANIC FIRE SMIP/RES GRADING PERMIT. 21.75 r _ 251 SMIP/NON—RES PLAN ISSUE FEE 22.00 BUILDING—DIV—> PERMIT ISSUE PLAN=CHECK TOTAL PAID DUE TOTALS ---- > 21.75 22.00 0.00 43.75 43.75 .00 REVENUE DIVISION TOTALS--> COLLECTED: 43.75 OVER/SHORT: ,00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK 43.-75 if fE if �E i[- iE 3E �E'1F dF lE 9f iE �E � �E• iE iE 1E iE• fF * � it• iE'1E 9E lE �E'IE 1E'IE lE iE iE.* �(- � fE iE iE iE i'E fE iE iE � iE iF iE in: �E � � iE * � iE * 3E iF iE• fE 1E iE � iE }F'YE �F � iE )F � � � ?f iH iE I N D I V I D U A L F" E E B R E A K D O W N TYPE QTY D E S C R I P T I O N' UNIT COST TOTAL COST MEC 1 REPAIR/ALT COOLING, UNIT/SYS W/CNTLS 12.25 12.25 MEC 1. VAV BOX '} 9.50 9.50 END -OF FEES r' h 04-02-1997/61:19 PHA43.75 RCPT0:01-0004324 .r. PERMIT : 982298 CONSTRUCTION AND PLANNING APPROVALS Permit # Date Inspector POOL & SPA APPROVALS Permit # Date Inspector, 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location 2. Soil Pipe•Undrgrnd. 53, Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. 54. Forms 4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding 5. Steel Reinforcement' 56. Rough Plumbing & Pressure Test 6: Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE 7, Footings 58. Electrical Conduit-Undrgrnd. R% -,Foundation 59. Gas Pipe, 0 Undrgrnd., Test 9. Water Pipe-Undrgrnd. 60. Backwash Lines, P -Trap, 0 Updrgrnd. 10. Structural Floor System 61, APPROVAL TO DECK 11, Property Sewer Line & House Connection 62, Backwash & Receptor -Final 12. Sewer Cap 63, Heater & Vent -Final ) 13. Roof Drains 64. Plumbing System - Final 14. Rough Plumbing ;' 65. Electrical -Final 15. Rough Electrical -Conduit 66. Solar System -Final 16. Rough Electric Wiring 67. Fencing & Access Approval 17. Rough Wiring Sign 68. APPROVED FOR PLASTERING 1$. Rough Electrical•T Bar Ceiling 69. POOLJSPA SYSTEMS FINAL = 19. Rough Heating & Air'Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit # 20. Rough Factory Fireplace 21, Ducts, in Structure 70. Underground Hydro 22. Ducts, Ventilating 71, Product Piping 0 Gas 0 Oil 23. Gas Pipe -Rough & Test 72, Underground Flush 24, Rbof Framing - 73.' Undergrnd. Storage Tank 0 Gas 0 Oil 25. Roof Sheathing 74, Overhead Hydro 26, T -Bar Ceiling (Structural) & Monocoat 75. Dry Chemicai 27. Frame and Flashing - 76, Dry Standpipe 28, Lathing &.Siding 77. FIXED SYSTEM FINAL 29. Insulation 78, FIRE PREV. FINAL 30. Drywall Nailing - HEALTH DEPT.'REQUIREMENT 31. Plaster Brown Coat 79, FINAL INSPECTION 32. Electrical Power Meter -Final 80, FOOD CERTIFICATE ISSUED 33. Final -Electric Notes: 34. Final Heating & Air Conditioning 35. Final Gas Pipe Test L?v-LEE 0 36, Hood or Canopy 37. Final Factory Fireplace 38. Final Plumbing 39. Water Service -Final 40, Gas Service -Final 41. Solar Domestic -Final 42. Backflow Preventer 43. Backflow irrigation 44. Landscape Irrigation System 45. Sound Attenuation 46. Handicap Regulations 47. FINAL STRUCTURE & BUILDING 48. FINAL PLANNING 49. Electric Release to Edison 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY NoDate 4';l � .� -. .�'�T�, •r �'� y j � :p•• - ..__. _ �_ _�� .wn `.MP^W'�� vw�+Tn�..,M/�_-�T �_ .-.... .. -•. �.,�y � _ _. w __ - Cit'y o Costa 20 e s a Development Services, Division of Building and Safety J 0 CERTIFICATE OF OCCUPANCY This certificate is issued pursuant to�tlie_requirernerfts fof ,' e -Uniform Building Code, Section 308 adopted by'the`City of Costa Mesa certifies, at ttie;time,of its_ ssuance the building structure herein below described was inspected and%app id�for occiipaney�as Bows: i��x > BuildingAddress 3333 BBISTOLeSTREET UNIT 1403Bld . Permit No. B 700 Use Group B-2 Type'of Construction IFR -SP Fire,Zonei c, ,: ;;€ Use Zone CIS C e =Strom Te ant " � -i( Auilm JI�SJEWSI.ERS" Owner of Building - Address 3 15 Fariv"I'r-kck Zfi �f 7 BUILDING OFFICIAL COW? , r� � U/ Date � November 20, 1995 REQUIRED TO BE POS TED-IN"A CONSPTCOUS PLACE ADDRESS OF BOILDING: 3333 BRISTOL ST UNIT: 1403 OWNEITSKAMEIFlMft C J SEGERSTROM FLOOD: AO -38 ADomss: 3315 FAIRVIEW DR 3 r , 'COSTA MESA, CA 92626 APPL. AWUNQ ADDRESS: ARCHrrECT OR Elf mil: BRAND & ALLEN ARCH Lic. No, C 2 0 2 9 0 ARCH. DR EHD,'s ADDRESS: 1400 POST OAK BL urar: 200 HOUSTON TX 77056 cwmAvorsNAME: WALTER M. ANDERSON (714)891-1627 cowmAcroR's ifmum 10572 B ARB E T T E ALT ADDREss: GARDEN GROVE CA mmm: 301942 92643 UNT: NONE LICENSED CONTRACTORS DECLARATION: I hereby affirm under penMy of perjury that I am licensed under provisions of Chapter B (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Cm LIC. No.: 0 0 9 3 61 LIC. CLASS: B uc, 1 4 2 EX : 02/96 Date: Contractor. OWNER BUILDER DECLARATION: I hereby affirm under peneby of perjury That I am exempt from the Contractors License Law for the following reason (Section 7031.5 Business and Professions Code: Any city or county which requires a permit to omalruci, alter. improve, 'K, molish, a repair any structure, prior to its issuance, also requires the applicant for such pwmh to fib a signed ata'~ that he or she +''i'licarseprovisionspursuant to the provisions of the Contractors License Law [Chapter 0 (oommenmeg with Section 7000► d Division 3 d the :usinon and Professions Go -del or that hex she is exempt therefrom and the basis for the alleged exemption. Any violation d Section 7031.5 by any applicant tot a permit subjects the applicart to a civil penally of net more than five hundred dollars [5500]). ❑ 1, as owner of the property or my employees with wages as their sale compensation. win do the work, and the structure is not intended or off" for ado (Section 7044, Business and Professions Code: The Contractors 1icerse Law does rpm appy to an owner of property who bolds or improves theteon, and who does such work himself or herself or through his or heir own employees, provided that such improvements are not intended or offered for sale. 0, however. the building or imp rove nem is sold within one year of completion. the ownerbuildsr win have the burden of proving he or she did to build or improve for IM purpose of sets). [� I, as owner of the pruparly. am axcbxsivey contracting with licensed rnmraclors 10 construct the project (Section 7044, Business and Professions Code: The Contractors License Law does not appy to an owner of property who builds or improves thereon and who contracts for such projects with a c)mrador(s) licensed pursuant to the Contradors Loans Law). ❑ I am exempt under Section: 8. & P.C.. for this reason: Data: Owner: I do hereby certify that I am aware of and undesland the requirements of California Health and Safety Code Sections 25505, 25533, and 2553U, and that I or any future building occupant will I wit net (circle one) need to comply with said state codes and the requirements for a permit faoonandionormodification from the AiruCO tyWaanagerentDistrict. Residential construction appketatsareexempt from these provisions. Dale: Applicant: WORKER'S COMPENSATION DECLARATION: I hereby affirm under penally of perjury one of the following declarations: ❑ 1 he" end will maintain a certificate Or consent to 9e114rpsure fee werkete' compermo lon. as provided lot by Section 3700 at the Labor Code, tar the performance of the wait for which this pernat is issued. I have and will maintain wakes' compensation insurance, as requited by Section 3700 of the Labor Code, for the performance of the work for which this permit is ssued. My workars' P Lit.. ad on insurance ur e ll �p�r'y number aro: EXPIRES carrier: Policy Number, 10/01/95 (T his section need nor be sompfeted if the pis m r is Aar ane hundred do6era 151001 or fear.) I cedfy Not in the performance of the work la which this pamnl q issued. I shell net employ any person in any manner so as to become subject to the workers' compensation laws of Cardomis. roed I d ons reubjed to the wakars' Dont/pJej�an previa d corp 3700 ofthe Labor Code, 1 h wpN e p oats: 7 f Applicant: Warning: Faffure to secure workers' compsnsetlon coverege is unlawful, and shall sub)ecr an employer to criminal penaldes and civil lines rp to me hundred thousand dollars (S10Q000), In addition to the east of eomprnaerlon, dsmagss as provided for In Sectfon 3706 of the Labor Code, Interest and attorney's fees. CONSTRUCTION LENDING AGENCY: I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work for which this Permit is issued (Section 3047, Civ, C), LENDER'S NAME: LENDER'S ADDRESS: I certify that I have sad this application and stale that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building oonsuuttian and hereby authorize repxeserlatives of this city to anter upon the above-mentioned property for inspection ptnpesa'. WALTER ANDERSON / Prutl Dale: 5�)— 7— Signature m Ow nerlAgenUAppicanNContrartor (5151-46 WP) White -Sinding d Safety; Graeo-Rle; Canary -Applicant; Pink -Revenue: Goldenrod -Assessor CITY OF COSTA MESA — BUILDING PERMIT PERMIT NO: B 074100 PLAN CHECK NO: 03415-95 A CONSTRUCTION TYPE: PERMIT TYPE: STR JOB DESCRIPTION : 1233SF STORE TI VLf PERM NO: B 074100 GOVT: N SUPP: N PURPOSE: OTH SQ FT: 100,000 CLAIM VALUE: 100,000.00 CALC—VALUE: 100,000.00 GROUP OCC: B-2 / COMMENTS: "FRED JOAILLIER" JEWELERS STORE TI, Z O N I N G R E Q U I R E M E N T S S E T B A C K S — --- MAIN BUILDING ---------- --------- ACCESSORY BUILDING --------- FRNT FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN PARKING REQ: PROV: PARCEL: 41250107 ZNE: C1S REF NO: PLANNING NOTES> TENANT IMPROVEMENT TO RENOVATE SUITE FORMERLY OCCUPIED.BY > CHURCH'S SHOES FOR FRED JOAILLIER JEWELERS iE iF slit iE iE iF # iE dE � �E �f '1E lE �E �k dE � �E �(-:�E iE if iE iF dE � 9! � iE dE iE if iE iE �l4 If iE ? E iE iE 9f' �'iE lE * �'IF fE -lf 'IE if if irk IE �E �E � �E dF iE iE iE iE iE IE iE IE iE'lE'lE iE -If -1(- iE iE � IE iE D£ V E L O P, M E' N 'T S E R V I C E S R E Q U I R E M E N T S ZONING APPROVED BY DATE: BUILDING APPROVED BY r DATE: APPLICATION ISSUED `%BY: r. DATE: % �E�EiE�*-1E��i4itiE#i4ifif#�E��->E*� *iEiE#ifiEa4iE'lf� iEiE LEGALIZATION:N .r F E E S U M M A R Y STRUCTURAL'SEGMENT:Y BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT 639.50 SMI PLAN 103.92 21.00—RES ISSUE FEE BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE TOTALS ---- > 660.50 0.00 103.92 764.42 764.42 .00 REVENUE DIVISION TOTALS--> COLLECTED: 660,50 OVER/SHORT: .00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK 639.50 21.00 iE iF iE d4- FE 3F iF iE ♦f iE �E iE iE iE iE iE iE aE iE iE �E iE iE iE if iE �F iE ')E iE iE ifiF iE 9E iE iE iE iE iE * * iE � iE iE �E * * tF � * � iE 9F iE iE 9E �E tE iE * iE iE �E )E 9E 3F * * iE iE iE iE iE � 3E iE iE I N D I V I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST SFC 100000 T.I. STORE BY VALUE/$1 1.00 100,000.00 END OF FEES 01 00189743-00189749 T CR T 650.50 OATEt €9/07/95 TME: 11:5a CONSTSUCTION AND PLANNING APP7FOVALS Permit # Date Inspector POO SPA APPROVALS Permit pate Inspector 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location 2. `Soil Pipe-Undrgrnd. 53. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. 54. Forms 4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding 51. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6. Electrical LIFER Grnd. 57, APPROVAL TO COVER-GUNITE 7. Footings 58. Electrical Conduit-Undrgrnd. 8. Foundation- 59. Gas Pipe, © Undrgrnd., Test 9. Water Pipe-.Undrgrnd. 60. Backwash Lines, P -Trap, ❑ Undrgrnd. 10. Structural Floor System 61, APPROVAL TO DECK 11, Property Sewer Line & House Connection 62. Backwash & Receptor -Final 12. Sewer Cap 63. Heater & Vent -Final 13. Roof Drains 64. Plumbing System - Final 14. Rough Plumbing 65. Electrical -Final 15. Rough efectricai-Conduit 66. Solar System -Final 16, Rough Electric Wiring 67. Fencing & Access Approval 17. Rough Wiring Sign 68. APPROVED FOR PLASTERING 18. Rough Electrical -T Bar Ceiling 69. PpOLISPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS . Permit # 20, Rough Factory Fireplace 21. Ducts, in Structure 70. Underground Hydro 22. Ducts, Ventilating 71, Product Piping 0 Gas 0 oil 23. Gas Pipe -Rough & Test 72, Underground Flush 24, Roof Framing 73. Undergrnd. Storage -Tank El Gas E]Oil 25. Roof Sheathing 74. Overhead Hydro 26, T•Bar Ceiling (Structural) & Mgnocoat 15. Dry Chemical 27. Frame and Flashing � �76. Dry Standpipe 77., FIXED SYSTEM FINAL 28. Lathing & Siding .. 29. Insulation 30. Drywall Nailing �0 31, Plaster Brown Coat . 78. FIRE PREY. FINAL HEALTH DEPT. REQUIREMENT 79. FINAL INSPECTION 32. Electrical Power Meter -Final ° 80. FOOD CERTIFICATE ISSUED 33. Finaf Electric Notes-, 34. Final Heating & Air Conditioning.,, 35. Final Gas Pipe -.Test, , ,•• 1 36. Hood or Canopy 37. Final Factory Fireplace ~ ; 38. Final Plumbing - 39. Water Service -Final 40. Gas Service -Final 41. Solar Domestic -Final 42. Backflow Preventer 43. Backflow Irrigation 44. Landscape Irriqation System 45, Sound Attenuation 46. Handicap Regulations 47, FINAL STRUCTURE & BUILDING 48.- FINAL PLANNING 49: Electric Release to Edison 50. Gas Release to Southern California Gas Co r - - 51. CERTIFICATE OF OCCUPANCY No. Date W i ADDRESS OF SOLOING: 3333 BRISTOL ST OwNER'sNAMEIF*MN: C J SEGERSTROM ADDRESS: 3315 FAIRVTEW DR I 'COSTAA MESA, CA 92626 &PPL. MAILING ADDRESS: ARCHITECTOREN101EER: BRAND & ALLEN ARCH Rcft OR ENG.'S ADDRESS: 1400 POST OAK BL HOUSTON COfITRACTOR'S NAME: WEST RAY CO CIDWACTOWSMAIING 1525 MACARTHUR BL UNIT: 1403 FLOOD: AO -38 LIc.ND: C20290 UNIT: 200 TX 77056 (714)854-7127 ADDRESS: COSTA MESA CA mw, 237876 92626 UNIT: 0010 LICENSED CONTRACTORS DECLARATION: l hereby affirm under penalty of perjury that I am lKentied under provisions d Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my lig is in full force and effect. CfTY LIC. NO..: 0 0 613 9 Lic. Cuss: C —10 uc. NO.: 2 u 0 7 6 �DI I o -5 a s Contractor: 0 ER BUILDER DECLARATION: I hereby affirm under penalty of perjury that I am exempt from the Contractors Boerne Law for she I reason (Section 7031.S Business and Profession* Cade: Any city or county which requires a permit to oonstrucl. alter, improve. olmh, or repel any stirxgure, prior to is issuance. also requires the applicant la such pannd to fib a signed statement that he or she licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Divalon 3 of the -Amro sa and Protasworn Code] or that he or she is exempt Iherehom and the basis for the *Raged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (5500]). ❑ I, as owner tithe property or my employees with wages as their ode compensation, will do the work, and the structure is not intended or offered for sale (Section 7o44, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however. the building a improvement is sold within one year of oompblion. the ownerbutder will have the burden of proving he or she did not build or improve for the purpose of sale). ❑ I, as owner of the property, am exclusively contracting with ", - -, a contractors to construct the project (Section 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon and who contracts for such projects with a oortector(s) licensed purallenl to the Contractors Lioeme Law). ❑ I am exempt under Section: B. A P,C., for this reason: Date: Owner: I do hereby certify that I am aware of and understand the requirement* of Caliomle Health and Safety Code Sections 25505, 25533, and 25534, and that I or any future building occupant will I will not (circle one) need to comply with said state codes and the requirements for a permtforcautnlction or modifrcalion from the Ai u�anagemem District. Residential consirudion applications era exempt from these provisions. Date: Applicant: WORKER'S COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following dedarwionw ❑ I have and will maintain a cwtificase of consent to sell -insure for waferscompensation, as provided la by Section 3700 of the Labor Code. for the performance of the work for which thin permit is issued. ❑ I have and will maintain workms' compensation insurance. as required by Section 3700 of the Labor Cade, for the partamence of the work fa which this permit is issued. My workers' compensation insurance carrier and polity number we: Carrier: Policy Number: �r r rs ion need not be comp*W M the permk is for one hundred dollars [Stool or less.) ] Wily that in the performance of the work for which this permit is issued, I shell not employ any person in arty manner no as to subject to the workers' compensation haws of California, and agree t subject to the workers' eamperr swoon provisions of Section 3700 of the Labor Code, I shell forth imply vA:h those Date: i =� • !;;L Applicant: warning: Fa Run to secure wo*mcorriparmation coverage la untaarM, and dldf sub*t an arroolaywr to nafminal penalties and dull ffrtp cp to one hundred thousand doffan ($1010.0001 In addltlan to the coat of corloelnatlork danagsa as provldrd for In Socdon 3706 of fha Labor Code, Interest, and saomeY's tap. CONSTRUCTION LENDING AGENCY: I hereby affirm under penalty of perjury that them is a construction lending agency for the performance of the work for which this perms is issued {Section 3097, Civ, C). LENDER'S NAME: LENDER'S ADDRESS: I certify that I have read this application end state that the above information is contact. I agree to comply with all city and county ordinances and state laws retailing to building construction and hereby authorize representatives of this edyID 611101' upon the above-menlioned property for inspection purposes. ,SAID HR (5151-46.WP) Whte-Buildirp 6 Safety; Date: - 5� Pink -Revenue; Goldenrod -Assessor CITY OF COSTA MESA - BUILDING PERMIT PERM NO: £ 074480 PERMIT NO: E 074480 PLAN CHECK NO: N GOVT: N SUPP: N CONSTRUCTION TYPE: PERMIT TYPE: ELE PURPOSE: OTH JOB DESCRIPTION : 1233SF STORE TI SQ FT: CLAIM VALUE: CALC-VALUE: GROUP OCC: B-2 / COMMENTS: "FRED JOAILLIER" JEWELERS STORE TI, REF: B-74100 Z O N I N G R E Q U I R E M E N T S S E T B A C K S ------------ MAIN BUILDING ---------- --------- ACCESSORY BUILDING---------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN PARKING REQ: PROV: PARCEL: 41250107 ZNE: REF NO: PLANNING NOTES> iP � iF iE dE 9F dE dE �E � 4E �F �E iE * * iF * � � 3E �E iE iE iE iE 3E � * iF iE iF iE �E iE iE �E iE if• iE iE iE iE �E iE 3E }E �E iF iE 3E dE iE iE * iE aE �E # iE -IE �E 3E iE 9E iE # dE 9E aE iE � -1E �E iE # �E iE it• D E V E L O P M E N T S E R V I C E S R E Q U I R E M E N T S / ZONING APPROVED BY DATE: BUILDING APPROVED BY ,.. DATE: APPLICATION ISSUED BY: DATE: Q +E' iE iE iF iE iF # # �F 3%'Yr � 3E'1i' � iF iF iE• 9E iE �F �E yt tit• �E }E iE iE iF iE'JE iE i� iE '3i iE !F LEGALIZATION:N F E,E7 S U M M A R Y STRUCTURAL SEGMENT:N BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMTP/RES GRATING PERMIT 100.00 50% SMTP/NON-RES PLAN - ISSUE FEE 15.00 BUILDING -DTV-> PERMIT ISSUE PLAN -CHECK TOTAL PAID DUE TOTALS-----> 100,00 15.00 0.00 1115.00 115.00 ,00 REVENUE DIVISION TOTALS--> COLLECTED: 115.00 OVER/SHORT: .00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN -CHECK 115.00 iE �E iE iF IE iE �E'1E iE iE iF �E iE �E iF iF'vF iE � iF �E }F iE iE �E iE 3E iE �E- �E iE iF iE 3E � iE iE jE � iE iE ;'F �E �E iE iE iE � * iE iE iE i(• )E iF -IE �E iF iE iE -lf i(iF �f• iF dE iE• # �E iE iE �E iF .}F iE * iE 3E iE I N D I V I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST ELE 20 FIXTURES, LIGHTING 1 ST 20 EA, ,75 15,00 ELE 58 FIXTURES, LIGHTING ADDITIONAL EA. .45 26.10 ELE 18 RECEPT/OUTLET 1 ST 20 EA. .75 13.50 ELE 20 RECEPT/SWITCH 1 ST 20 EA. .75 15,00 ELE 2 RECEPT/SWITCH ADDITIONAL EA. .45 .90 ELE 1 SERVICES BELOW 600 V & BELOW 201 AMP 18.50 18.50 ELE L SUB—PANEL 11.00 11,00 END OF FEES 01 001910'32-013191632 TOT DATE: 10/1!7/9; til'`. S 10too 115.00 CONSTRUCTION AND PLANNf11iG _ AOP OVALS Permit # Date Inspector POO 63 1 APPROVALS Perittit# Date Inspector 1. Temporary Electrical Service or Pgie 52, Pool &Equipment Location.) i'N, 'r 2.` Soil Pipe-Undrgrnd. _ 53. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. 54. Forms I 4, Flectrical Conduit-Undrgrnd, 55. Electrical Bonding t + 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6. Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE 7. Footings 58. Electrical Conduit. Undrgrnd. 8. Foundation 59. Gas Pipe, ❑ Undrgrnd., Test 9. Water Pipe-Undrgrnd. i 60. Backwash Lines, P -Trap, t^7. Undrgrnd. 10. Structural Floor System 61. APPROVAL TO DECK 11. Property Sewer Line & House d` rtection 62. Backwash & Receptor -Final 12. Sewer Capt' 63. Heater & Vent -Final 13, Roof Drains 1, 64. Plumbing System - FinaP, 14, Rough Plumbing 65. Electrical -Final t r 15. Rough Electrical -Conduit �� 66. Solar System -Final 16. Rough Electric Wiring 67, Fencing & Access Approval _ 17. Rough Wiring Sign 68. APPROVED FOR PLASTERING 18. Rough Electrical -T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL ' 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit # 20, Rough Factory Fireplace 21, Ducts, in Structure 70. Underground Hydra 22. Ducts, Ventilating 71. Product Piping 0 Gas ©Oil 23. Gas Pipe -Rough & Test 72. Underground Flush 24. Roof Framing 73. Undergrnd. Storage Tank © Gas ❑ Oil 25. Roof Sheathing 74, Overhead Hydro 26. T -Bar Ceiling (Structural) & Monocoat 75. Dry Chemical 27. Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding 77. FIXED SYSTEM FINAL 29. Insulation 78, FIRE PREV. FINAL 30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat 79. FINAL INSPECTION 32, Electrical Power Meter -Final n FOOD CERTIFICATE ISSUED 33. Fina! Electric �l�x�JC I les" 34. Final Heating & Air Conditioning 35. Final Gas Pipe -Test 36. Hood or Canopy l,! 37. Final Factory Fireplace 38. Final Plumbing 39. Water Service -Final 40, Gas Service -Final 41. Solar Domestic -Final 42. Backflow Preventer 43. Backflow Irrigation 44. Landscape Irrigation System 45. Sound Attenuation 46. Handicap Regulations 47. FINAL STRUCTURE & BUILDING 48. FINAL PLANNING " 49. Electric Release to Edison 50, Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY No. Date ADDRESS OF 6u1LD913: 3333 B R I E TOi, ST UNIT: 1403 ONMEICSNWEIFIQMIk C J SEGEnTROM FLOOD: AO -38 �ADDRfm 3315 FAIRVIEW DR 'COSTA MESA, CA 92626 ADPL.YAIUND ADDRESS: AMITECTORENMEER: BRAND & ALLEN ARCH Lsc.flo.-: C20290 ARCH. OR ENa's ADORES$: 1400 POST OAK BL UNIT: 200 HOUSTON TX 77056 CONIRACTOR'SKAYE: L B PLUMBING COMPANY (714)838-8415 comACTOR'8NAa1110 11632 MARBLE ARCH DR arm SANTA ANA CA urNo.: 287240 92705 uNt LICENSED CONTRACTORS DECLARATION: I hereby affirm under penalty of perjury that I am licensed under provisiom of Chapter 9 (commencing with Section 7006) of Division 3 of the Business end Professions Coda, and my ",ansa is in full Face and affed. CITY uc-c.)NO,: 0y 17 8 6 0 LIC. CLASS: C 3 6 LIC. N01y 2 8 7 2 4 0 ECP : 03/96 Date: ` /'�:li�f �� Contract OWNER BUILDER DECLARATION: I hereby affirm under jury that I am exempt from the Contractors License Law for the following reason (Section 7031.5 Business and Professions : A y city a county whkh requires a perm& to construct, after, improve, •lemdah, or repair any structure, prior b as eauarwe, also requires the applicant for such permit to file a signed statement thiel he or she boarmed pursuant to the provisions of the Contractors License Law [Chaper 9 (commencing with Section 7000) of Diveion 3 of the .usioess and Prdessions Code] or that he or she is exempt therefrom and the basis fa the alleged examption. Any violation of Section 71131.5 by my applicant for a perms subjects the applicant to a civil penalty of not moa than five hundred dollars ]$500D, ❑ 1, as owner of the Property or my employees with wages as their Bole compensation, will do the work, and the structure is not intended or offered for sale (Section 7064, Business and Professions Code: The Coniradnrs License Law does not apply to an owner of property who builds or inpnaves thereon, and oda does such work hims" or hersell or through his or her own employees. Provided lhm such improvements are not intended or uttered for safe. 0. however, the building or improvement is sold within one year of completion, the owner -budder vA9 have the burden of pmvmg he or she did not build or improve for the purpose of sale). ❑ I, as owner of the property, am aaohusively contracting with licensed contractor to construct the project (Section 7044. Business end Professions Code: The Contractor License Law does not apply to an owner of properly who builds or improves thereon and who contracts for such projects with a "tractor(s) licensed pursuant to the Contractors License Law). ❑ I am exampl under Section: B. & P.c-, for this reason: Date: Owner. I do hereby certify that I am aware at and understand the requirements of Caldomia Heefth and Safety Cade Sections 25505, 25533, and 25534, and that I or any future building occupant will l will nol (circle one) need to comply with said state codes and the requirements for a permit foreonstmclion a modification from the Airlyy ma gement District. Residemial construction applications ere exempt from these pro0sios. Date: Applicant: WORKER'S COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the tolfowirg dsdaralio s: ❑ 1 have and wig maintain a candirate of consent to salfdn=m for worker' compensation. as provided for by Section 3700 of Iha Labor Code, for the performance of the wok for which this permit is issued. ❑ I have and wig maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy number ars; Casser: ST8'E FUND EXPIRES Policy Number. Q70E81-95 10/24/95 . this section creed not he completed d the psmml is for one hundred dollars (stool or lass.) ❑ I certify that in the Wommnce of the work for which this permit is issued. I shall riot employ any person in any manner so as to become mbjed to the workers' oompensafion laws of Calif and agree r 9 1 should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I forthwith CZvwhh=. Datta: T/ Appy Warning: Failure to secure workars' calwaraadon a unlewrL{ and shall aub*t an employer to crfmhtal panalffes and civil fines rap to one hundred thousand dollen (5104000), In addfflon to fhe coat of rompsnaadon, demages as provided for In Section 3706 of Iha Labor Code, Interest, end afromey's fees. CONSTRUCTION LENDING AGENCY: I hereby affirm under penalty of perjury the them is a construction lending agency for the performance of the work for which this permit is issued (Section 3697, civ. C). LENDER'S NAME: LENDER'S ADDRESS: I certify that I have read this application and state that the above information is cared. I agree to comply with an city and county ordinances and suite laws relating to building construction and hereby authorize represantatives of this city to anter upon the above-menlioned property for inspection purposes. LARRY BALDERRAMA M M.aW (5151.45.WP) White -Building d Safoty; Gmenr File; Canary -Applicant; Pink -Revenue; Goldenrod -Assessor CITY OF COSTA MESA — BUILDING PERMIT PERMIT NO: P 074375 PLAN CHECK NO: N CONSTRUCTION TYPE: PERMIT TYPE: PLU JOB DESCRIPTION 1233SF STORE TI/ PLUMBING CLAIM VALUE: CALC—VALUE: PERM NO: P 074375 GOVT: N SUPP: N PURPOSE: OTH SQ FT: GROUP OCC: B-2 / COMMENTS: "FRED JOAILLIER" JEWELERS STORE TI REF B-74100 Z O N I N G R E Q U I R E M E N T S S E T B A C K S ------------ MAIN BUILDING ---------- ---------- ACCESSORY BUILDING--------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RIGHT: FT IN LEFT: FT IN RGHT: FT IN PARKING REQ: PROV: PARCEL: 41250107 ZNE: REF NO: PLANNING NOTES> > r� D E V E L O P M E N T S E R V I C E S v R E Q U I R E M E N T S ZONING APPROVED BY DATE: BUILDING APPROVED BY : DATE: APPLICATION ISSUED 8 - I = //]f * DATES / * LEGALIZATION:N F E E S U M M A R Y STRUCTURAL SEGMENT:N BLDG PMT PLUMBING ELECTRIC MrECHANIC FIRE SMIP/RES GRADING PERMIT 21.00 25% "� SMIP/NON—RES PLAN ISSUE FEE 20.00 �' BUILDING -DIV-> PERMIT ISSUE PLAN-GH•ECK TOTAL PAID DUE TOTALS-----> 21.00 20.00 ` y0..00_ 41.00 41.00 .00 REVENUE DIVISION TOTALS--> COLL-ECTED: 41.00 OVER/SHORT: 00 BLDG PMT PLUMBING ELECTRIC MECHANIC,.. FIRE SMIP/TOT GRADING PLAN -CHECK 41..00 9E -lE iE �(- iE iE iE iE fE dF iE �E iE iE �E iE � it aE iF it ifs �E iE * it• iE iE iE iE iE �E # -1E iE aE i!ft�E � � iE dE dE dE iE 9E iE• iE �E iE iE �E iE iE iF iE iF iE if 1E iE iE iF fE i6 iE * 3E ie- iE �E �E �E �E iE �f �E dE � I N D I V I D U A L- F iE E B R E A K D O W N S_ TYPE QTY D E S C R I P T I O+N� UNIT COST TOTAL COST FLU 1 WASH BASIN ! PLU 1 WATER CLOSET (TOILET) PLU 1 WATER HEATER AND/OR LfF��IIT� END' Ia F FE S A �� f 7.00 7.00 7.00 7.00 7.00 7.00 0' 0319102-00191092 'ft QT 41.00 DATE. 09E29'95 TIME: 15-32 �r CONSTRUCTION AND PLANNING Date A��OVALS Permit # Inspector POOL PA APPROVALS Permit # Date Inspector �_ 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd. 53, Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. 54. Forms 4. Electrical Conduit -Undrgrnd. 55. Electrical Bonding r ;a 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test +6- Electrical LIFER Grnd. 57. APPROVAL TO COVER-GUNITE ' 7. Footings 58, Electrical Conduit-Undrgrnd. S. Foundation 59. Gas Pipe, ❑ Undrgrnd., Test 9. (Nater Pipe-Undrgrnd. % 60. Backwash Lines, P•Trap, C� 6r drgrnd. 10. Structural Floor System '' 61. APPROVAL TO DECK j 11. Property Sewer Line & House Cor]ngction 1 62. Backwash & Receptor -Fina.-'" 12. Sewer Cap v 63. Heater & Vent -Final = 13. Roof Drains 64. Plumbing System • Final 14. Rough Plumbing 4-Z 1 65. Electrical -Final 15. Rough Electrical -Conduit / , 66. Solar System -Final 16. Rough Er ectric wiring ; 67. Fencing & Access Approval 17. Rough Wiring Sign 68. APPROVED FOR PLASTERING 18. Rough Electrical•T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT, REQUIREMENT APPROVALS Permit # 20. Rough Factory Fireplace 21, Ducts, in Structure 70. Underground Hydra 22. Ducts, Ventilating 71. Product Piping ❑Gas ❑Oil 23. Gas Pipe -Rough & Test 72, Underground Flush 24. Roof Framing 73, Undergrnd. Storage Tank ❑ Gas ❑ Oil 25. Roof Sheathing 74, Overhead Hydro 26. T -Sar Ceiling (Structural) & Monocoat 75. Dry Chemical 27. Frame and Flashing 76. Dry Standpipe 28, Lathing & Siding 77, FIXED SYSTEM FINAL 29, Insulation 78, FIRE PREV. FINAL 30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat 79. FINAL INSPECTION 32, Electrical Power Meter -Final 80. FOOD CERTIFICATE ISSUED 33. Final Electric 34. Final Heating & Air Conditioning Notes: _Zc6S�� T _ Ap G&2 35. Final Gas Pipe -Test 36. Hood or Canopy 37. Final Factory Fireplace 38. Final Plumbing [ r- r- 39. water Service -Final 39. 40. Gas Service -Final r �� 41. Solar Domestic -Final 42. Backflow Preventer 43. Backflow Irrigation 44. Landscape irrigation System 45, Sound Attenuation 46. Handicap Regulations 47. FINAL STRUCTURE & BUILDING j 48. FINAL PLANNING , 49. Electric Release to Edison 50. Gas Release to Southern California Gas Co t' 51. CERTIFICATE OF OCCUPANCY No. Date �I ADDRESS OF ewLDtNG: 3333 BRISTOL ST OWNER'S NAMEif: IG10WN: C ,J SEG 7RSTAOM rADDRE9s: 3315 FAIRVIEW DR �.S COS=A MESA, CA 92626 r APPL. Mul1NG ADORES - ARCHITECT OREIIOOtan: BRAND & ALLEN ARCH ARCH. OR Da S ADDRESS: 1400 POST OAK BL HOUSTON TX CONTRUTOnNAME: THERMALAIR INCORPORATED CONTRACTOITSMAIUNG 1140 N RED GUM ST ADDRESS: ANAHEIM CA UNIT: 1403 FLOOD: AO -38 ucwN C20290 UNIT: 200 77056 (818)442-3341 Ur. NO.: 102216 92806 Ute; LICENSED CONTRACTORS DECLARATION: I hereby affirm under penalty of perjury that licensed under provialons of Chapter B (commencing with Seetion 7006) of Division 3 of the Business and Professions Code my a Anse a in fun force and effed. CrIY LIC, No.: 0 0 6 0 6 9 LIC. CLASS: C 2 0 LI 1 EXP: 0 3 Dab: Comrador. OWNER BU DER OECLA ATION: 1 hereby affirm under penalty Flury lh exempt from the Can adore License w for I fdiowiq mason (Section 7031.5 Business end Professions Coda: city or which requires a pi= o oonstrud. Ilemol'sh, or repair erry stnxture, prior to its issuance, also requires I for such permit to fie a signed sWennscd that he or she h licensed pursuant to the previsions of the Contradom License Law [Chapter 9 (commencing with Section 70001 of Division 3 of the Su imesa and Proton" Codel or that he or she is exempt therefrom end the basis for the alleged exemption, Any violation of Section 7031.5 by any applicarq for a permit subjects the appkard to a dvil penehy of not more than five hundred dollars MMI). ❑ 1. as owner of the property or my employees with wages as their sole compensation, will do the work. and the structure is not intended or offered lir sole (Section 7044, Business end Professions Code: The Contractors Lomas Law does not apply to an owner of property who buids or improves thereon, end who does such work himself or herself or through his or her own employees, provided that such improvements are not hdended or offend for sale. If, however. the building or improvement Is toll within one year of completion. the owner -builder will have the burden of proving he or she did not build or Improve for the purpose d sale). ❑ I, as ower d the property. am exclusively contradihp with II- , contractors to oonstrud the projecl (Section 7044, Bwimss and Professions Cods: The Cortractom License Law doom not Appy to an owner of property who builds or improves thereon end who owrads for such projects with a corsractor(s) licensed pursuant to the Contractors Llcenss Lawl. ❑ I am exampt under Section: B. A P.C., for this reason: Date: Owner: I do hereby cerliy that I am aware of and understand the requirements of California Fealth and Safety Code Seders 25506, 25533, and 25534, end that I or any Mum building occupant will i wit red (cine one) need to onmpy wth said stab codes and the requiremams for a permit for construdlonormodificaten1mmlheAir uady PlanagnernantDurtrid.RpidemialoorMrualonappicatlonsamexempt from Owe PIOlAslons. Date: Applicant: WORKER'S COMPENSATION DECLARATION: I hereby affirm under penalty of per[ury one of Na following declarations: ❑ 1 have and willmaintain a certHoate d consent to seHdrsure for worker' oompanestIon, as provided for by Section 3700 d the Labor Code, for the performance of the work for which this permit Is Issued, ❑ 1 have mrd will maintain workers' compenswion insurance, as required by Section 3700 of the I A Code, for the padormenoe d the work for which this pamlt is paved. My waken'pare oration insurance carter and poky number are: CardS.0 Carrier: FEC0 EXPIRES Polley Number: 4 03/31/96 This moon read not be compktad I the permhf k Aar one hun&ad dales 151001 at 7"1 ❑ I certify Uel In the perlornhenca of the work for which this permit ie {nu s emPtoY arty person n any manner to become subject to the workers' compensation laws c Paldo d I becanne aubjed Ic provis' d Section 3700 d theLabor Code II fort with with Data: Appy Warning! .Aura to s un wodrsn' comparnadon ciyHag'e I kwftd, It subject ar to to r:rbrtlnel and e!W! Imes ys to one hundred thousand ddkra (ftOg000), addldon s cost o/ eompsvlsa" l maga as pro In Secdovt 3706 of the Labor Cods, Interest and stforney'o / CONSTRUCTION LENDING AGENCY: I hereby affirm under peneUy of perjay that there in e construction ending agency for the performance of the work for which this permit is issued (Sedim 3097, Civ. Cl. LENDER'S NAME: LENDER'S ADDRESS: I certify that I have reed this application and stats that the above information is =Fred. 1 agree to comply with all city and county ordinances and state ewe reeding to building construction and hereby authorize reprseenialim of this ciryto enter upon the above-mentioned property for !,,,I,pur�er—J-NHN n?UENTE JR Dade: (5151 Whim -Building & Salaty; Goren -Fib; Canary-Appicem; Pink-Amenw: Goldenrod-Asseswr CITY OF COSTA MESA — BUILDTNG PERMIT PERMIT NO: M 074344 PLAN CHECK NO: N CONSTRUCTION TYPE: PERMIT TYPE: MEC JOB DESCRIPTION : 1233SF STORE TI CLAIM VALUE: CALC—VALUE: PERM NO: M 074344 GOVT: N SUPP: N PURPOSE: OTH SQ FT: GROUP OCC: B-2 / COMMENTS: "FRED JOAILLIER" JEWELERS STORE TI, RE:#8741.00 Z 0 N I N G R E Q U I R E M E N T S S E T B A C K S ------------- MAIN BUILDING ---------- --------- ACCESSORY BUILDING--------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN —LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN PARKING REQ: PROV: PARCEL: 41250107 ZNE: REF NO: PLANNING NOTES>� 7 •� r ' D E V E L O P M E N T -S E R'V I C E S R E Q U I R E M E N T S ZONING APPROVED BY DATE: `BUILDING APPROVED BY /i DATE: .APPLICATION ISSUED BY: :�'� DATE: 210 iE*iElEiE*itiElE3E1F9E1E**iE**fEiE9FiE *****iE**iE*****ViEiE LEGALIZATION:N F E E S U M M A R Y STRUCTURAL SEGMENT:N ,_. BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT �. V 11.00 PLAN t— 25% SMIP/NON—RES , ISSUE FEE 15.00 BUILDING—DIV—> PERMIT ISSUE PLAN -CHECK TOTAL PAID DUE TOTALS ---- > 11.00 15.00 0'.00, 26.00 26.00 .00 REVENUE DIVISION TOTALS--> COLLECTED: 26.00 OVER/SHORT: 00 BLDG PMT PLUMBING ELECTRIC MECHANIC ` FIRE SMIP/TOT GRADING PLAN—CHECK 26.00 3E �E lE iF iE iE iF �F iF 3E iF 3F it iE f# i4 iE 3F iF * iE iE �E iF �E * iE iF iE iF iE * iE � # � YE ;tiE iE �E ifc 3E �.iE iF iE 9E 9E iE jE it iE �E iF iE iE �E 1E iE iE iF �E iF iF iE iE iE 9F f# �E � -)E iE iE 3E �E iE lE -IE I N D I V I D U A L' FIE E,, B R E A K D O W N TYPE QTY D E S C R I P T I O. -N�UNIT COST TOTAL COST MEC 1 VAV BOX 6.50 6.50 MEC 1 VENTILATION FAN CONN TOXSTNGLE DUCT 4.50 4.50 END 'OFA FEES .i ': , O1 �10190901-nC19040Y T0T 26,09 DATE. TR 3i:G5' i � r i CONSTRUCTION AND PLANNING A ROVAL.S Permit # Gate l"Spector POOL ,PA APPROVALS Permit # Date 1{tspe4tor 1: "temporary Electrical Service or P,dje' 52. Pool & Equipment Location t -� 2' Soil Pipe-Undrgrnd. 53. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. r 54. Forms 4. Llectrical Conduit-Undrgrnd. 55, Electrical Bonding , " 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test +� `6. Electrical UFER.Grnd, 57, APPROVAL TO COVER•GUNITE- 7. Footings 58. Electrical Conduit-Undrgrnd. f' 8. Foundation A 59, Gas Pipe, D Und[grnd., Test . > 9. Water Pipe-Undrgrnd. 60. Backwash Lines, P•Trap, 0 U drgrnd. 10. $tructuraf Floor System 61, APPROVAL TO DEC} 11. Property Sewer Line & Hous6 Coririection 62. Backwash & Receptor-Final` 12• Sewer Cap 63. Heater & Vent-Final , 13. Roof Drains 64. Plumbing System - Finan, 14. Rough Plumbing _ 65. Electrical-Final rl -- 15. Rough Electrical-Conduit 'j B6, Solar System-Final 16, Rough Electric Wiring 67, Fencing & Access Approval_ , 17. Rough Wiring Sign f: `• 68. APPROVED FOR PLASTER NGS 18. Rough Electricai-T Bar Ceiling 69, POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning 75 Aw FIRE DEPT. REQUIREMENT APPROVALS Permit # 20. Rough Factory Fireplace 21, Ducts, in Structure 70. Underground Hydro 22. Ducts, Ventilating 71, Product Piping 0 Gas 0 Oil 23. Gas Pipe-Rough & Test 72. Underground Flush 24. Roof Framing 73. -Undergrnd. Storage Tank 0 Gas © Oil 25. Roof Sheathing 74. Overhead Hydro 26. T-Bar Ceiling (Structural) & Monocoat 75. Dry Chemical 27. Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding 77. FIXED SYSTEM FINAL 29. Insulation 78, FIRE PREY. FINAL. 30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31, Plaster Brown Coat 79, FINAL INSPE=CTION 32, Electrical Power Meter-Final 33. Final Electricr,} 34, Final Heating & Air Conditioning L 4$ J 80, FOOD CERTIFICATE ISSUED Notes: C• ST��z2�sd �1_. s� 35. Final Gas Pipe-Test - 36. Hood or Canopy 37. Final Factory Fireplace 38. Final Plumbing 39. Water Service-Final 40, Gas Service-Final 41, Solar Domestic-Final 42, Backflow Preventer 43. Backflow Irrigation 44. Landscape Irrigation System 45, Sound Attenuation 46. Handicap Regulations r 47. FINAL STRUCTURE & BUILDING 48. FINAL PLANNING 49. Electric Release to Edison 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY No. Date ADDRESS OF 111.1111.0010: 3333 BRISTOL ST OWNER'S NAME IF IDIDWN: C J SEG ERS T ROM ADDRESS: 3315 FAIRVIEW DR COSTA MESA, CA 92626 ADPL. MAILING ADDRES& IARCHITECT OR ENGINEER: ARCH. OR ENa'a ADDRESS: UW.. 1403 FLOOD: AO -38 LIC, NO.: UNIT: CONrRAcraraNiME TRI—COUNTY FIRE (714)589-4207 cONiRACTORs MAILING 23052 AL I CA P K Y ADDRESS: MISSION VIEJO CA LJc.No.: 659326 92692 UNIT: LICENSED CONTRACTORS DECLARATION: I hereby affirm under penalty of perjury that 1 am licensed under provisions of Chapter 9 loommencing with Section 7000) of Division 3 d the Business and Professions Code, and my lioame is in full face and effect. CITY LIC. NO.: 058754 uc. cLAsse C —16 uc^ NO, 6 5 9 3 EXP: 03/96 ale: 1 Q^ _ q_6 Contractor: --- ��� /OWNER BUILDER DECLARATION: I hereby aMrm under penalty of perjury that I am exempt from the Contractors License Law for dee follti g reason (Section 7031.5 Business and Professions Coda: Any city or county which requires s permit to Construct, akar, improve, demolish, or repair any structure, prior to eissuance. s issnce. also requires the applicant for such permit to file signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing w4h Section 1000) of Division 3 of the Business and Professions Codel or that he or she is exempt therefrom and the basin for the alleged exemption. Any violation of Section 7031.5 by any applicant far a permit subjects the applicant to a civil penalty of not more than Live hundred dollars jMT). 0 1, as owner d the property or my employees with wages as their sok compensation. will do the work, and the structure is rat intended a olferod for sale (Section 7044, Business and Professions Code: The Contractors License Law does not apply to an owner d property who =, or impro+es Ihereon. and who does such work himself or home# or through his of her own employees. provided then such improvements are hat intended or dfared fen sale. If. however, the building or improvement is sold within one yam of completion. the ownerbtrii1der will have the burden of proving he or she did not build or improve lot the purpose of sale►. Q I. as owner of the property, am exclusively ooruract with licensed contractors to oahsirud thio usitefy eh9 project Isedion 7044.13ueinaes and Prdessions Code: The Contradore License Law does not apply to an owner of property who builds or improves thereon and who contracts for such projects with a cxsaradoe(s) licensed pursuant to the Contractors License Law). Q I am exempt under Section: B. b P.C., for this reason: Date: Owner: I do hereby cenity, that I am aware of and understand the requirements of California Health and Safety Code Sediors 25505, 25533, and 25534, and that I or any future building ompent will h will not (circle one) need to comply with said two nodes and the requiremema for a pertmt forconsttuction a modihcationtromthe Aiwa ySi�anagemem llis7rid. Rasidentielmstnsiion appiratlam are exempt from these prarisiane- Date: Applicant: WORKER'S COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: Q 1 have and will maintain a certil'ic4e of consent to salf4mure for workers compemabon, as provided lor by Section 3700 of the Labor Code, for the performance of the work lor which this permit is issued. I have and will maintain workers' compensation isuranoe, as required by Section 3700 of the Labor Code, for the performance of the work for which this permh is issued. My workers' compensation insurance racier and poky number are: carrier: 2STATE FUND EXPIRES Policy Number. 999 ? q — g s-- - - 01/01/96 (This section need not be comphered if the permit is for nes hundred dollars (Stool or leas.) I oandy that in the Performance of the work for which this permit is issued, I shall not employ any person in any manner so so as to became subject to the workers' campsnsation laws of California, and agree that 0 1 should became subjed to the workers' compensation provisions of Section 3700 of the Labor Code. 1 shall lonhwith comply oee p 'sons. (!s ✓ _ 3 — J f — Apli cmC Warning: Faffurs to secure workars' conposrusdon coverage is unUwhd. and shall steb*f an employer to crJmfnsl panaldes and dvff fines tip to one hundred thousand dolbus {$104000), In a"Wri to the cost of conWenssthon, damages ss provhded W In Section 3706 of ft Labor Cods, Interest, and affomey'a less. CONSTRUCTION LENDING AGENCY: I hereby af6rrn under penally of perjury Ilial them is a ninstrerdion larding agency for the performance of the work for which this permit is issued (Section 3097, Civ. C). LENDER'S NAME: h LENDER'S ADDRESS: I certify that I have read this application and stat. that the above information is torted. I agree to comply with all City and county ordinances and state laws totaling to building construction and hereby authorize represenintives of this city to enter upon the above-mentioned property for inspection purposes. TOM/CAROL PONTOLILLO Print Name -~L Dale: 1515148.WPh Whie-Buildino d Safety; Gran -File; Catwy-AppFranl; Pink -Revenue; Goldenrod -Assessor t CITY OF COSTA MESA — BUILDING PERMIT PERMIT NO: F 074418 PLAN CHECK NO: 03762-95 L CONSTRUCTION TYPE: PERMIT TYPE: FIR JOB DESCRIPTION : RELOCATE EXISTING SPRINKLERS CLAIM VALUE: 1,000.00 CALC—VALUE: PERM NO: F 079418 GOVT: N SUPP: N PURPOSE: OTH SQ FT: GROUP OCC:'B-2 / COMMENTS: "FRED JOAILLIER" JEWELERS STORE TI REF: B-74100 Z 0 N I N G R E Q U I R E M E N T S S E T B A C K S ------------- MAIN BUILDING ---------- --------- ACCESSORY BUILDING--------- FRNT: FT 'IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT :IN RGHT: FT IN LEFT: FT IN RGHT: FT IN PARKING RE8: PROV: PARCEL: 41250107 ZNE: REF NO: PLANNING NTES> > ##'lE##�#�F#iE####!E###iE#IE#�E#######IE##aE#'iFlfiEiE'1!•iE�E�EiF#�F######�1E�############�E######�F###�F# D E V E L O P M E N T S E R V I C E S -R E Q U I R E M E.N T S ZONING APPROVED BY DATE: BUILDING APPROVED BY : DATE: 4SEMENT:N APPLICATION ISSUED BY: DATE:LEGALIZATION:N F E E U M M A R Y STRUCTURAL BLDG PMT PLUMBING ELECTRIC MECHANIC PERMIT PLAN ISSUE FEE BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTALS-----> 25.00 0.00 16.25 REVENUE DIVISION TOTALS--> COLLECTED: BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING 25.00 65% SMIP/NON--RES 36.25 TOTAL PAID DUE 41.25 41.25 .00 25.00 OVER/SHORT: 00 FIRE SMIP/TOT GRADING PLAN—CHECK 25.00 I N D I V I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST FIR 25 FIRE EQUIP FEE (FROM BLDG VAL TABLE) END OF FEES 1.00 01 00191289-00191289 TCI "I' DATE= 10/03195 TIME: 11:44 25.00 25.00 ADDRESS OF BUILDING: ; UNIT,OWNER'S NAME IF KNOWN: 3333 BRISTOL ST 1403 ADDREs6: C.J. SEGERSTROM & SONS FLOOD: AO -38 3315 FAIRVIEW RD COSTA MESA GaPL. l�l AEss: (714)546-0110 IARCHRECT OR ENGINEER: ARCH, OR ENG: S ADDRESS: LIC, No.: UNT: CONTRACTORSAcTONAME: WALTER M. ANDERSON (714)891-1627 CONTFtACTOR'AD REI 10572 B AR B E T T E AV mw..' GARDEN GROVE CA g 3j,QJ94(Q2}N LICENSED CONTRACTORS DECLARATION: I hereby affirm uppenTalt3d perjury that I am licensed under provisionNol'"C�h& 9 (commend ng with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full farce and affect. CITY LIC. NO.: LIC. CLASS: LI;a�2 OX 361 B /96 Date: Contradar: CCXXrr++�_r� 11..1r_ OWNER BUILDER DECLARATION: I hereby affirm under penalty of perjury that I am exempt from the Contractors License Law for the ,flowing reason (Sodion 7031.5 Business and Professions Code: Any city or county which requires a permit to construct, after, improve, amoleh, or repair any structure. prior to its issuance, also requires the applicant lot such permit to fib a signed statement that he or she a licensed pursuant to the provisional of the Conlradors License Law !Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars IS5001f. ❑ I, as owner of the property or my employees with wages as their We compensation, wdl do the work, and the structure is not intended or offered for sale (Section 7044, Business and Professions Code: The Conlradons License Law does not applyto an owrerd property who builds or improves thereon. and who does such work himaelt or herself or through his or her own employees. provided Thal such improvements are not intended or offered for sale. 11, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving he or she did net build or improve for the purpose of sale). ❑ I, as owner of the property, am exriunivefy, ocntradng with licensed contractors to carnstrud the project (Sedion 7044, Business and Professions Code: The Contractors License Law does net appy to an owner of property who build* or improves thereon and who contracts for such projects with a oontrador(s) licensed pursuant to the Contractors License Law). ❑ I am exempt under Section: B. 8 P.C., For Lias reason: Date: Cromer I do hereby candy that I am aware of and understand the requirements of California Health and Safety Code Sections 25505, 25533, and 25534, and that I or any future building occupant t AI 1 will net {circle one) need to comply with said state nodes and the requirements for a permit loromstructionor modificationfrom the Ai u=ty y anagement District. Residential construction applications arsexempt from these providers. Dale: Applicant: WORKER'S COMPENSATION DECLARATION: 1 hereby affirm under penalty of perjury one of the following declarations: ❑ I have end wiltmaintain a certificate of consent to seHrnwre for workers' compensation, as provided for by Section 37DO d the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain worirore' compensation insurance, as required by Section 3700 of the Labor Code. for the performanos of the work for which this permit is issued. My workers' compensation insurance carrier arid policy number are: Carrier: Policy Number: EXPIRES (This section need rof be compiated 7 the Penni is y6o1 or fess.) 10/01/95 ❑ I Gamy that in the performance of the work for which this permit is issued. I shall not employ any person in any manner so as to become subject to the workers' compensation laws d California, that R 1 should subject to the warless' con tion provisions of Section 3700 d the labor Code, i shall f ply with P i Date:./a'1 _ Applicasd: Warning: Failure to secure workers' eompanssffon coverage Is unlawful, and shell aub(eet an employer to eHmfnel pe"W" and civil tinea up to one hundred thousand dallers (S109 000), In addlden to Me cwt of compensation, damages as proWdsd for In Section 3706 of Me Labor Cork, Intersal, and afromey's fees. CONSTRUCTION LENDING AGENCY: I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the wort( for which this pend is issued (Section 3097. Civ. C). LENDER'S NAME: LENDER'S ADDRESS: I certify that I have reed this application and slate that the above information is correct. 1 agree to comply with all dry and county ordinances and state laws reletog to building construction and hereby authorize representatives of this city to enter upon the above-menlioned property for inspection r Data: Signature d dAgentlAppirantAContracxor (5151-46.WP) While -Building t: Safely: Green-Fle: Canary -Applicant: Pink -Revenue; Goldenrod -Assessor CITY OF COSTA MESA — BUILDING PERMIT �F PERMIT NO: B 074026 PLAN CHECK NO: N GOVT: H SUPP: N CONSTRUCTION TYPE: IFR SP PERMIT TYPE: STR PURPOSE: OTH JOB DESCRIPTION ; INTERIOR DEMO OF STORE FRONT/PARTITIONS SQ FT: 6,000 CLAIM VALUE: 6,000.00 CALC--VALUE: 6,000.00 GROUP OCC: B-2 / COMMENTS: FRED JOAILLLIER JEWELERS INTERIOR DEMO REF PL CK # 3415-95A Z O N I N G R E Q U I R E M E N T S S E T B A C K S ------------ MAIN BUILDING -----------' ---------- ACCESSORY BUILDING--------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RIGHT: FT IN PARKING REQ: PROV: PARCEL: 41250107 ZNE: REF NO: PLANNING NOTES> f�,f > �. �E if � * i[• � iE iF # * * * iE lE iE iE iE iE iE 9E iE fE 9E iE iE iE iE• iE iE � # iF l(- iE iF jE �E'lE'}F dE -IE iF iE iF iF iE iF aE dE � iE �E �E fF dE �E �E -IE iE �E iE �E iE �E �E dE * � -1E iE �E iF 3E � iE iF �E iE �E D E V E L O P M E N T S E R V I C E S R E Q U I R E M E N -,T;- S ZONING APPROVED BY DATE: BUILDING APPROVED BY : DATE: APPLICATION ISSUED BY: DATE:l� jE * iE 1E iE �E iE iE iE dE iE iE iF �E 9F iE iF iE iE iE iE iE 'tE �E iE � �F iE � iF'>E �(' �E � LEGALIZATION:N F E E S U M M A R Y STRUCTURAL SEGMENT:Y BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT 81.00 SMTP/NON—RES PLAN 1.26 ISSUE FEE BUILDING—DIV--> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE TOTALS ---- > 82.26 0.00 0.00 82.26 82.26 .00 REVENUE DIVISION TOTALS---> COLLECTED: 82.26 OVER/SHORT: 00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK 81.00 1.26 iE iF dE iE iE iE iE -1E iE 9F iE iE iE iE iE � * iE iE 9E iF 9E iE iE iE iE -?E �(- iE'rE iE iE �E �E �E iE iE �E i(- iF �E dE �E iE �E aE iE -IE �E �E iE 3E iE iF �E �E -lE -IE'1E'1E iE• if"iE �F'ME iF dE iE iE -lE -lE -IE ♦E � iE iE aE'�E +F- I N D I V I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST SFC 6000 DEMOLISH BY VALUE COMMERCIAL NOZONE 1.00 6,000.00 END OF FEES U, 00M't ; $-061894 49 T C_I T '87.26 DATE: 09/0V95 TIME: OMS CONSTRUCTION AND PLANNING APPROVALS Permit # - Date Inspector t? t_ & SPA , ' APPROVALS Permit Date Enspector 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location r 2. Soil Pipe-Undrgrnd. 53, Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. 54. Forms 4. Electrical Conduit•Undrgrnd, 55. Electrical Bonding, 5. Steel Reinforcement • 56. Rough Plumbing & Pressure Test 6.. Electrical LIFER Grnd. 57, APPROVAL TO COVER-GUNITE 7. Footings 58. Electrical Conduit•Undrgrnd: 8. Foundation 59. Gas Pipe, 0 Undrgrnd., Test 9. Water Pipe-Undrgrnd. 60. Backwash Lines,P-Trap, © -Undrgrnd. ` 10. Structural Floor System 61. APPROVAL TO DECK 47 _ 11, Property Sewer Line & House Connection fit. Backwash & Receptor -Final 12. Sewer Cap 63. Heater & Vent -Final 13. Roo#'Drains - 64. Plumbing System, -.Final 14. Rough Plumbing 65. Electrical -Final 15. Rough Electrical -Conduit 66, Solar System -Final f' 16. Rough Electric Wiring 67. Fencing & Access Approval 17. Rough Wiring Sign 68: APPROVED FOR PLASTERING 18. Rough Electrical -T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19, Rough Heating ,& Air Conditioning FIRE DEPT. REQUIREMENT APPROVAi S,. . Permit # - -- 20, Rough Factory Fireplace 21. Duets, in Structure 70. Underground Hydra 22. Ducts, Ventilating v 71. Product Piping C] Gas 00il 23. Gas Pipe -Rough & Test 72, Underground Flush 24, Roof Framing 73. Undergrnd. Storage Tank © Gas G OiI 25. Roof Sheathing 74. Overhead Hydro 26. T•Bar Ceiling (Structural) & Monocoat 75. Dry Chemical 27. Frame and Flashing 76, Dry= Standpipe 28. Lathing & Siding 77. FIXED SYSTEM FINAL 29- Insulation 78. FIRE PREV. FINAL 30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Plaster BroWn Coat - 79. FINAL INSPECTION -32. Electrical Power Meter -Final 80, FOOD CERTIFICATE ISSUED - 33. Final Electric Notes: E 34, Final Heating & Air Conditioning 35. Final Gas Pipe -Test 36. Hood or Canopy 37. Final Factory Fireplace 38. Final Plumbing 39. Water Service -Final 40. Gas Service -Final ' 41, Solar Dornestic-Final 42. Backflow Preventer Y 43. Backflow Irrigation l 44. Landscape Irrigation System 45. Sound Attenuation 46. Handicap Regulations 47. FINAL STRUCTURE & BUILDING 48. FINAL PLANNING 49. Electric Release to Edison 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY No. Date _ _ r CL Y OF COSTA ML -,)A Development Services, Division of Building and Safety CERTIFICATE OF OCCUPANCY This certificate is issued pursuant to the requirements°of the Uniform Building Code, Section 308 adopted by the City of Costa Mesa certifies that at the time of its issuance the building structure herein below described was inspected and approved for occupancy as follows: Building Address 3 3 34 •,B r k� t`0.1""S t. Sit e, 1400 4 =. ` Bldg: Permit Number F C 0 7 T 0 0 0 7 9 Use Clothing. ('2,;Fi60,'s' f ) k, Group M TypeofConstruction 1-F}R .` _ Fire Zone XXXxXXx.- Use Zone Ri�iD ly ; Owner 6f Building South,, C.oas't'Tlaza Tenant G bRGIO ARMANi Address 3315 Fairview- Rd.'; Costa !+less,, CA � n J BUILDING OFFICIAL-Khanh Q. Nguyen, C.B:G.'-- Date •11/26/07 REQUIRED TO BE POSTED IN A CONSPICUOUS PLACE ��j 0 _ ft CITY OF COSTA'MESA BUILDING DIVISION 77 FAIR DRIVE, COSTA MESA, CA 92626 - (714) 754-5273 - Fax (714) 754-4856 - www.ci.costa-mesa.ca.us FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BC10-00198 PERMIT TYPE: B_COMBO Sub Type: COM—ALT STATUS: ISSUED DATE ISSUED: 06/17/2010 ISSUED BY: RMD JOB ADDRESS: 3333 1400 BRISTOL ST CM Suite/Unit: 1400 APN: 41250107 Zoning:PDC, , Vicinity: SPACE 1400 Primary Occ: Const Type: I -A SQ. FT: 2128 Valuation:' $160,000.00 SCOPE OF WORK: 2,128 SF INTERIOR TI FOR ",GIORGIO ARMANIIEMPORIO ARMANI", SPACE 1400. WORK TO INCLUDE NEW PARTITION WALLS, FLOORING, FINISHES•NEW DISPLAY FIXTURES, ADD/RELOCATE 24 LIGHT FIXTS, 19 OUTLETS, 4 SWITCHES. OWNER: SOUTH COAST PLAZA' Address: 3315 FAIRVIEW RD Unit: Phone: City/State4ip: COSTA MESA, CA APPLICANT: VALLO, MARK Address: Unit: Phone: 818-446-4648 City/StatelzZip: CONTRACTOR: SIERRA PACIFIC CONSTRUCTORS License No. 433163 Phone: 818-225-6000 Address: 22466 VENTURA BLVDUnit: Cell: City/State: WOODLAND HILLS, CA ZipCode 91367 ARCHITECT: PAUL J BUFFING, Am License No.C4264 PHONE:949-660-8062 ENGINEER: License No. PHONE: COMBINATION PERMITTEE SUMMARY Building Plan Check: $216.09 Building Fees: $1,329.75 Electrical Fees: $73.72 Mechanical Fees: $0.00 Plumbing Fees: $0.00. SMIP Residential: $0.00' SMIP Commercial: $33.60 Bldg Sid Admin Fund $7..00 TOTAL FEES: $1;660.16 'Refer to fee receipts for all fees paid for project _ HOURS FOR CONSTRUCTION ACTIVITY: EFFECTIVE 3/18/2010 - PER CMMC Sec. 13-279 Monday thru Friday - 7:00 am thru 7:00 pm. Saturdays- 9:00 am thru 6:00 pm. Prohibited all hours- Sundays and the following Federal holidays: New Years Day,_Memorial Day, Independence Day, Labor Day, Thanksgiving Day and Christmas Day NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE t. [NSPECTION TYPE DATE IN171TAL5 CODE M INSPECTION TYPE DATE INTmALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site .1 204 Final Demolition 250 Final Building/Occupancy WORKERS' COMPENSATION DECLARATION: hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: CaMer�� (This section ee�completeed ifthe permit is valued at one hundred dollars ($100) or less ) Polcf yN tuber. 5-�4_66CIf- L00/b4fivc%Y! ❑ I certify that in the performance of the; work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Call forthwi co ly with these provisions. WAj4kcant's Signature 45l] eaz,.. WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. c11l, ;cP#' om" Com Cont�actor's Signature spate`^ CONSTRUCTION LENDfNG AGENCY: ❑ I hereby affirm that there is a construction fending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lenders Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): 0 I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sate. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature Date 3057-46(3107) Owner ID verified bdnvver*,I,,ense. El Yes D No Y Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Date Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the s=ire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If 'yes", attach certificate of compliance'from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Sr relf_ of r{sj Gare te/ %i i AiidforyAurhortzetl (y14) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT Job Address: 3333 BRISTOL ST Suite No 1400 Vicinity: 1400 Parcel Nunmber. 41250107 Applied: 08/02/2001 Applicant. BAGNALL,BRAD Res.. a/c package $0.00 Address: 7876 DEERING AVE -� $0.00 0 New Res (3+units) • $0.00 0 Pool I Spa $0.00 0 Phone: 818-883-5110 657 CANOGA PARK, CA"- ' Zip: 91304 Switches $23.46 '22• Non Res Appl $0.00, 0 Res Appl $0.0o ,-,0 Service to 200a $0.00 0 owner:/ SOUTH COAST PLAZA 0. - Service over 1000a $0.00 0 Motors to 1hp - $0.00 Address " %C J SERGERSTOM : '-' $0.00 i - 0 - -Motors Molars to 50hp COSTA MESA, CA • ; - Phone: Motors to 100hp $0.00 - 3315 FAIRVIEW RD Zip: 92626 0 Communication drops $20.90 "14 ' Sub panel to 200a i 0 Pole Light Pkg Contractor: - LAND MARK ELECTRIC INC . $0.00 Address: 7876'DEERING AVE $0.00 0 Intermed Pole $0.00 >'-.Phone: 818-8B3-5110 � CANOGA PARK, CA' - Zip: •91304 ` License: 418788 Status: ISSUED Applied: 08/02/2001 Issued: 08/02/2001 ISSUED BY: ' SCOPE OF PERMIT ` _ % REF B01-00934,,GEOR6I0ARMANI'SUITE 1400.' - f 657 LIGHTS, 66 OUTLETS, 22 SWITCHES, 19 COMMUNICATON DROPS, .1-MISC. ELEC. EQUIP: FEE SUMMARY Quantity Quantity ISSUE FEE • $23.50 0 - Temp service test $0.00 0 Res.. a/c package $0.00 1 New Res (1-2 units) $0.00 0 New Res (3+units) • $0.00 0 Pool I Spa $0.00 0 Lighting Fixts $487.01 657 Recept Outlets $55.58 66 , Switches $23.46 '22• Non Res Appl $0.00, 0 Res Appl $0.0o ,-,0 Service to 200a $0.00 0 Service to 1000a , ,�� �$o.,00 0. - Service over 1000a $0.00 0 Motors to 1hp - $0.00 -, 0 Motors to 10hp $0.00 i - 0 - -Motors Molars to 50hp x,$0.00- 0 Motors to 100hp $0.00 - 0 Motors over 100hp $0.00 ' 0 Communication drops $20.90 "14 ' Sub panel to 200a $0.00 0 Pole Light Pkg $0.00 0 Sign Circuits $0.00 0 Temp Pwr Pole $0.00 0 Intermed Pole $0.00 0 Temp Dist,System 1 Lighting $0.00 0 Busway 1100 ft $0.00 0 - Standing Section $0.00 0 Misc Electrical Equipment $18.20 1 ;Transformers up to 1 kvalkw $0.00 0 ................up to 10 kva/kw $0.00 0 ...............up to 50 kvalkw $0.00 0 ...............up to 100 kvalkw _ $0.00 0 ..................over 100 kvalkw $0.00 0 " Low Voltage Equipment $0.00 , 0 Low Volt Wiring System I Ckt $0.00 Misc. Conduit $0.00 "0 0 - " Misc: Conductor $O.DO 0 Circus ( gen or ride) $0.00 0 Circus (mech ride or lights) -$0.00 0 ' Christmas Tree Stand $0.00 , r0 Fireworks Stand $O.DO 0 Other Electrical Fee $0.00 Investigation Fee $0.00 -Plan Check Fee $0.00 Reinspection Fee $0.00 TOTAL CALCULATED FEES $628.65 COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12.21.92) EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days, or if work Is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result In the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2448.48 (rxW) C DECLARATIONS '-Now WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 10- I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. y workers' compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed it the permit is valued at one hundred dollars ($100) or less.) ❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' comps allort"f94v fCaiifomnC� �iTiat If I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith co with these p mt. 'e cant S€gnatu D d WARNING: FAI O SECURE WORKS PENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJE AN EMPLOYER O CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED E ($1 ),IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED R IN SECTION OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. rontr�to E CONTRACTORS ECLARATION: affirm that I am liggn d under revisions of Chapter 9 (commencing with Section 7000) of Divisio of i siness and rofessions Code, and my license is in full d effect. Lic. # `� % lass # [ rs Signature: Date: fr' o� ONSTRUC LENDING AGENCY: reby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lenders Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty o1 not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or Improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License taws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, wilt be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, Califomia Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity Of hazardous materials equal to or greater then a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ........................................................................................................... ..........................................................................................................................................................................................................................................................I............ 2 Does or wilt the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ............................................................................................................................................................................................................................................................................................................................................................................... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. .... n-il'y' r'........................._.................................................. 'l,if'..................al"t'i-a''n"...................................................................led*....................... ..e ..................o.................................................................. A If an RMPP is presently required, has Section 25534 of the Califomia Health and Safety Code bean fully complied w€th? ❑Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application aggermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential (wilding permits). .......................................................................................................................................................................................................................................................................................................................................... 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ....................................................................................................................................................................................................................................................................................................................................................•...................... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ............................................................................................................................................................................................................................................................................................................................................................... 8 (If "yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the Information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. r�fJi Legal Owner(s) Date ( Date COVE I. iNSPECTfQfLTYPE RM INT1T16LS CcODE! INSPECTIONTYPE 2M INTMALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 206 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy ,I (714) 754-5273 • Fax (714) 754-4856 • www.cl.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 PLUMBING PERMIT .lob Address: 3333 BRISTOL ST Status: ISSUED Suite No 1400 Applied: 08!0612001 Issued: 08/06/2001 Vicinity: 1400 ISSUED BY: Parcel Nunmber: 41250107 Applicant: O'MARA,FRAN Address: 16805 SIERRA HWY ,• Phone:, (661)252-6702 ; CANYON"COUNTRY, CA Zip: 91351 r Owner:: 'SOUTH COAST PLAZA Address '%C J�SERGERSTOM COSTA MESA, CA Phone:. 3315 FAIRVIEW RD Zip:" 92626 Contractor: , THOMAS W O'MARA PLUMBING_,>' Address: 16805 SIERRA HWY " Phone: (661) 252-6702 CANYON COUNTRY, CA Zip: 91351 License: 684369 Arch Eng Address: Phone: Zip:, License: SCOPE OF PERMIT REF 1301-00934, SUITE 1400 GIORGIOAARMANI - 1 DISHWASHER, 1 FLOOR SINK, 1 KITCHEN SINK, 1 SINK/MOP- 2 WASH BASINS, 2 WASH, BASINS, 2 TOILETS AND i WATER HEATER (ELECTRIC). ' FEE SUMMARY - AMT QTY AMT QTY AMT QTY ISSUE FEE $23.50 LaundryTub / Washer $0.00 0 Sump Pump $0.00 0 Backflow irrigation $0.00 - 0 ' Landscape Irrigation $0.00 0 Swimming Pool $0.00 0 Backflow Preventer $0,00, 0 P -Trap $0.00 0 Trap Primer $0.00 0 Bathtub $0.00 0 Pressure Regulator $0.00 0 Urinal 50.00 0 Clarifier System $0.00 0 Process Piping (per 10 ft) $0.00 0 Vacuum Brkr Bkflow(1-4) $0,00 0 Connect (Ice,Soda,etc) $0,00 0. Receptors $0.00 0 Vacuum Brkr Bkflow(5+) $0,00 0 Dental Units $0.001 0 Septic Tank $0.00 0 Wash Basin $19.60 2 Dishwasher $9.80 _ 1 Sewer Cap for Demo $0.00 0 Wash Basin Set $0.00 0 Drain, Floor $0.00 0 Sewer Connect $0.00 0 Waste and Vent System $0.00 0 Drain, Rainwater $0.00 0 Sewer Private Line $0.00 - 0 Water Closet (Toilet) $19.60 2 Drain, Roof $0.00 0 Shower , $0.00 0• Water Heater / vent $12.30 1 Drinking Fountain $0.00 0 Sink, bar $0.00 0 Water Piping (fnst or Rep,) $0.00 0 Expansion Tank $0.00 0 Sink, commercial $0.00 0 Water Re -pipe $0.00 0 Gas Earthquake Valve $0.00 0 Sink, Floor $9.80 1 Water Service $0.00 0 Gas (1-4 outlets) $0.00 0 Sink, kitchen $9.80 1 Water Softener $0.00 0 Gas (Over 4 outlets) $0.00 0 Sink, service/mop $9.80 1 OTHER $0.00 Gas Repipe $0.00 0 Spa (private) $0.00 0 VIOLATION $0.00 Gas Service $0.00 0 Spa (public) $0.00 0 PLAN CHECK $0.00 Interceptors (Grease, Oil) $0.00 0 REINSPECTION $0.00 0 Interceptors (Sand Auto) $0.00 0 TOTAL CALCULATED FEES: $114.20 NOTICE: The work authorized by this permit shall comply vdth all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work Is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 / Z 244E -4e (W) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ t have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My wo oompensatlon insurance carrier and licy number are - Carrier: Carrier. y_A � AZ4 Policy NumberV4"VC 0// a (This section need not be complotoffifthepormitis valued ono hundred dollars ($100) or less.) ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that If I should become subject to th rkars' cam n tion provisions of Section 3700 of the Labor Code, I shall forthwith comply with these vlslo s. / -AppilcantSig ialst'��i-�� WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS U LAWFUL AN SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CAVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 37060E THE LABOR CODE, INTEREST, AND ATTORNErS FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that.l,am liven ed rmde Provl Ions of Chapter 9 (commencing with Section 7000) of Division 3 of the Buelness.an rolessions Code, and my license is in full force and .effec Lica If Class Contractor's Signature14 Dat 9: Gr se ! CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Data: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Sectlon 7DOO) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation a1 Section 7031.5 by any applicant for a perrr+: subjects the applicant to a civil penalty of not more than five hundred dollars ($500).); ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement Is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, l will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature; Data: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has a1 any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 2DO cubic feet of compressed gas at standard temperature and pressure). ..................._.......................•..........................................................................._...................__........................_.....................__..................._.................................................._.............._._................_..................._......•...._ 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _ ........................ ................................... ..................................... _............................................. I'll ........................... .................................................................................. ..................... .....................-... ............. ................... _ 3 Does or will theaflppplicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes 13No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ..F-­­ _......................._.............._........................................__................................................. __._..................... __..................... ---........................................ _.._._.............. _.._...._............._............._....._....... 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No .................................................................................................................................................................. ........................ ................ ..................................... ....................................................... I ......................... ... ........................... 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this a plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes U No (Section 65850.2 of the California Government Code requires that the requested information be fumished on applications for non-residential building permits). ...................................................................................................................................................................................................................................................................................................................................... 6 Will any pan of the facility to be constructed under this permit be within 1000 feet from the outer boundaries o1 a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ............ ............................................................................... .......•.- 11.............. .......... ..................................................... _..................... __............................ ................................................ _...... __._................. _................. _........................ _.. 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency Is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No .................................................................................................................................................................................................................................. ........................................................................... ................................. ............................... .... 8 (If yes", attach certificate of compliance from mho appropriate air po]Iution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given Is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature Ot Legal Owner(s) Date f And/Or Authorized App Icant0 hetet RAS INTMALS CODES ItlSEE09dUPE RAN 1NTITIAL;£ 1616 Fixed System f=inal Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing �1 NIr 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.cl.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 MECHANICAL PERMIT .lob Address: 3333 BRISTOL ST Status: ISSUED Suite No 1400 Applied: 07/06/2001 Issued: 08/01/2001 Vicinity: GEORGIO ARMANI (STE 1400) Parcel Number: 41250107 ISSUED BY: Applicant: DAHME, CAROL. Address: 650 COCHRAN.ST'. - _ 1 UNIT 2-" . �� _ Phone: 805-5152-9188 SIMI VALLEY, CAv , Zip: 93065 Owner" SOUTH COAST PLAZA Address: / '%C- f SERGERSTOM COSTA'MESA, CA Phone: 3315,FAIRVIEW RD Zip: 92626 �. Contractor: DAHME HEATING & AIR CONDITIONING INC Address: 650 COCHRAN ST UNIT 2 -Phone: 805-582-9188 SIMI VALLEY; CA',, Zip: ' 93065 ` License: 590084 SCOPE OF PERMIT RELOCATION ADDITION OF GRILLS & DUCT WORK FOR AN INTERIOR STORE TI FOR "GEORGIO ARMANI',IN STE-1400. 5 REPAIRlALT COOLINGIHEAT,15 VAV BOXES. REF: B01-00934 Quantity - ISSUE FEE $23.50 Inst FAU <100 k BTU $0.00 0 Inst FAU >100 k BTU $0.00 0 Repair]Alt Cooling/Heat $68.50 5 Inst 1 Rep. Recess Wall Htr, $0.00 0 Ref rig Sys <100 k BTU $0.00 0 Ref rig Sys >100 k BTU $0.00 0 Gas Piping, $0.00 0 Factory Fireplace ,$0.00_ �0 Hood wlMech Exhaust $0.00 , 0) VAV Box $53.25 - 5 Vent Fan / Single Duct ` $0.00 _ '0 Appliance $0.00 - 0 �_� Fire Dampers "$0.00 0 Smoke Dampers , • $0.00. 0 Inst or Relocate Appl Vent $0.00 0 Air Handlers < 10000cfm $0.00 0 Air Handlers > 10000cfm $0.00 0, Floor Furnace -50:00 0 Floor or Suspend Heater $0.00--,01 0 FEE SUMMARY' ' - Quantity Repair 1 Alt Absorbtion Unit $0.00 0 Repair 1 Alt Refrigeration Unit $0.00 0 Ventillation System $0.00 0 Evaporative Cooler $0.00 0 Commercial Incinerator $0.00 , 0 Domestic Incinerator t ^. $0.00 r0 Compressors /Absorption Systems Up to 3 hp 1100 k BTU $0.00 0 3 To 15 hp 1!500 k BTU' , $0.00 0 15 To 30 hp! 1,000 k BTU $0.00 0 ' 30 To 50 hp 11,750 k BTU , $0.00 0 Over 50 hp 1 Over 1,750 BTU $0.00 0 Boilers ' _ Up to 3 hp. -- '$0.00 0 3 To 15 hp $0.00 0 15 to 30 hp $0.00 0 ' 30 to50 hp' �, �; / $0.00 0 Over 50 hp $0.00 0 Other Mechanical Fee . , - Investigation Fee-- Plan Check'Fee . $0.00 Reinspection Fee $0.00 TOTAL CALCULATED FEES $145.25 COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work Is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must Comply with all applicable codes, and -all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of third. FOR INSPECTIONS CALL: (714) 754-5626 `/ 244646 (WW) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declaratlons: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the tabor Code, for the performance of the work for which this permit is Issued. have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. My worker sompansati ' on Insurance carrier and policy number are: Carrier: tEuO [ aJ Policy Number: --P,>1Qj - O[ (This section need not be completed Ir the permit is valued at one hundred dollars ($100) or less.) ❑ t certify that in the performance of the work for which this permit Is issued, I shall not employ any person In any manner so as to become subject to the workers' compensation laws of Celifomia, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shell forthwith comply with these provisions. Appllcant'Signature:--- �Aate:— -7 WARNIN13:'FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER -To CRimiNAI. PENALTIES AND CIVIL FlNES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that t am licen under pr vi ons o1 Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Pr fesslons de, and my license is in full force and effect. Lic. q A P1 Class a Contractors'Slgnaturei Date: ,- i r —AW CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the partam+ance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lenders Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to Its Issuance, also requires the applicant for such permit to fila a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a perms' subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her awn employees, provided that such improvements are not Intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of safe.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verttied by driver's license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec, 341, Title 8, California AdministraNe Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ...................................'.t'u'................................__._................"t"o,........... r,e.*g"1s"ir-a-....................io,r................,,,.....,...........,.................'ia"l.............. ............................................................................ 2 Does or will the applicant or present or future building occupant need to fila a registration form for acutely hazardous materials? ❑Yes ❑ NO (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet o1 compressed gas at standard temperature and pressure). ..............................................................................................................................................................................................................................................................................................................:.. ..........._ .............. 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and tiling with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. _......................_.......................—.......................................................................................... _..................._.......... ...................................................... _................. ........................ _ _.............�................ 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑Yes ❑ No .....................................................................................................................__...----•......----.........................................................................................................................................................._....................._................._................ 5 Does or will the applicant Or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? iU Yes 19 No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). _..._................._........................_.........................._---•--.--......................._...................._..........................................................-................ ----......................... ..... ..... 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? [-]Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). - ......................................... ........................................... _........ _... _..................................... ........................................................------------........................................................................................................................... ..............._ _. 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all Of the disclosures proscribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ..........................-......__...-------...........................I.............------......................................................................................................._.......................................................__r- -... attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty Of perjury the information given above Is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Data: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the Information given is correct. I agree to comply with ail state laws and city ordinances relating to building Construction, and authorize representatives of the City of Costa Mesa to enter upon the above-describ oparty for inspection urposes. I agree not to occupy or allow Occupancy of any building authorized by this permit until final inspection. Date )�nqn�l�u!liodidd Applicant Date CODE I. INSPECTION TYPE RM It{TMA CODE t INSPECTION TYPE tt Qd 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 209 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.cl.costa-mosa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 BUILDING PERMIT Job Address: 3333 BRISTOL ST Status: ISSUED Suite: 1400 Applied: 06/19/2001 Vicinity: SPACE 1400 Issued: 07/31/2001 Parcel Number: 41250107 Zoning: PDC PDC Applicant: BAUTISTA, JOHN ISSUED BY: Address: 22466 VENTURA BL Phone: (818) 225-6000 WOODLAND HILLS, CA Zip: 91367 Owner: SOUTH COAST PLAZA` Address /%C J "SERGERSTOM COSTA MESA, CA Phone: 3315 FAIRVIEW RD Zip: 92626 Contractor: SIERRA PACIFIC CONSTRUCTORS Address: 22466 VENTURA BLVD Phone: (818)225-6000 WOODLAND HILLS, CA Zip: 91367 - License: 433163 Arch : LAURENCE ALLEN ARCHITECT Eng: Address: 3306 HELMS AVE Address: Phone: (310) 287-1200 Phone: " CULVBR CITY, CA - Zip: 90232 License: License: SCOPE_ OF PERMIT 5320 SQ FT INTERIOR STORE T.I. FOR "GEORGIO ARMANI" (SPACE 1400). FEE SUMMARY Plan Check: $718.45 Calc Valuation: $750,000.00 Permit: $4,421.25 Claim Valuation: $750,000.00 SMTP Res: $0.00 SMIP Com: $157.50 Other: $0.00 Inspection: $0.00 Total: $5,297.20 PLANNING & ZONING SETBACKS MAIN STRUCTURE Front 0-0 Rear 0-0 Leff 0-0 Right 0-0 ACCESSORY Front 0-0 Rear 0-0 Left 0-0 Right" 0-0 PARKING Existing: 0 Required: 0 Proposed: 0 NOTES: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work Is not commenced within 180 days, or if work Is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 244646 (SM) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Lagar Code, for the performance of the work for which this permit is Issued. ezI have and will maintain workers' compensation Insurance, as required by sectlon 3700 of the Labor Code, for the performance of the work for which this permit is Issued. My workers' compensation Insurance carrier and policy number are: Carrier. -I 0 - C4_1k . Re Policy Number. � o�� 7 (chis section need not beMmpidtad iffhe (mit Is valued at one hundred dollars f$ 100) or lass.) ❑ I Certify that in the performance of t work for which this permit is Issued, I shall not employ any person In any manner so as to become subject to the workers' compensation laws of C 'fort agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these p Applicant Signature, ("Data:-:.�_ 7� Si A %VARNING:TAIL SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PjLNALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND E ($100,700). IN ADDITION TOTHE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. INTEREST, AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am ficonsed under provisl ns of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Pr sions Code, and my license is in full force and effect. Lic. # Class q SContractora Signature: rDate a CONSTRUCTI N LENDING AGENCY: ❑ I hereby affirm that there Is a construction lending agency for the performance of the work for which this permit is issued, (Sec, 3097, Civil Code). Lenders Name: Lenders Address: Signature: Data: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, altar, Improve, demolish, or repair any structure, prior to Its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Lew (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permk subjects the applicant to a civil penalty of not more than five hundred dollars (3500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or Improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. It, however, the building or Improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to Construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License taws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or dead): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth Into which a person is required to descend, will be made In connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Dlvlslon of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 WIII the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure).............. ..._........................................................................... ....._...._................. —_._..---...._.—_....._._ 2 Does or will the applicant or present or future building occupant need to lila a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safely Code, with soma exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight o1 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _.-..............._.....................................................—._............ 3 Does or will the applicant or present or future building occupant need to prepare en RMPP (RiskManagement and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Masa Fire Department may require the preparation, certification and filing with the Fire apartment of an RMPP by businesses which are required to register acutely hazardous matorlais with the Fire Department. ................................................................._.....................................................................................,..,.,,........................................................................................................... ..................._............................................................._.......... 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No .............................................._........................ ................................................_..........................................................................,................................................................................................................................._ ....... 5 Does or will the appilcant or present or future building occupant require for the work which Is the subject of this Eplication ag9rmit for such construction or modification from the South Coast Alr Quality Management District or from any other air pollution control district or agency? ❑❑ Yes C] No (Section 65850.2 of the California Goverment Code requires that the requested information be furnished on applications for non-residential building permits). .................. .......................... ................. ............... .........................-......................................................... ................................................................................................. _..............._.................__....... 8 WIII any part of the facility to t>a constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (it yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). .................... ............._............................................................ .............................. .................................... ... ..............1............................................................................................. ---................ - ................... -- 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ................rtifi. -------liar... from ..------... ._. ....---.l officer). _..............._........................ __................. _................. _..—_..... _..... _..... _ 8 (It'yes', attach certificate of compliance from the appropriate air pollution contrd officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the Information given above is correct. i agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Dale: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perfury that I have read this application and state that the Information given is correct. 1 agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. IgnatDate ,,And/Or Authoriz p ( ata coQf, P. INSPECTION TYPE 2M INTITIALaR CODE 1 INSPECTION TYPE 1?dIF INTITIA $ 1618 Fixed System Final Fire Prevention 206 Final Mechanical 1268 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaintng Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site y 204 Final Demolition 250 Final Building/Occupancy /�_ / "d mw_a J, )f (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa,ca.usBUILDING PERMIT Job Address: 3333 BRISTOL ST Suite: 1400 Vicinity: SPACE 1400 - GEORGIO ARMANI Parcel Number: 41250107 Zoning: PDC PDC Applicant: BAUTISTA, JOHN Address: 22466 VENTURA BLVD Phone: (818) 225-6000 Phone: (818) 225-6000 WOODLAND HILLS, CA Zip: 91367 License: 433163 Arch : Eng: Address: Address: 77 FAIR DRIVE, COSTA MESA, CA 92626 ISSUED BY: Status: WOODLAND HILLS, CA Zip: 91367 Owner: SOUTH COAST PLAZA 06/25/2001 Address %C J SERGERSTOM SMIP Com: $5.25 COSTA MESA, CA Phone: Inspection: 3315 FAIRVIEW RD Zip: 92626 Contractor: SIERRA PACIFIC CONSTRUCTORS Address: 22466 VENTURA BLVD Phone: (818) 225-6000 WOODLAND HILLS, CA Zip: 91367 License: 433163 Arch : Eng: Address: Address: 77 FAIR DRIVE, COSTA MESA, CA 92626 ISSUED BY: Status: ISSUED Applied: 06/25/2001 Issued: 06/25/2001 Phone: Phone: Zip: License: License: SCOPE OF PERMIT INTERIOR DEMOLITION OF EXISTING SPACE FOR'FUTURE T.I. FOR "GEORGIO ARMANI" (SPACE 1400). REF: B01-00934 Total: FEE SUMMARY Plan Check: $0.00 Calc Valuation: $25,000.00 Permit: $391.25 Claim Valuation: $25,000.00 SMIP Res: $0.00 SMIP Com: $5.25 Other: $0.00 Inspection: $0.00 .. Total: $396.50 PLANNING & ZONING-' SETBACKS MAIN STRUCTURE Front 0-,0 ` Rear 0-0 Left 0-0 Right 0-0 ACCESSORY Front 0-0 Rear 0-0 Left 0-0 Right-, 0-0 PARKING Existing: 0 Required: 0 Proposed: . ,0 NOTES: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work Is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 244646 (6100) DECLARATiONS WORKERS' COMPENSATION DECLARATION: 1 hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. I hale and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Lssued. My works' compensation Insurance carrier and policy number are: 'Carrier: .. dPolicy Number. / (This section need not be completed if !ha permit is valued atone hundred doffers ($100) or fess.) - - C] I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Callf0 and ee that if I should b me subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith Comply with these provisio _ 'Applicant Signature: ' Date: A a: e WARNING: FAILURE T RE WORKERS COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL NALTIES D CML FINES UP TO ONE HUNDRED THOUSAND 5100,000), IN ADDITIONTO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under pr ions of Chapt (commencing with Section 7000) of Division 3 of the Business and fessions Code, and my license is in full force and effect. Lfa. r I Class It ° Contractors Signature: Date: 2rT O l - - CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is issued. (Sec. 3097, Civil Code). Lenders Name: Lender's Address; Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to Its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Coda) or that he or she is exempt therefrom and the basis for the alleged exemption, Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or Improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contraclor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feat in depth into which a person Is required to descend, will be made In connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec, 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to fila and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the appiiCani or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ..........----............ _ -- -..._........ _....... _.-......... _..... --........................................ -... __................. _... .---....._..._-- ._.M.._.------- 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, Certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. _....................__..............................._—................_..............-_...................... -................... ........ .................................................................. ..._......................... _................ ................... - 4 If an RMPP is presently required, has Section 25534 of the California Health and Safely Code been fully complied with? ❑ Yes ❑ No .............-..................---......................... _ __ ........_._............ — ................. .- -- ....... -..................._............................................................................ _....................... _.- ............. - ............. -- - 6 Does or will the applicant or present or future building occupant require for the work which is the subject of this application armit for such construction or modification EEe from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes u No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ... ............... —_.................. ......_ _ _--._.........-.—.._............ ---....................._.... 6 WIII any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes j] No (If yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ---...._................ —_................. .._..................._.. -............................................... .... - _— ........-.................. ........._.... 7 If a permit from the South Coast Air Quality - Management- District..or.. o-ther air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (If yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. se k_AndlOr.Au ohzad Applicant -Da ..- ' CODE P. INSPECTIONTYPE QM INTMACODE! INSPECTION TYPE Ilium 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Rotalning Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy _ R - 07 _0 1 �� (714) 754-5273 - Fax (714) 754-4856 - www.cl.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 BUILDING PERMIT Job Address: 3333 BRISTOL ST Suite! 1400 Vicinity: 1400 Parcel Number: 41250107 Applicant: JOHN NEESON Address: Zoning: PDC PDC ISSUE=D BY: Status: ISSUED Applied: 09/07/2004 Issued: 09/08/2004 NOTICE: The work authorfzed by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-562$ !446.413 (6=) Phone. 310-963-4480 " Zip: Owner: SOUTH COAST PLAZA Address i COSTA MESA CA' Phone: 33151FAIRVIEW ROAD. " < Zip: 92626 Contractor: SIERRA PACIFIC CONSTRUCTORS f Address:'22466 VENTURA BLVD Phone: (818) 225-6000 WOODLAND HILLS, CA Zip: 91367,."' License: _ 433163 Arch Eng: Address: Address: Phone: Phone: Zip: License: License: " SCOPE OF PERMIT FACADE CHANGES TO FACADE T07GORGIO ARMANI".INSTALL CURVED GLASS, MINOR CHANGES INSIDE. J_ FEE SUMMARY Plan Check: $486.69 - Calc Valuation: 565,000.00 Permit: $748.75 "_ .h_'"� r. ` ._ _ J'% _ - Claim Valuation: $65,000.00 SMIP Res- $0.00 SMIP Com: $13.65 Other: $0.00 Ihspection-, $0.00 Total: ` $1,,249.09 `fit. ,,� PLANNING & ZONING, ' SETBACKS � MAIN STRUCTURE Front 0-0 -Rear. 0;J0 Left 0-0 _ ` Right " -0"0 Q '' ' -Left '0-'0 - ACCESSORY Frant 0 Rear 0- 0' Right 0- Oz PARKING Existincl. `:0 Re uired:`" 0 ProRosed: 0 NOTES: NOTICE: The work authorfzed by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-562$ !446.413 (6=) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by, section 3700 of the Labor Code, for the performance of the work for which this permit is issued. J I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workerc mpensatlon Insure ce carrier and policy number are: _Carrirer. L f Policy Number:, I h (This section need not be co plated it the permit is valued at one hundred doflars ($100) or less.) ❑ I certify that in the part ance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of C lifornia, and ree that it I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with thass pr w1 Ions 'Applicant Sia Date: _ a��4 I _ - — WARNING: FAILURE TO SEC E WORK MPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL ENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLAR E ($100 ), IN AD I N TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. I LICENSED CONTRACTORS DECLARATION: I hereby affirm fhat.l.am licensed under provisions of Cha ter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and.effect..Lia. #/ Class k 7 e lContractor's'Signatura: Date:.1� e r— — . CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a constructionding agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason {Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No, Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 6, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ............................................................................................................................................................................................................................................................................................................................................ 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 o1 the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an R M P P (Risk Management and Prevontion Program for acutely hazardous materials)? ❑ Yes ❑ No Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire apartment of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ............................................................................................................................................................................................................................................................................................................ 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No .................................................................................................................................................................................... ...... .................... 5 Does or will the applicant or present or future building occupant require for the work which is the subject at this a plication aermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes E No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ... .......................................................................................... 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). .... .......................................................................................................................................................................................................................................----.......................................... 7 H a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ......................................................................................................................................................................................................................................................----.......................................... 6 {If jes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Sig fur a al0wner(s) Date -g�•D� /rid/ r ized.Appticant Dat` CODE R, p INMIALS CODE I INSPECTION TYPE DATE fhrEMLS 1616 inal Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 f=inal Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 , Final Building/Occupancy ""I v (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us ELECTRICAL PERMIT Job Address: 3333 BRISTOL ST Suite No 1400 Vicinity: Parcel Nunmber: 41250107 ' Applicant: TROY CHRISTIAN Address: T7 FAIR DRIVE, COSTA MESA, CA 92626 Status: ISSUED Applied: 04/05/2005 lssued: 04/05/2005 ISSUED BY: 9/k SCOPE OF PERMIT - INSTALL 3 LIGHT FIXTURES FOR 'GEROGE AIRMAN]" FACADE UPGRADE, RE:804-01564. Phone: 818-225-6000 FEE SUMMARY Zip Owner: SOUTH COAST PLAZA . Quantity Address Quantity ISSUE FEE COSTA MESA CA Phone: ' Temp -Dist System 1 Lighting 3315 FAIRVIEW ROAD Zip: 92626 Contractor: SIERRA PACIFIC CONSTRUCTORS Address: 22466 VENTURA BLVD 0 Res. a1c package $0.00Standing Phone: (818)225-6000 Section WOODLAND HILLS, CA Zip: 91367 New Res (1-2 units) $0.00 License: 433163 SCOPE OF PERMIT - INSTALL 3 LIGHT FIXTURES FOR 'GEROGE AIRMAN]" FACADE UPGRADE, RE:804-01564. NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 ?446-46 (6100) FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 Temp -Dist System 1 Lighting $0.00 0 Temp service test $0.00 - Busway 1100 ft $0.00 0 Res. a1c package $0.00Standing Section $0.00 01, New Res (1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0 New Res (3+units) $0.00 0 Transformers up to.1 kvalkw $0.00 0 Pool 1 Spa $0.00 0 ....up to 10 kvalkw 30.00 0 Lighting Fixts $3.30 3 - s .::..........up to 50 kvalkw $0.00 0 • Recept Outlets $0.00 0 ...........'....up to 100 kvalkw $0.00. 0 Switches $0.00 0 . .............'..:..over'100 kvalkw $0.00 0 Non Res Appl $0.00 0 Low Voltage Equipment - _ ,• $0.00 0 . Res Appl $0.00; 0 .. 'Low Volt Wiring System 1 Ckt $0.00 0 Service to 200a $0.00 �' . 0 Misc. Conduit "$0:00 "0 Service to 1000a $0,00. .. -0 Misc. Conductor $0.000 Service over 1000a $OAD D Circus ( gen or ride) l $0.00 'o Motors to ihp $0.00' 0 - Circus (meth ride or lights) $0.00 0" Motors to i0hp $0.00 0 Christmas Tree Stand $OAO 0 Motors to 50hp $0.00. '0 Fireworks Stand. - $0.00. 0 Motors to i00hp $0.00 0 Other Electrical Fee $0.00 Motors over 100hp 10.000 Communication drops $01001,,--"_ 0.001. --_. �0 Investigation Fee,' Sub panel to 200a $0,00 l' , 0 _ Plan Check Fee. - % '� $0.00 Pole Light Pkg $0.00 '0- _- _ R_einspectiona 66- - $0.00 Sign Circuits $0.00 D Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $26.80 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 ?446-46 (6100) DECLARATIONS WORKERS' CQMPENSATION DECLARATION: I hereby aflirm under penalty of perjury one of the following declarations: ❑ f have and will maintain a certificate of consent to sail-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this penult Is Issued. ❑ I have and will maintain workers' compensation insurance, as required by section 3 00 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier; Policy Number: (This section need not Us coj6olefed if the permit is valued at one hundred dollars x$100) or less.} ❑ I certify that in the performance of the rk for blob s permit is Issued, i shall not employ any person in any manner so as to become subject to the workers' compensation laws of Califamia e e t It I ould become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith tom I with these provis' / Applicant Signature: I Date: WARNING: FAILURE TO SECURE KERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRE THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, 11TEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under rovls s Che r 9 (commencing with Section 000) of Division 3 o1 the Business and Professions Code, and my license is in full force and effect Lic. 4 Class 0 Contract r,s Signature. Date: CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a Construction tending agency for the performance of the work for which this permit is issued. (Sec. 3097, CMI Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit to the a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Coda) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Cade: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contracior(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type o1 document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth Into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, talsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, Calilomia Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number; HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 o1 the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .........................................................................................................................................................................................................................................................................................._........................................._------•- ........................... 2 Dues or will tha applicant or present ar future building occupant need to lila a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ..................._.................................................................................... ................................ ..................................................................................................................... .............................................................................................................. 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ............................................................................................................................................................................................................................................................................................................................................................................ 4 It an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No ................................................... ............................................................... _................................................................... ... .......................................................... .......................................... -....... .................... .......11.11.......................... 5 Does or will the applicant ar present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes � No (Section 65850.2 of the California Government Code requires that the requested Information be furnished on applications for non-residential building permits). _................ ...... _.......................................... ..... ...... ........................................ ......................... _._.................... __................ __................... _...................................... ... ............................... -................................................................... ... 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (11 'yes". the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). -........._....................................................................................................................................................................................................................................................................................................... 7 If .......a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ................................................................ _..................................................................................................................................................................................................................................................................... ................ 8 (If jes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city Ordinances regarding Hazardous Materials and Emissions. Signature: Data: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. i agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described properly for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. gn a Of Legal Owner(s) Dale *h—cFOr Authorized Applicant Date Sit INSpECTIQH TYPE RM INTIT16LCODE P INSPECTION TYPE p3 IRIMA63 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical (/J7•fC'7T7>�C_�- 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approve$ 203 Final Sign 222 Final Site 204 Final Demolition 250 Final BuildinglOccupancy M I CITY OF COSTA MESA BUILDING DIVISION 77 FAIR DRIVE, COSTA MESA, CA 92626 - (714) 754-5273 - Fax (714) 754-4856 • www.ci.costa-mesa.ca.us FOR INSPECTIONS CALL: (714) 754-5626 PERMIT TYPE: B_COMBO Sub Type: COM -ALT JOB ADDRESS: 333' x'2$5=8RISTOL:S APM 41250107 Zoning:PDC, , Vicinity: SPACE 1255 Const Type: I -A SQ. FT: 1510 PERMIT NUMBER: BC10-00336 STATUS: ISSUED DATE ISSUED: 09/1712010 ISSUED BY: KJB SuitelUnit: 1255 •` Primary Occ: Phone: Valuation: $195,000.00 SCOPE OF WORK: 1,510 SF INTERIOR TI FOR "ANNE FONTAINE", SPACE 1255, WORK TO INCLUDE IMPROVEMENTS TO STORE FRONT, SALES AREA, FITTING AREAS, RESTROOM. ELECTRICAL, MECHANICAL AND PLUMBING WORK. MECH: 2 VAV BOXES, 1 VENT FAN. ELEC: 143 LIGHT FIXT, 15 OUTLETS, 7 SWITCHES, 9 COMM DROPS. PLUMBINGA FLOOR DRAIN, 1 DRINKING FOUNTAIN, 1 P -TRAP, 1 TRAP PRIMER, 1 WASTE AND VENT, 1 TOILET, 1 WATER HEATER, 1 WASH BASIN. OWNER: SOUTH COAST PLAZA Phone: Fixed System Final Fire Prevention APPLICANT: PAT IMBRIALE Phone: 757-566-3032 CONTRACTOR: DAVID A NICE BUILDERS Phone: 757-566-3032 Cell: ARCHITECT: ATMOSPHERE DESIGN ENGINEER: COMBINATION PERMIT FEE SUMMARY Building Plan Check: Building Fees: Electrical Fees: Mechanical Fees: Plumbing Fees: SMIP Residential: SMIP Commercial: Bldg Std Admin Fund TOTAL FEES: Address: 3315 FAIRVIEW RD City/State/Zip: COSTA MESA, CA Address: City/State/zZip: %License No. 709012 Address: 4571 WARE CREEK RDUnit: City/State: WILLIAMSBURG, VA License No.31289 License No. $247.94 $11,525.75 $169.39 $52.05 $101.90 $0.00 $40.95 $ 8.00 $2,145.98 Unit: Unit: : ZipCode 23188 PHONE:914-244-1300 PHONE: 'Refer to fee receipts for all fees paid for project _ HOURS FOR CONSTRUCTION ACTIVITY: EFFECTIVE 3118/2010 - PER CMMC Sec. 13-279 Monday thru Friday - 7:00 am thru 7:00 pm. Saturdays- 9:00 am thru 6:00 pm. Prohibited all hours - Sundays and the following Federal holidays: New Years Day, Memorial Day, Independence Day, Labor DaX, Thanksgiving Day and Christmas Da NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE /, INSPECTION TYPE 1616 Fixed System Final Fire Prevention 1266 Pool Spa Final 200 Final Re -Roof 201 Final BlocklRetaining Wall 202 Final Factory Fire Place 203 Final Sign 204 Final pemolition DATE INTMALS CODER INSPECTION TYPE 206 Final Mechanical 208 Final Plumbing 210 Final Electrical 212 Final Fire Prevention 220 Final Planning Approval 222 Final Site 250 Final Building/Occupancy INTITIAL 11Dq jD T 1i -q -ID FW j -ID --tib �� j1- -to V ZV WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are;. �„� / rr*/e 4-_C C S V,41 (This section need not be completed it tthe permd is vat at one hundred "ars (S 100) Of less.) ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of th or Code, shall on "th comply with these provisio s. ell � L� tlgntb-Signature WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. 0 �nM,ract Signature a e CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lenders Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penally of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractors) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature 305746 (3107) Date Owner ID verified by drivers license. ❑ Yes []No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Division of Industrial Safety Permit Number: Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department, 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (if "yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. gnatle of L I ergs) l?at 7 thonz plieant (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.19,4„;1-DING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Status: ISSUED Suite: 1255 Applied: 07/25/2005 Vicinity: EMPORIO ARMANI, SPACE 1255 Issued: 07/25/2005 Primary Occ: M Display/Sale Merchandise Type of Construction: V -N Parcel Number: 41250107 Zoning: PDC Applicant: JOEL SULLEVA ISSUED BY: r�XD Address: 22466 VENTURA BLVD Phone: (818)225-6000 WOODLAND MILLS, CA Zip."'.91367..-` Owner: SOUTH COAST-PLAZX` < Address COSTA'MESACA Phone:" 3315 FAIRVIEW ROAD : Zip: • • 926213 Contractor: SIERRA PACIFIC CONSTRUCTORS Address: 22466 VENTURA"BLVD Phone: (818)225-6000 .WOODLAND HILLS, CA Zip: 91367 ,, License: 433163 Arch Eng: Address: Address: Phone: Phone: :.,. Zip; License: r ,;;, /-License: SCOPE OF PERMIT REMOVE EXISTING CASH WRAP AND ENCLOSE' EXISTING OPENING WITH NEW DOOR FOR "EMPORIO ARMANI'; SPACE 9.255. FEE SUMMARY :... f Plan Check: $81.41 j Calc Valuation:: '; ,. $6,000.00 Permit: $125.25 -- ,Claim Valuation:., $6;000.00 SMIP Res: SMTP Com: $1.26: Other: .$0.00 Inspection: $0:00 Total: $207:92' ,: PLANNING & ZONING SETBACKS.. MAIN STRUCTURE Front 0-,0, Rear- ,z 0. 0 Left „ 0 0 w. Right -,9-0 ACCESSORY Front, ='0,.0 _' • 3 Rear, --0-0 Left 0-0, ” ~., Right- '' 0-0',, PARKING Existing: '0 Required: v "0 '.' Proposed � 0., •n NOTES, v NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Caiifomia statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required lnspeci1ons and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2440-" tWw1 WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the _--_work for which this permit is issued. ❑�'I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. My o ars' compensati uranc carnVnd policy number are: -A -carrier: �lr.+ !� ` Policy Numbs' r` 15 3S/3 ,(7his'section need not be completed it the permit is valued at one hundred dollars ($100) or less.) ❑ f certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manna( so as to become subject to the workers' compensation laws o lif nla, and a at If I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with thes r i ' s �signat . :7k a s. a plica�t_51gr�atur . ..Data;.;_�_ WARNING: FAILURE T SECURE WORKER ' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER FO CRIMINAL -PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I he►eby'atflrm thatI 'll ad under rovisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full fajce and effect Lim y ontracto's SignalerCD!aIZ: O CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a Construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code), Lender's Name: Lendees Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that i am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, star, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (Commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than live hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for safe (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.9. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high" (Chap. 3.2, Grp 2, Art 2, Sec, 341, Tiffs 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). "................. *as"o ....'r f'"t,'u".............d-ir...... G'c' ...""."...."..........d,t'........................................f'o"r.....io-'r........................iir'...........................G. ?'.""..............................."...................... ................................... .................................................... 2 Dces or will the applicant or present or future building occupant need to fife a registration form for acutely hazardous materials? ❑Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ...............................................---.........................................................................................................................................................""""""""""""""""""•""""""""•""""""""""•""-""""""""--"""""....................................................................................... 3 Does or will the appplicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ f, [Section 25534 of the California Health and Safety Code provides that the Costs Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. .......................... ............................................................................................................................................................................................................."........ ................. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code boon fully complied with? [:]Yes ❑ No .............................................."-"""".........................................................................--"•"""""...................................................................................................................................................................................................................................... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a er mit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes f N0 (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ""••..................................................................................................................................................................................................................................................... ............................... 8 Will any pan of the facility to be constructed under this permit be within 1000 feet from tho outer boundaries of a school? ❑ Yes ❑ No (if 'fres", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permitfrom the South Coast Air Quality Management District or, alter air pollution control district or agency is roquired for the work which is tho subject of this application, have all of the disclosures proscribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No """""................................................................................................................................."..............................".""""""."""""""""""."""""""""."".""""""""""".""".""" ............................... 8 (lf "yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. atura Of Legal Owners)r— Date 101, CAnd/Or.Authorized.AppGcant-.--"-- Date CODE /. INSPECTION TYPE DATE1NTITIALS CODE N INSPECTION TYPE Qg%F. iNMIAL 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy t1� CITY OF COSTA MESA BUILDING DIVISION r77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa. s �. FOR INSPECTIONS CALL: (714) 754-5626 VF07-00285 FIRE SUPRESSION PERMIT Job Address: 3333 BRISTOL ST : _ - - =-.fir "_ - Status: ISSUED Suite: 1255 ;` "• -` Applied: 10/03/2007 Vicinity:" 1� _-` Issued: 10/05/2007 Parcel Nunmber: 41250107;? F f, -:-Zoning -PDC�I , •`w'0..' «�V "A� `P-' ;��y-y1�.4� Applicant: LAB1, ASSAF, " : f • < Address: 6923 FARMDALE AV Phone: ,'818-982-0126 rHy �'•,��. NORTH -HOLLYWOOD, CA Zip: L91605-6211 t`tF', '�- _� ;Fs?"r ._fir;l �'.•�.,.4• '" $ fi ;y'�'. -. ,'; j Owner: SOUTI 1 COAST -PL AZA,,_ : !' > r;� Address COSTA MESA CA 1 Phone: 3315 FAIRVIEW,ROALI �- _ Zip; 92626.- contractor: 2626.-Contractor: REGENCY FIRE PROTECTION -INC Address: 6923 FARMOALE AV _ -- Phone: 818-982-0126 NORTH HOLLYWOOD, CA Zip: 91605-6211' y License: 523116 SCOPE OF PERMIT Fi�,n�i11(�i?Y�A'7 RELOCATE 9 OVERHEAD SPRINKLERS FOR "EMPORIO ARMANI" IN SPACE 1255. REF.:.BC07-00036 FEE S_ UMMARY: " Plan Check: $63.21 ; ^ _- .Calc Valuation: $3,250.00 Permit: $97.25 - `` - ', f4 ` = -'Claimed Valuation: $3,250.00 Other: $0.00 Total: $160.46 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE 1, INSPEMN TYPE PAR WITIAL5 CODE N INSPECTION TYPE �Aif, INTMAL5 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final BlocklRetaining Wall 212 Final Fire Prevention �D 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 f=inal Site 204 Final Demolition 250 Final Building/Occupancy S� �I WORKERS' COMPENSATION DECLARATION: Owner ID verified by driver's I, e. ❑ Yes ❑ No I hereby affirm under penalty of perjury one of the following declarations: Driver's License No. Expires: ❑ I have and will maintain a certificate of consent to self -Insure for workers' Verification of Ownership by (type of document, i.e. - property tax bill or deed): compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: permit is issued. My workers' compensation Insurance carrier and policy ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a number are: l ` person is required to descend, will be made in connection with work authorized Carrier: —�n�� �/1 Z-2 ` c/[^ r"�r� p l I t p by this permit, and that no building structure, scaffolding, falsewnrk, or demolition I'Tnissectionneed+winecwn0erederneperrnd2va dafone hundreddotlarsW00)orless-) or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp /2 Art 2, Sec. 341, Title 8, California Administrative Code), Policy Number: S Yzj {pt✓ jp yj S G' ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject ❑ As owner builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. to the workers' compensation laws of California, and agree that if I should become subject tott} workers' compensation provisions of Section 3700 of Applicant's Signature the L bor Code, sh I forth t ith comply with theseprovisions. / ' O S Ci / Division of Industrial Safety Permit Number: licant's Si nature Dalpf Date p g HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE 1. Will the applicant or present or future building occupant need to file and IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL certify a Business Plan for emergency response to release or threatened PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS release of a hazardous material? ❑ Yes ❑ No ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS (Section 25505 of the California Health and Safety Code requires, with some PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND exceptions, that a Business Plan be filed with the Costa Mesa Fire ATTORNEY'S FEES. Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. 1 ` Lic. # S, 2 31 ! 'ss # I (d "[ a Signature Qat Q CONSTRUCTION LENDING AGENCY: / 5/ ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Dale 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California OWNER -BUILDER DECLARATIONS: Health and Safety Code been fully complied with? ❑Yes ❑ No I hereby affirm that under penalty of perjury that i am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractors) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature 305746 (3107) Date 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (if 'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct..) agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. ' Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: i certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. �7 Signature of Le Owner( Date _ GsG�� And/or ulh7z Appli nt to C1''Y OF COSTA MI 'A Development Services, Division of Building and Safety CERTIFICATE OF OCCUPANCY This certificate is issued pursuant to the require merits of the Uniform Building Code, Section 308 adopted by the City of Costa Mesa certifies that at the time of its issuance the building structure herein below described was inspected and approved for occupancy as follows:, Building Address 3333 Bristol 'St. ,-bSte •1255, Bldg. Permit NumberBC07-00036 Use Clothing - (.6,531) 'Ys M 1 -FR '' X•XXXXX. RMD Group Type of Construction Fire Zo.ne Use Zone Owner of Building South -;Coast Plaza Tenant EMPORIO ARMANI Address 3315 Fairview Rd., Costa Mesa, CA F By - a/ BUILDING OFFICIAL-Khanh Q. Nguyen, C.B.O. v Date. 11/26/0 REQUIRED TO BE POSTED IN A CONSPICUOUS PLACE NOTICE- The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. DE /. INSPECTION TYPE DAFT INTMA CODE INSPECTION TYPE DATE INTMAL 1616 Fixed System Final Fire Prevention 206 Final Mechanical 11-1-07 _ Bav 1266 Poo! Spa Final 208 Final Plumbing �-7— 200 Final Re -Roof 210 Final Electrical %K 201 Final Block/Retaining Wall 212 Final Fire Prevention A= 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy CITY OF COSTA MESA ' ®r BUILDING DIVISION r F 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 - Fax (714) 754-4856 www.ci.costa-mesas s u ` FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER. BC07-00036 i PERMIT TYPE: B_COMBO STATUS: ISSUED Sub Type: COM—ALT DATE ISSUED: 08/09/2007 ISSUED BY: RMD JOB ADDRESS: 3333 1255 BRISTOL' ST CM Suite nit: _ .1255 APN: 41250107 Zoning:PDC, , Vicinity: EMPORIO ARMANI _ Primary Occ: Const Type: I -FR SQ.- FT:, - 6531 Valuation: $50,000.00 SCOPE OF WORK: 6,531 SF, INTERIOR T.I. FOR "EMPORIO ARMANI", SPACE 1255 STOCK ROOM ONLY NEW PARTITION WALLS WITH ELECTRICAL AND MECHANICAL WORK. OWNER: SOUTH COAST PLAZA - Address: , Unit: COSTA MESA CA Phone: City/State/Zip: 3315 FAIRVIEW ROAD APPLICANT: GLEASON, WILLIAM Address: Unit: Phone: 818-445-5691 City/StatelzZip: r CONTRACTOR: SIERRA PACIFIC CONSTRUCTORS = - Lidense No. 433163- 33163-Phone: Phone:818-225-6000 Address: 22466 VENTURA BLVDUnit: Cell: Citi/State' WOODLAND HILLS; CA ZipCode 91367 ARCHITECT: PAUL J RUFFING, AIA License No.C4264 � ' PHONE: 949-660-8062 ENGINEER: E License No. - PHONE: COMBINTATION PERMIT FEE SUMMARY Building Plan Check: $104.69 Building Fees: $644.25 Electrical Fees: $49.90 Mechanical Fees: $37.20 Plumbing Fees: $0.00 SMIP Residential $0.00 SMIP Commercial: $10.50. TOTAL FEES: $846.54 "Refer to fee receipts for all fees paid for project NOTICE- The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. DE /. INSPECTION TYPE DAFT INTMA CODE INSPECTION TYPE DATE INTMAL 1616 Fixed System Final Fire Prevention 206 Final Mechanical 11-1-07 _ Bav 1266 Poo! Spa Final 208 Final Plumbing �-7— 200 Final Re -Roof 210 Final Electrical %K 201 Final Block/Retaining Wall 212 Final Fire Prevention A= 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy WORKERS' COMPENSATION DECLARATION: - Owner ID verified by driver, ose. ❑ Yes ❑ No I hereby affirm under penalty of perjury one of the following declarations:.. Drivers License No. Expires:` I have and will maintain a certificate of consent to self-Insure'tor workers' Verification of Ownership by (type of document, i.e, - property tax bill or deed): cq pensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ f have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: Permit is issued. My workers' compensation Insurance Carrier and policy ❑ 1 hereby certify that no excavation rive (5) or more feet in depth into which a number are: person is required to descend, will be made in connection with work authorized /7� J by this permit, and that no building structure, scaffolding, faisework, Cr demolition Carrier, or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp frh?s sbaian Aeedndebutompfetedemeperrwavahre at one huWreddolars(5100)ariess.) 2, Art 2. Sec. 341, Title 8, California Administrative Code). Policy Number: C2_ (.4% — O ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensate ws of California, and agree that if I should become rkers' c mpensation provisions of Section 3700 of Ft d4� �plyese provisions. s' �1d8 Ap Ips nature r` Date WARNING: FAILU TO ECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL D L SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND IL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. 0 tragi gnature Date CONSTRUC NDING AGENCY: Q I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Division of Industrial Safety Permit Number: _ Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1, Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be riled with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons. or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No -T,Nction 25533 of the Califomia Health and Safety Code, with some eptions, requires registration with the Costa Mesa Fire Department by ---escta,.bt+siness which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4, If an RMPP is presently required, has Section 25534 of the California OWNER -BUILDER DECLARATIONS: Health and Safety Code been fully complied with? ❑ Yes ❑ No I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): EJ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she ,did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). [] I am exempt under sec. Business and Professions Code for this reason: 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be fumished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? []Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. if a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures proscribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If 'yes", attach certificate of -compliance from the appropriate air pollution control officer). CERTIFICATE OF COMOLIANCE: l certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous, Materials and Emissions. Signature Dale CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that i have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature Date 3057•46 (3107) � CMF 0865-46, rev. 10/84 White -Buil �:..,,-, a, ary 4ppllcant; Pink - Accounting; Goldenrod - Assessor 1 5083 9'/ I 1/87 25..°1,: Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations. • - . CITY 0E COSTA MESA CONSTRUCTION PERMIT PERMIT NO. 3 ) MMMFB*MMILOT O! NQ. 1- UNIT NO.199 �' Project AdFl.ess 33 3 S� �o�P C U APp�i: ant's Mailing Address TYPE OF CONSTRUCTION 1:1CONVERSION ❑ NEW El ADD ALTERATION LJ REPAIR (71 ` t i ' Owner's Name PQ RE f 7 s11� hone DEMOLISH OTHER A•P• # Zone �� i 971,J'(SRAY DESCRIPTION OF WORKIUSE OF BLDG" S Main Building: Accessory Building: ! Address E Z Arch/Eng.. License No. TYPE OF PERMIT GRADING FOUNDATION STRUCTURAL T Front - O w ❑ TENANT 1:1 ELECTRICAL PLUMBING ❑MECHANICAL B N Address ❑ OTHER r A Rear Contractor's Nam O& phone C µ Right N e� Address (Mailing) PROJECT DESCRIPTION SQ. FT. OCCUPANCY S G CONSTRUCTION TYPE VALUATION $ Left i } r R City License No. ZONE GRADING CV.YDS. ACRES Pin Ref. # g Parkin Re /Provided g Rect./Provided E LICENSED CONTRACTOR DECLARATION 5 - Q 1 hereby affirm that I am licensed under provisions of Charter 9 (commencing Remarks: Planning Notes: ' M with section 7000) of Division 3 of the Puniness a ofessions Code, a' d T my license is in full force and fe t. r _ S License as LIc o, NO Date Signature PLUMBING FEES ii WOR R5 O PENSATION DEC ON I hereby affirm that I have a certificate of consent to self -insure or a certificate - Bar Sink Showers ELECTRICAL FEES of Workers' Compensation Insurance, or a certified copy thereof (Section Backflow Preventer Service Sink Automatic Washer Transformer ❑ 15-50 KW - ��Policy 3800, Lab. C r No,— Comp Backflow Irrigation Sewer Cap _ ❑;50+ KW Construction Pole Sub. W Certified copy is hereby furnished. dn Certif'ed filed with the cit Bu vi Bathtubs' Sewer Connection Cooking Unit Meter ❑up to 100 amps _ DateAff Applican EXE NWT16 f& M WORKERS' CO TION LARAT10N Clarifiers - _ Solar Collectors . - Dishwasher Meter ❑Over 100 amps - (This section need not be completed if the permit is for one hundred L$100) or less)- Dishwasher - Solar Piping - - Dryers ❑Gas ❑Electric - Sub Pane! - I certify that in the performance of the work for which this permit is issued, I " - shall not employ any person in any manner so as to become subject to the Drinking�Fount ains Solar Tank Fan Motors ❑Q 1 HP C11'%B . Workers' Compensation Laws of California. Date Signature Floor Drains Swimming Pool w/Spa F"A.U. ' Inc. Solar C!9 15 HP ❑16-15+ NOTICE: if, after making this declaration, you should. become subject to the ' Workers' Compensation provisions of the Labor Code, you.must forthwith Floor Sinks Urinal Fixtures Microwave ' comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY Gas Service f -Outlets Water Closet Device Boxes Pale Light I hereby affirm that there i$ a construction lending agency fortheperformance _ of the work for which this permit is issued. (Section 3097 Civ. C.) Interceptors Water Heater - Outlets Range ' Lender's Name Lender's Address ' Kitchen Sink Water Service Switches • - Sign ' OWNER BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License, Law for the Lavatories Auto -Wash , Garbage Disposal Standing Sections following "reason (Section 7031.5 Business and Professional Code: Any city or county which requires a permit to construct, alter, improve, demolish or repair P—Trap=T Laundry Trays Generator ❑05 KW ❑5 15 KW Trash ' any -structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he/she is licensed pursuant to the provisions of Roof Drains the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he/she is -exempt therefrom and the basis for the alleged exemption. Any violation of Section r , 7031•.5.'by any applicant for a permit subjects the applicant to a civil . penalty of not more than five hundred dollars ($500). ❑ I, as owner of the property or my employees with wages as their sole ReinspeGtlOn Fee $15 Issue Fee compensation, will do the work, and the structure is not intended or offered Reinspection Fee - $15' Issue Fee $ 3 ' for sale (Section 7044, Business and Professional Code: The Contractor's MECHANICAL FEES License Law does not apply to an owner of a property who builds or improves thereon, and who does such work himself/herself or through his or her own Hood Type I ❑ DEVELOPMENT SERVICES REQUIREMENTS: - employees, provided that such Improvements are not Intended of offered for Boiler or Zoning Approved B , sale. If, however, the building or improvement is sold within one year of com- Canopy Type I1 El pletion, the owner will have the burden'of proving he/she did not build or im- Duct - Under Ground I Building Approved By Date -prove for the purpose of Sale)., 3 + ❑ 1, as owner,of the property, am exclusively contracting with licensed con- Duct - Structural Refrigeration System Application Issued By Dat / tractors to construct the project (Section 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who Duct - Ventilating 00-100,000 BTU ❑ 100,000 BTU SUMMARY OF FEES builds or improves ,thereon, andwho contracts for such projects with a con- _ tractor(s) Iicense.pursuant to the Contractor's License Law). I am aware that Exhaust System ❑ Multiple ❑ System-RepairlAlteration f BUILDING PERMIT $ SM IP $• proof off their Worker's Compensation insurance should be provided to me. ❑ I am exempt under Section B. & P. C. for this reason FirepllFact. Blt. ICBO Fire Dampers _ PLAN CHECK $ PERMIT ` ISSUANCE $ PLUMBING $ Date Owner Heating System & Ducting Registers ;" ° PLAN CHECK 25% $ ENERGY-P.C. $ .- I hereby certify that I have re d this application and state that the above 0- 100,000 BTU ❑100,000.BT ELECTRICAL $ GRADING $ ' ' information is corre I.agre mply with all city and county ordinances -� and state la rel m to in onstructlon, and hereby authorize repre- 'above-mentioned PLAN CHECK 50°6: $ MICROFILM $ - sentatives i cit t on the --,property for inspecure ur s s MECHANICAL $ TOTAL FEE $ �— Signature _ ,r SS " - ' t - keinspection Fee $75 Issue Fee $ 3 PLAN CHECK 25% . $ , , CMF 0865-46, rev. 10/84 White -Buil �:..,,-, a, ary 4ppllcant; Pink - Accounting; Goldenrod - Assessor 1 , P. j CONSTRUCTION AND* PLANNING POOL & SPA APPROVALS Permh % - Date +' Inspector APPROVALS Permit # '+ Date Inspector , I. Temporary Electrical Sewice or Pole 52. Pool & Equipment Location 2.' Soil Pipe-Undrgrnd.:•'"' `' 53. Steel Reinforcement"' 3. Electrical Conduit Utility-Undrgrnd. 54. Forms 4.. Electrical Conduit-Undrgrnd. 55. Electrical, Bonding r , ' 5. Steel Reinforcement - :. 56: Rough Plumbing &Pressure Test 6• Elecirical UFER Grnd. �.;;% 57. APPROVAL TO COVER-GUNITE 7. Footings =g. 'i 58. Electrical Conduit=Undrgrnd. 8. Foundation - 59. Gas Pipe, U Undrgrnd., Test 9. Water �Pipe Undrgrnd 60. Backwash.Lines,-P-Trap, ❑ Undrgrnd.' 10. Structural Floor System - 1 '• 61. APPROVAL TO DECK 11. Property Sewer Line & House Connection •2 • 62• Backwash & Receptor -Final 12, Sewer Cap may 63. Heater & Vent -Final . 13. Roof'Drains 64. Plumbing System - Final 14.- Rough Plumbing r 65. Electrical,Final " 15. Rough Electrical -Conduit 66. Solar=System Final 16. Rough Electric Wiring 67. Fe ting & Access Approval 17. Rough Wiring Sign 68.- APPROVED FOR PLASTERING ' 18. Rough Electrical -T Bar Ceiling 69, POOL/SPA SYSTEMS FINAL 19• Rough Heating & Air Conditioning :'' FIRE DEPT. REQUIREMENT APPROVALS Permit # _ 20. Rough Factory Fireplace 21, Ducts, in Structure 70. Underground Hydro 22. Ducts, Ventilating 71. Product Piping ❑ Gas ❑ Oil �. 23. Gas Pipe -Rough & Test i 72. Underground Flush ' ! 24. Roof Framing-" + 73. Undergrnd. Storage Tank ❑ Gas ❑ Oil 25. Roof Sheathing' • 74:..Ove,rhead Hydro . 26. T -Bar Ceiling (Structural) &Monocoat 75. Dry Chemical r 27. Frame and Flashing 76: Dry'Standpipe' 28. Lathing & Siding 77. FIXED SYSTEM FINAL ` 29. insulation 78. FIRE PREV. FINAL 30, Drywall Nailing HEALTH DEPT. RI QUIREMENT 31. Plaster Brown Coat 7 FINAL INSPECTION 32.. Electrical Power Meter -Final 0, FOOD CERTIFICATE ISSUED ✓� +� 33: Final Electric- otes: !.•34• Final'Heating & Air Conditioning .r 35., Final Gas Pipe -Test 36 IIHood or..Canopy. 31SiFindl Factory Fireplace `s 38` Final Plumbing t f 39!. Water Service -Final 40'. Gas Service -Final Ir',- -� Solar Domestic -Final 142. Backflow Preventer t43: Backflow Irrigation '.44-' Landscape Irrigation System:- �45 Souha Attenuation 46r,,•.Handicap Regulations r R( k 47r. FINAL STRUCTURE &•BUILDING 48F`Speecial Requirements Completed 49. Electric Release to. Edison ,50. Gas Release to Southern California Gas Co ��✓ . - 51. CERTIFICATE OF OCCUPANCY No. Date ' ►M�.�:.�►r�:!',.�rar.'�a11�i1�i�.�raiflN �`-;�°� x'�l.,iz::-s...; � ... _; -.... Applicant to fill in al! spaces except thosewithin heavy Lo .:dr lines and sign all appropriate declarations. with section 7000) of Division 3 of the Business and Professions Code, and my license is in f I f c and effect. 4 License I s 'c se No. • I Date Signature WORKERS' COMPENSATION DECLARATION 1 hereby affirm that I have a certificate of consent to self -insure or a certificate of Workers' Compensation Insurance, or a certi ped copy thereof (Se tion 3800, La hhh..K...GGGI�iG � � Policy NdY-,Company Certifi cop is hereby furnished, Cert ' p • • ed with the city Buil Dlvisio , } ate i Applicant l EXE'mpkioN OROM WORKERS' COMPENSATION D CLARATION i �\ (This section need not be completed if the permit Is for one hundred ($100) or less). I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation LawS,of California. Date' Signature NOTICE: If,after-making this declaration, you should become subject to the workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION t_ENDiNG AGENCY .1 hereby affirm that there'is a construction lending agency for the performance of the work for which tills permit is issued ,(Section 3097 Civ, C.) Lender's Name -Lender's Address - OWNER BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the fallowing reason (Section 7031.5 Business and Professional Code: Any city or county which requires ,a.permit to construct, alter, improve, demolish or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he/she is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of • Division 3 of the Business and Professions Code) or that he/she' is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500). . , ❑ I, as owner of the' property or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Section 7044, Business and Professional Code: The Contractor's License taw does not apply to an owner of a property who build$ or improves thereon, and who does such.work himself/herself or through his or her own employees, provideo that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of com- pletion, the -owner will have the burden of proving he/she did not build or im- rove for the purpose of sale), ' ito, as owner of the property, am exclusively contracting with licensed con- tracrsto construct the Project Se tion 7044, Business and professions Code: The Contractor's License Law does not apply to an owner of property who buildsor improves thereon, and who contracts for such projects with a con- tract or($) license pursuant to.the Contractor's License Law). I am aware that proof of their Worker's Compensation insurance Sri ould be provided to me: ❑• I am exempt under Sectiori B!& P. C. for this reason•. Date Owner I herebycertify that -1 have read this application and state that the above information is correct. I agree to comply with all;city and county ordinances' and state laws relating' to building construction, and hereby authorize reore-. sentatives of t Is city tQ enter up0 the above-mentioned property f4i inspection qui es. Bar Sink' Backflow Preventer Backflow Irrigation Bathtubs Clarifiers Dishwasher Drinking Fountains Floor Drains Floor Sinks Gas Service r Outlets Interceptors Kitchen Sink Lavatories P—Trap Roof Drains Reinspection Fee PLUMBING Showers Service Sink Sewer -Cap Sewer Connection Solar Collectors Solar Piping - Solar Tank Swimming Pool vv/Spa Urinal Water Closet Water Heater Water Service Auto -Wash Laundry Trays $15 Issue Fee I• MECHANICAL BoilerHood or Type I ED - Under Ground Canopy Type I! 'E1 \ Duct - Structural Refrigeration System Duct - Ventilating 1-10-100,000 BTU ❑ 100,000 BTU Exhaust System- El Multiple ❑ System Repair/Alteration Firepl/Fact. Bit, ICBO # Fire Dampers Heating System & Ducting- Registers ❑ 0-100,000 BTU ❑ 100,000 BT I Signature --� -- - - rlala r Reinspection Fee $15 Issue Fee Drivers' License or SSS# _ CMF 0865-46, rev. 10184 White - Building; -___ A- PpHcant; Pink - Accounting; Goldenrod - Assessor 09ll .)/26/87 Accessory Building 123.55 TL .Zone •: . _ ` Z ,O N ~ G R Parking Req./Provided r E M T 5 ELECTRICAL Automatic Washer Transformer ❑ 15-50 KW - Construction Pole Sub. ❑ 50 + KW Cooking Unit Meter. Oup to 100 amps CITY OF COSTA MEA CONST �j UCT Ifr1N qER AI P IT NQ.�oi r /4J TRACT NO. LOT NO. UNIT NO. Fixtures Microwave Projbct Address r' Outlets Range Switches - Sign Garbage Disposal Standing Sections Applicant's Mail' Address G7.c %rLyc % S. /� , TYPE OF CONSTRUCTION,"'NEW ADD ALTERATION REPAI R ELECTRICAL i i`f d i�h'G //s , 1:1 CONVERSION DEMOLISH El OTHER ' _ A,P, # MICROFI LM- Owner's Name 0 �.,7lc_TZ `.., DES IP QFl �O.R'�C/USE OAF BLDG. -� - TOTAL FEE Address ra y` }�/`-G IeE�%(//�%OL. S Main Building: Arch/Eng. License No B T� TYPE OF PERMIT GRADING ❑FOUNDATION 0 STRUCTURAL T Front Address oc ❑ TENANT ❑ ELECTRICAL ' ❑ PLUMBING ❑ MECHANICAL B Rear 1 Contractor's Nam ; /� Phone OTHER A Address (mailing) - �/ PROJECT DESCRIPTION SQ.'FT.-?��• OCCUPAN � C K Right. CONSTRUCTION TYPE VALUATION:$ S Left City License No. ZONE GRADING CU. YDS, ACRES Ping, Ref. # ' LICENSED CONTRACTOR DECLARATION g• I hereby affirm that I am licensed under provisions of Charter 9 (commencing Remarks: ^ *7 -.. r7 /__.f f . ' ' Plannin Not with section 7000) of Division 3 of the Business and Professions Code, and my license is in f I f c and effect. 4 License I s 'c se No. • I Date Signature WORKERS' COMPENSATION DECLARATION 1 hereby affirm that I have a certificate of consent to self -insure or a certificate of Workers' Compensation Insurance, or a certi ped copy thereof (Se tion 3800, La hhh..K...GGGI�iG � � Policy NdY-,Company Certifi cop is hereby furnished, Cert ' p • • ed with the city Buil Dlvisio , } ate i Applicant l EXE'mpkioN OROM WORKERS' COMPENSATION D CLARATION i �\ (This section need not be completed if the permit Is for one hundred ($100) or less). I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation LawS,of California. Date' Signature NOTICE: If,after-making this declaration, you should become subject to the workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION t_ENDiNG AGENCY .1 hereby affirm that there'is a construction lending agency for the performance of the work for which tills permit is issued ,(Section 3097 Civ, C.) Lender's Name -Lender's Address - OWNER BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the fallowing reason (Section 7031.5 Business and Professional Code: Any city or county which requires ,a.permit to construct, alter, improve, demolish or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he/she is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of • Division 3 of the Business and Professions Code) or that he/she' is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500). . , ❑ I, as owner of the' property or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Section 7044, Business and Professional Code: The Contractor's License taw does not apply to an owner of a property who build$ or improves thereon, and who does such.work himself/herself or through his or her own employees, provideo that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of com- pletion, the -owner will have the burden of proving he/she did not build or im- rove for the purpose of sale), ' ito, as owner of the property, am exclusively contracting with licensed con- tracrsto construct the Project Se tion 7044, Business and professions Code: The Contractor's License Law does not apply to an owner of property who buildsor improves thereon, and who contracts for such projects with a con- tract or($) license pursuant to.the Contractor's License Law). I am aware that proof of their Worker's Compensation insurance Sri ould be provided to me: ❑• I am exempt under Sectiori B!& P. C. for this reason•. Date Owner I herebycertify that -1 have read this application and state that the above information is correct. I agree to comply with all;city and county ordinances' and state laws relating' to building construction, and hereby authorize reore-. sentatives of t Is city tQ enter up0 the above-mentioned property f4i inspection qui es. Bar Sink' Backflow Preventer Backflow Irrigation Bathtubs Clarifiers Dishwasher Drinking Fountains Floor Drains Floor Sinks Gas Service r Outlets Interceptors Kitchen Sink Lavatories P—Trap Roof Drains Reinspection Fee PLUMBING Showers Service Sink Sewer -Cap Sewer Connection Solar Collectors Solar Piping - Solar Tank Swimming Pool vv/Spa Urinal Water Closet Water Heater Water Service Auto -Wash Laundry Trays $15 Issue Fee I• MECHANICAL BoilerHood or Type I ED - Under Ground Canopy Type I! 'E1 \ Duct - Structural Refrigeration System Duct - Ventilating 1-10-100,000 BTU ❑ 100,000 BTU Exhaust System- El Multiple ❑ System Repair/Alteration Firepl/Fact. Bit, ICBO # Fire Dampers Heating System & Ducting- Registers ❑ 0-100,000 BTU ❑ 100,000 BT I Signature --� -- - - rlala r Reinspection Fee $15 Issue Fee Drivers' License or SSS# _ CMF 0865-46, rev. 10184 White - Building; -___ A- PpHcant; Pink - Accounting; Goldenrod - Assessor 09ll .)/26/87 Accessory Building 123.55 TL .Zone •: . _ ` Z ,O N ~ G R Parking Req./Provided r E M T 5 ELECTRICAL Automatic Washer Transformer ❑ 15-50 KW - Construction Pole Sub. ❑ 50 + KW Cooking Unit Meter. Oup to 100 amps Dishwasher Dryers []Gas ❑Electric Meter Clover' 100amps Sub. Panel Fan Motors E10-11. HP Ell -8 F.A.U. Inc. So lar E] 9.15 HP El 16-15+ Fixtures Microwave Device Boxes Pole Light Outlets Range Switches - Sign Garbage Disposal Standing Sections Generator 00-5 KW C-15-15 KW Trash Compactor ;�F 3 ' Reinspection Fee $15 Is'sue•Fee EES DEVELOPMENT SERVICES REQUIREMENTS: Zoning Approved By Building Approved By V - Application Issued By FEES w. , -A SUMM RY OF FEES BUILDING PERMIT~ ,$ $MIP PLAN CHECK $ PERMIT _ PLUMBING $ ISSUANCE $ _ PLAN CHECK2506 $ ENERGy P.C. n ' $ • } ELECTRICAL $ GRADING $ PLAN CHECK 50% $ MICROFI LM- $ MECHANICAL $ TOTAL FEE $ 3 PLAN CHECK 25% $ CONSTRUCTION AND'PLANNING APPROVALS ' Permit # Date Inspector POOL & SPA APPROVALS Permit # Date Inspector 1: Temporary Electrical Service or Pole 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. 54. Forms 4• Electrical Conduit-Undrgrnd. 55. Electrical Bonding 5. Steel Reinforcement 4 56. Rough Plumbing & Pressure Test 6• Electrical UFER Grnd_ 57. APPROVAL TO COVER-GUNITE 7. Footings ( i 58, Electrical Conduit-Undrgrnd. 8. Foundation „ ' 59. Gas Pipe, ❑ Undrgrnd., Test 9. Water Pipe-Undrgrnd. 60. Backwash Lines, P -Trap, ❑ Undrgrnd. 10. Structural Floor System 61. APPROVAL TO DECK 11. Property Sewer Line & House Connection 62. Backwash & Receptor -Final 12, Sewer Cap 63, Heater & Vent -Final 13. Roof Drains 64. Plumbing System - Final 14, Rough Plumbing 65. Electrical -Final 15.Rough Electrical -Conduit 66. Solar System -Final 16_ Rough Electric Wiring 67. Fencing & Access Approval 17. Rough Wiring Sign 68. APPROVED FOR PLASTERING 18. Rough Electrical -T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19, Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT • APPROVALS Permit # L 20. Rough Factory Fireplace 21. Ducts, in Structure 70. Underground Hydro ' 22. Ducts, Ventilating 71. Product Piping ❑ Gas ❑ Oil 23. Gas Pipe -Rough & Test 72. Underground Flush 24. Roof Framing 73. Undergrnd. Storage Tank ❑ Gas ❑ Oil - 25. Roof Sheathing 74. Overhead Hydro - 26. T -Bar Ceiling (Structural) &,Monocoat 75. Dry Chemical 27. Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding 77. FIXED SYSTEM FINAL 29- Insulation 78. FIRE PREY. FINAL „ 30. Drywall Nailing HEALTH DEPT. REQUIREMENT . 31. Plaster Brown Coat 79. FINAL INSPECTION 32. Electrical Power Meter -Final 80• FOOD CERTIFICATE ISSUED ' 33. Final Electric Notes: 34. Final Heating &'`Air Conditioning = 35. Final Gas Pipe -Test 36, Hood or Canopy 37, Final Factory Fireplace 38. Final Plumbing 39. Water Service -Final , 40. Gas Service -Final [,41. Solar Domestic -Final X42. Backflow Preventer .rlh f v �;i43. Backflow Irrigation r r' J r 44: Landscape Irrigation System %�45. Sound Attenuation 46. Handicap Regulations ; 47• FINAL STRUCTURE & BUILDING 48. Special Requirements Completed 49. Electric Release to Edison 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY No Date i �.b....:�..---- --�.�..� �_ ._�..,.... ,.tr�.__a _�: bow...• .. .. _kv�-,. �._. -. '.... ----"..�.�.� _. �._ .. - _ ,�._ - - _, ..._.. I1 r7n - R ti,. _ X33 1/7� L 1't`F`tZ r1 an - �s excep those within te3_vky b rde lines and sign all appropriate declarations. i ITY Of COSTA MESA. CONSTRUCTION. PERMIT Project Address 'Sd �i'f i L' GA S i . • ��+11 LJI� ia+! fret "� Applicant's Mailii g'Address ,. L _M sv�Tl� d . Owner's Name il"G�IkliTW-0-f ¢ �7Gb ` # Phone r i+'s,�S/� Address 3 3 3 3 �} Ge.S 7 3" O. TRACT NO, LOT No. NST NO. TYPE011CONSTRUCTiON NEW ADD ALTERATIDW REPAIR u ONVERSIDN El DEMOLISH ❑OTHER DESC IPTI N OF WORKIUSE OF BL G. 'ST%6 �Y n �� �E 2ll%5 9/03/BG f ti, TL A.P. # F_ Zone i J S Main -Building: i Accessor Buildin 9 Y 4 l _ i ArchlEng.=�"'N�a'E��LicenseNo. PE OF PERMIT` GRADING ❑FOUNDATION STRUCTURAL Address TENANT ❑ ELECTRICAL' ❑ PLUMBING ❑ MECHANICALMKJ _Contractor's Name O .Sr "�^ ones OTHER / 2 F_ 7p Rnv1Cs +✓G� .'- a+alfa-+�� 'Addresslinailing)1 1'� E-+Qa ,�1 PROJECT: DESCRIPTION SQ. FT. Z41 F G OCCUPANCY CONSTRI CTION TYPE VALUATIONS 1190 �Qd •City License No, ZONE' GRADING CU.YDS. ACRES - LICENSED CONTRACTOR DECLARATION f hereby affirm that i amlicensed under provisions of Charter 9 (commencing, Remarks: with'section 7000)'of Division 3 of the Business and Professions Code, and T Front �h B ;Rear A' N, I'Ii C R ight N $ Left R ping Ref # , Parking Req',/Provided E Planning Notes: - ) Q M _ T S� my license is in full force and effect. ' ,)V— G - I_ License Class- lassZ Datr ' DateZ"'bf+ Signatur PLUMBING FEES 1 j ' WORKERS' COMPENSATION D TION se - s I hereby affirm that I have a certificate of consent to ure or a certificate of Workers' Compensation' Insurance, or 'a. certified Copy 'thereof (Section - 3800,r 380x, Lab. C.)/ ae Polic No. ! 3 companyS ,fid Certified copy is hereby furnished- i Bar Sink! ^ Backflow Preventer Backflow Irrigation I Showers _ i* -Service Sink Sewer Ca P ELECTRICAL i FEES _- Automatic Washer` - Trensformer''❑ 15-50 KW ' �. Construction Pole Sub, r ❑ 50 ,KW ' Cooking Unit Meter El up to 100 amps { Certiiietl'copy �is ffiled with the city. Build' Divisl Date Z 34p, Applicant ` EXEMPTION FROM WORKERS' CO SATIO E ARATION (This sectionlneed not be completed if.the permit -is for ne hundred ($100) or less), i i i iDishwasher- I certify that in the performance of the work for which this permit is issued, I shall not Compensation Laws of,California. employ,any person in any manner so as to become subject to the Workers' Bathtubs Clarifiers Drinking Fountains ' Sewer Connection Solar Collectors - Solar Piping j Solar Tank Dishwasher Over 100 ps Meter ❑ am -T - Dryers ❑Gas ❑ElectricY ' Sub Panel I Fan i r Motors E10-1;HP ❑1'/: = S - _ - ' Date Signature NOTICE: If, after- making this declaration, you should becomeFAU subject to the Workers!, Compensation provisions of the, Labor Code, -.you must -forthwith comply, with such provisions or this permit shall be deemed revoked. CONSTRUCTION 'LENDING AGENCY c I hereby affirm that•there'is a construction ]ending agency for the performance ' Floor Drains - , - Floor -Sinks _ Gas Service Swimming Pool w/Spa •^ Urinal • - - •-- - Outlets - Water Closet s ,,. ' Inc. Solar T E14-115HP�5 016-15+ r , r "'•- -- "" ' - Microwave - 4 -le"- Fixtures, _ r _ "'- - - ece DviBoxes Pole ole Light of the work ,for,.whiCh this permit is _issued- (Section 3097 'Civ., C.) Lenders .Name' Interco' pt01'S k - _Water Heater - r^ r� - Outlets , Range Lender's Address _ iKitchen Sink : = Water Service + ; I Switches n Si g OWI,4ER BUILDER' DECLARATION L = _ I hereby,affirm that I am exempt-from'the Contractor's License Law fGarbage or the Lavatories ! -Auto-Wash - t' following reason (Section 7,031.5 Business and Professional Code: Any'city orP county)which requires a permit to construct, alter, improve, Aemolish.or repair P—Trap - Laundr Tra s - any -structure, prior to its issuance, also requires the applicant for such permit yr y + to file a signed statement that- he/she is licensed pursuant to the provisions,of r ' mencing with Section 7000) of Roof D Ihe Contractor's License -Law (Chapter 9.(comrains Division 3' of the Business and Professions -Code) or that he/she is exempt. Disposal , Standing Sections ' Generator ❑05 KW ❑5-15 KW Trash Compactor t i t 'therefrom, and; the basis for theialleged exemption, 'Any violation of Section 7031.5 by 'any applicant afora - permit +subjects the applicant to. a civil enaity of: not more than five hundred dollars ($500). 1, as owner of the property or my' employees with, wages as ,their. sole' Reinspection Fee W " $15 Issue Fee I •� i $:3 1' ' Reinspection Fee $15 Issue Fee $ 3 'compensation, will do the work, and the structure is not intended or offered for sale (Section 7044, Business and 'Professional rCode: The Contractor's License Law does not apply to an owner of a property who builds or Improves thereon, and who does such.work himself/herself or through his or her own employees, provided that such improvements are not Intended or offered for. sale. If, however, the building or improvement is sold within one year of com- pletion', the owner will have the burden of proving.he/she,did not build or im-. g_rove for the purpose of sale), L I I, as owner of the property,'am exclusively contracting with licensed con- tractors to construct the project[Section 7044, Business and Professions Code: The'Contractor•s, License Law does not apply to an owner of property who' builds or Improves' thereon• and'who contracts for -such projects with a con- tractor(sf license!pursuant to the Contractor's License Law). I am aware that proof Off their Worker's Compensation insurance should be provided to me! ❑,Lam exempt under +SectIon&;P.; B. C,•for this reason MECHANICAL -IF ES _. - Boiler Hood or Type I ❑ - Canopy Type Il ❑• �� Duct- Underbround _ _ 7c i Duct -Structural Refrigeration System T Duct Ventilatin ©0-100,000 BTU EJ 160,000 BTU g Exhaust System ❑ Multiple ❑ System Repair/Alier8tion Firepl/Fact. Bit. ICBG # Fire Dampers DEVELOPMENT SERVICES REQUIREMENTS: Zoning Approved By - ,+, ..._._.. ' _ nate ' ' Budding Approved By Data Application Issued By ' pat ; 1 BUILDING PERMIT PLAN CHECK PLUMBING i PLAN CHECK 2596 ELECTRICAL PLAN CHECK ' 50% MECHANICAL PLAN 25% f UM ARY OF FEES $'r •�$�� SMIP $ $ 1 I PERMIT. $ l ISSUANCE $ $ ; ENERGY P.C. $ $ GRADING $ + 'MICROFILM $ $ .�! $ F 'TOTAL FEE $ I $ j [_ Date Owner i Heating System & Ducting; Registers I' hereby, certify that'l have read 'this application and state -that the above- ❑¢100;000 BTU ❑100,000 BT s Informatlon.is correct. I agree to comply with all city and county ordinances, } and state laws relating to building construction, and hereby authorize repre- sentatives of this city to center uppn t above-mentioned' propertyi for i inspection urpv s Q �j •-_ p Z� Slgnatpate 7 �"]'^' _ �, w Reins ction Fee i $15' Issue Fee Drlvars: Llcense or SS �1_ - �- --� Pe i '$ 3' CMF 0865.46, rev. 10/84 White -Building; Ca nary�Applicant'rmn--•,.,,..__.�a°oldenrotl -Assessor - l I CONSTRUCTION AND PLANNING APPROVALS Permit # Date Inspector POOL & SPA APPROVALS Permit # Date Inspector 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd, v 53. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. 54. Forms 4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6• Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE� 7. -Footings 58. Electrical Conduit-Undrgrnd, u 8., Foundation 59. Gas Pipe, ❑ Undrgrnd., Test 9.. Water Pipe-Undrgrnd. 60. Backwash Lines, P -Trap, 0 Undrgrnd. i 10. StructuraI'Floor System 61. APPROVAL TO DECK 11. Property Sewer:_Line & House Connection 62. Backwash &Receptor -Final a 12. -Sewer Cap 63. Heater & Vent -Final 13.. Roof Drains 64. Plumbing System - Final 14, Rough Plumbing- 65. Electrical -Final 15. Rough Electrical -Conduit 66. Solar System -Final - 16. Rough Electric Wiring 67. -Fencing & Access Approval 17. Rough Wiring Sign 68.' APPROVED FOR PLASTERING 18. Rough Electrical -T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL - 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit # _ 20. Rough Factory Fireplace 21. Ducts, -in Structure 70. Underground Hydro 22. Ducts, Ventilating 71. Product Piping 0 Gas 0 Oil 23. Gas Pipe -Rough & Test 72. Underground Flush' " 24. Roof Framing 73. Undergrnd. Storage Tank 0 Gas ❑ Oil 25. Roof Sheathing 74. Overhead Hydro 26. T -Bar Ceiling (Structural) & Monocoat 75. Dry Chemical 27. Frame and Flashing 76. Dry Standpipe 28. Lathing 8i Siding 77. FIXED SYSTEM FINAL 29. Insulation 78. FIRE PREV. FINAL 30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31, Plaster Brown Coat 79. FINAL INSPECTION 32. Electrical Power Meter -Final 80: FOOD CERTIFICATE ISSUED 33. Final Electric Notes:,��f 34. Final Heating & Air Conditioning w 35. Final Gas Pipe -Test 36. Hood or. -Canopy 37. Final Factory Fireplace , 38. Final Plumbing 39. Water Service -Final 40. Gas Service -Final 41. Solar Domestic -Final 42. Backflow Preventer 43. Backflow Irrigation 44. .&ndscape Irrigation System y. - 45. Sound Attenuation 46. Handicap Regulations 47. FINAL STRUCTURE & BUILDING` 0 ' 48. Special Requirements Completed 49. Electric Release to Edison _ r 50. Gas Release to Southern California Gas Co 51, CERTIFICATE OF OCCUPANCY Nom Date - . t - - -.- - Applicant to fill in all spaces except those within heavy border lines and.sign all appropriate declarations. CITY -OF COSTA MESA 'CO TRUCT O P IT p PERMIT NO. i pTRACT NO. ' LOT NO. UNIT N po� �a � 1 861 2/05/87 �1{� rte 3 7L ! Project Address . �� p �1-7 r '� I t I App) icant'i: Meiling Address i `' I 0lti � S Fl. 5A TYPE o� coN STRUCTION NEW' kADU ALTERATION REPAIR ' ❑ CONVERSION l?EMOLISH ❑OTHER ' - '� r-� .'t/ �_ owner's Name Phone , � ti•- -- +-- - - A.P. # - - }-Q � Q-� _ _ ..- _ . ,. , Zone C 1 „� y9 W 0, DESCRIPTION OF WORK/USE OF BLDG., yv i Address �_1 7� w•rlen a .sin , , 1 S Main Building: ! Accessory Building: b:.� Arch/Eng.' 6N �'E F icense No's �% OZ D ,/� TYPE OF -PERMIT ! GRADING FOUNDATION RUCTURAL T Front' f i r O _ dN IS Address 3 U+'• C /Q�� �" f 0 �t �/V� J• 0 TENANT ❑ ELECTRICAL ' ❑ PLUMBING ❑ MECHANICAL I B N ..%a� Contracto'r's Name .�,�!Jeff-ib'fr7/}-3F�faG' PFionel[; �s� r T— - ❑ OTHER_-- '`- I C Rear N Right g f� ( F Tf © y __ Address {mailing) " f PROJECT. DESCRIPTION SQ. FT, j OCCUPANCY -- •-K rN t� t�Ti ; G Y D/ Q 7- Cit License No. _ F? 0�7 n :CQNSTRUCTION'TYP VALUATION $ U+ 1 S Left R LICENSED CONTRACTOR DECLARATION �� ZONE RARING CU.ACRES '� - - ,:.Remarks�.�. Ping. Ref. # i ; Parkirig,Req./Provided EE I hereby affirm that 1 am licensed under. provisions of Charter 9 (commencing -� Planning Notes: Ra�• �+eE f B M with section 7000)'of Division 3 of the Business. and 'Professions Code, and -. j2 - - ! _ U my license is' full force nd effect. f �� F License ass 't� fUk►tXr [_j,J _ License ti�1 I}'O' �' .1 _ _ I• - k `�- r•• .y�5 S - Date ��'t �/T' _ Signature t:' i PLUMBING F WORKERS' COMPENSATION DECLARATION I hereby affirm•that,I have a certificate of consent to self -Insure or a certificate Bar Sink ; " ! i Showers. ` i i : _ ; ELECTRICALI r �' of Workers' Compensation Insurance, or a certified copylthereof (Section • 3800, Lab. C.) ! r ; t , Backflow Preventer Service Sink AutOmatic,Washer Transfor r -50 KW P y No. Qp� Companyi('�ia� I��J�aJ/f±.0 Certified copy is'hereby furnished, r, 'Backflow Irrigation �' i , Sewer'Ca _ P Construction- Pole Sub..,, 50+KW. , _ i J Cerii ietl p is filetl with the city• uildAing Division. • M19j3 a Bathtubs Sewer Connection - Cooking Unit ; Meter �up to 100 amps Date Applicant_- -1tiill '.'. C� = EXEMPTION FROM WORKERS' COMPENSATION DECLARATION 4+" r Clarifiers ;Solar ColleC s i �^ yf ' LL _ - Dis_iiwasher _ ; _ • -- Meter ❑ovec 100 ps , (This section need not be completed if the permit Is for one hundred -($100) or less).F �,, - - - Dishvvashe," ' - Pi L '. - ' - - _ I certify that in the, performance of the work for which'this permit is Issued, I, Solar g ' ' Dryers ❑Gas ❑Electric .a i . Sub Pane! , - - - shall not employ any person do any manner so as to become subject to the Workers' Compensation Laws of California. •� d'. r Drinking Fountains 3 j So Tarik ( - Fan _ Motors 1 HP ❑1 lz.- B Date Signature - Floor -Drains' ; wirrmir:g Poo! wlSpa ° r F q.U. l ` ` In Dior Og-15 HP ❑16-1,5+ i _ NOTICE: If, after making this'declaraticn, you..shoWd become_subject"to the. _ - _ x Workers' Compensation provisions; of the Labor Code, you must forthwith comply with such' prgvisions or this permit shall •be deemed revoked. _ Floor Sinks ' •Urinal , .F Fixtures ; 1 IGYOWaVe, l ; CONSTRUCTION LENDING, AGENCY r ! I hereby affirm that there is a construction lending agency for the performance _ Gas Service Outlets � y Water Closet --� r r t Device Boxes ; Pole Light • ( , • of the work 'for which this permit Is issued (Section 3097 Clv. C.) Lender's Name r t"? _.,,� W � Interceptors ;,Water Heater - Outlets Range .Lender's Address ' • �� - OWNER BUILDER DECLARATION Kitchen Sink .;_Water Service - - r - Switches - - - t- - Sign ' I hereby affirm that.l•am"exempt from the Contractor's License Law for the following Lavatoriesr•,Auto-Wash ' ' Garbage Disposal Standing Sections { ,reason (Section ,7031.5 Buslness and Professional Code: Any city or county which requires a permit to construct, alter, improve, demolish or repair any structure, prior. to its issuance, also.requires the applicant for such permit P -Trap undr 'Tia s y y Generator 5 KW❑5-15 KW Trash_ Compactor _ to file a signed statement that he/she Is licensed pursuant to the provisions of the Contractor's Ro rains ��- . >° •. - License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) -or that he/she is exempt '- - - - - - - -- - - -- - - - - - - - - - therefrom. and the basis,for the alleged exemption. Any violation of Section 7031.5 --by any applicant for a permit subjects the applicant to a civil rpenalty'of I i not more than five hundred dollars ($500), r t , ❑ I, as owner of the property or my employees with wages as their sole Reinspection Fee. $15 .. Issue Fee. $,3 t compensation, will do the work, and the structure is not intended or offered Reinspection Fee $15' Issue Fee $ 3 r for said (Section 7044, Business and Professional Code: The Contractor's -' MECHANICAL 'FEE i • License, law doesrnot apply to an owner of a property who build$ or improves i thereon, and who does such work himself/herself or through his or her own employees, provided that such improvements are not Intended or offered for safe. If,'however,-the building or improvement is sold within one year of com- have the burden iin- Boiler I -.- - Hood or Type I ❑ Canopy Type (I ❑ DEVELOPMENT SERVICES REQUIREMENTS: 1 Zoning Approved By S `'""` `pate tv, , `� .pletion,-the Owner will of proving he/she did not build or for Duct - Under Grourid - Building Approved El Date '7 '2 �Eve -the purpose of sale), the with 'Application .I, as.owner of property, am exclusively contracting licensed con- Duct -Structural Refrigeration S m. Issued tractorst6construct the project (Section 7044, Business and Professions Code: The, Con tract or's r Li cerise Law does4not apply to an owner, of• property who Duct - Ventilating ❑0.10 BTU ❑100,000 BTU SUMMARY SUMMARY OF'FEE builds or improves -thereon, and who. contracts for such projects with a con- tractorw license pursuant to the Contractor's License Law). I -am aware that-, Exhaust 5ystemi ❑ _Multiple ❑ ystem Re air /Alteration _ BUILDING PERMIT' "$ � vv0 DQ SMIP tt proof o their Worker's Compensation insurance should be provided to me^: 0:'I. exempt °B.'& P •- - PLAN CHECK $ 3 - 33�I`� PERMIT„ ,am under Section P. C. -for this reason Firep1lFact. Blt: ICBG # Fire Dampers _ ISSUANCE $ - = Date �- Owner' 1 hereby, certify -that' I read Heatin S stem & D n 9 Y 9' E , ❑0-100,000 ` Registers 9 PLUMBING $. PLAN CHECK - 2546- $� . ENERGY P.C. $ - - have .this application antl state that the above information is -I 8 -100,000 B -- I - GRADING $ correct.' agr.-ee,to-comply with all city and county ordinances; and state laws relating: to building.construction; and -hereby authorize rapid-� sentatives : f.{this c"ty to enter up n the above- entioned ;property •for inspection p poses. - - ELECTRICAL - $_ PLANICHECK 5096 MECHANICAL $ MICROFILM $ + _- , ' _ Signature Date 1 1 - ` TOTAL FEE $ Delvers''License or 55 �_r f-�J„ `, Bin§pection Fee :$150 •. Issue Fee ., $' 3 PLAN CHECK 25°6 $ - CMF 0865-4,6, rev, 10/84 White - Building; Canary - Applicant; Pink - Accounting; Goldenrod - Assessor 4 - " M CONSTRUCTION AND PLANNING "APPROVALS Permit Date inspector POOL & SPA APPROVALS Permit Date Inspector 1, Temporary Electrical Service or Pole 52. Pool Equipment Location rY 2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement;: 3. Electrical Conduit Utility-Undigrnd. 54. Forms 4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding 5. Steel Reinforcement 56. Rough Plumbing.& Piessore Test 6. Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE 7. Footings 58. Electrical Conduit-Undrgrnd. 8. Foundation 59. Gas Pipe, D'Undrgrn"d., Test 9. Water Pipe-Undrgrnd. 60. Backwash Lines, P -Trap, [I Undrgrnd. 10. Structural Floor System 61. APPROVAL TO DECK 11. Property Sewer Line & House Connection 62. Backwash & Receptor -Final 12. Sewer Cap 63. Heater & Vent -Final 13. Roof Drains 64. Plumbing System - Final 14. Rough Plumbing 65. Electrical -Final 15. Rough Electrical-Conduit66. Sola� System -Final 16. Rough Electric Wiring 67. Fincing & Access Approval 17. Rough Wiring Sign 68." APPROVED FOR PLASTERING' 18. Rough E16drical-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit 20. Rough Factory Fireplace 21. Ducts, in Structure 70. Underground Hydro 22. Ducts, Ventilating 71. Product Piping 0 Gas E]Oil 23. Gas Pipe -Rough & Test 72. Underground Flush 24, Roof Framing 73. Undergrnd. Storage Tank DGas 00it 25. Roof Sheathing 74. Overhead Hydro �If6. T -Bar Ceiling (Structural) & Monocoat -75. Ory Chemical 27. Frame and Flashing 76. Dry,Standpipe 28. Lathing & Siding 77. FIXED SYSTEM FINAL 29. Insulation 78. FIRE PREY. FINAL 30.' Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat 79.- FINAL INSPECTION 32. Electrical Power Meter -Final 80. FOOD CERTIFICATE ISSUED' 33. Final Electric Notes: Sri rz r 414<z. 4or,5. 34. Final. Heating & Air Conditioning, Aq� 35. Final Gas Pipe -Test 36. Hood or Canopy 37. Final Factory Fireplace le -7 "A AAff-jr~ 38. Final Plumbing 39. Water Service -Final 40, Gas Service -Final ,41. Solar Domestic -Final `42'. Backflow Preventer 143. Backflow Irrigation 44. Landscape Irrigation System ,146. Sound Attenuation r. -46. Handicap Regulations 47. FINAL STRUCTURE & BUILDING 48. Special Requirements Completed 49. Electric Release to Edison 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY No Date (714) 754-5273 • Fax (714) 754-4856 • www.cl.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 FIRE SUPRESSION PERMIT N Job Address: 3333 BRISTOL ST Suite: 1805 Vicinity: SPACE 1805 (YUJEAN KANG ASIAN BISTRO) Status: ISSUED Applied: 06/28/2002 Issued: 07/01/2002 Parcel Number: 41250107 Zoning:_PDC PDC ISSUED DY: Applicant: SHARONI, ]TAY-.." Address: Phone: 818-982-0126 Zip: Owner// SOUTH COAST FtAZA i Address- %; COSTA MESA CA'' Phone: '3315 FAIRVIEW-ROAD Zip: 92626 contractors REGENCY FIRE PROTECTION INC Address: 6923. FARM DALE AV a ' • ' Phone: 818-982-0126 NORTH HOLLYWOOD, CA Zip: - 91605-621.1 Licerise: '52311fi SCOPE OF PERMIT ; RELOCATION OF 48 EXISTING SPRINKLER PENDENT HEADS TO CONFORM WITH THE NEW WALLS AND CEILING LAYOUT; INSTALL UPRIGHT HEAD UNDER EXPOSED ROBINSON DECK FOR "YUJEAN KANG ASIAN BISTRO" IN SPACE 1805. \ REF: B02700261 t . _ to - r- >r/ - _ .. __ .. �� -• _ _ _, ' j FEE SUMMARY f, Plan Check: $72.31 Calc Valuation: $4,160.00 , Permit: $111.25 _ _ _ 'Claimed Valuation:' .$4;166:00' Other: $0.00 Total: $183.56 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or it work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 2448-46 {6/001 C DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: _ ❑ 1 have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is Issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the perfomTanoa of the work for which this permh Is Ismued. workers' compensatlon Iru�rance carrier and policy number are: - Carrie�r � tti t1 - Policy Number. �` fl -IVs Carrier � (This section need not be completed it the permit is valued at one hundred dollars {$100) or less.) £J I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws ois alifornia, end agree that if I should become subject to the workers' compensation provislons of Section 3700 of the Labor Code, I shall forbhwtth camphy with these pions. Applicant Signature: Dale: _k�WARNING: FAILURE TO SE ORKERT COMPENSATION OOYERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND OIVIL FINES UP TO CNE HUNDRED TH SAND DOLLARE (5100.90(}), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commendng with Section 7000) of Division 3 of the Business and Professions Code, and my license is In full force and effect. Lic. a b.- Class C 6 Contrector's Signature: Date: r% CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lenders Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of DHlsfon 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a pard} subjects the applicant to a civil penalty of not more than No hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for safe. If, however, the building or Improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, em EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Lew does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 em exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, felsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chep. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number. HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to rile and certify a Business Plan for emergency response to release or threatened release of a hazerdorLs material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fre Department by each business which of any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gafiorts, or 200 cubic feet of compressed gas at standard temperature and pressure). ............. ...... I'll ..................... ...... .......... ..............._............_ . ......_...................._.._.—....................... 3 Does or will theaappplicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes 13No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been tufty complied with? ❑ Yes ❑ No ................................ _...._............_ -----..._- ---- 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a�p f(cation a�enail for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agenc�rl ❑ Yas [„1 No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ......... ..................... ._....... ...................... •--..._............................ 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the cuter boundaries of a school? ❑ Yes (J No (If yes', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district of agency is required for the work which is the subfect of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8_(W—yes`, attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. 1 agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signalur Legal Owner(s) Date AndlOr Authorized Applicant Dale CODE INSPECMN TYPE RIM KIIIIIALS CODE I INSPECTION TYPE RIM 1Tl ITIA 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1268 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final BlocklRetaining Well 212 Final Fire Prevention 202 Final Factory Fire Piece 220 Final Planning Approval 203 Pinel Sign 222 Final Site 204 Final Demolition 250 Final BuildinglOocupancy F City of C0,9ta 21)e.5a Development Services; Division of Building and Safety- CERTIFICATE afety- CERTIFICATE OP OCCUPANCY This certificate issued pursuant to��tl�e requirements of. -the Uniform Building Code, Section 308 adopted by the City of'Costa Mesa certifies�thavat4 e tiffiiL, f its,Qissuance the building structure herein below described was inspected and appro`vedim56c—c — ey as follows:- Building Address 3333 BR.&MnL23TRS$T UNITi2213 v Bldg. Permit No. B 76158 Use .REAL/'� �,' Group B Type of C�n�struction I- Frre,Zone Use Zone Cls W TM Owner of Building C.3: Sekerstro>a•`& Sons Tenant "L 77 `AddreS5 r 3333, BRISTOL TREE f UNIT: 21 0T' A i4a '�•" s . 7 sUrlDnvG OFFICIAL -It on*? 3beacaKI �1 Date , �fa�r 7 1997 REQUIRED TO BE POSTED-INAA CONSPICOUS PLACE =i ,_ Cof Costa 210esa Development Services, Division of Building and Safety CERTIFICATE OF OCCUPANCY This certificate is issued pursuant tothe.>requireme tifint`s of,the Uniform Building Code, Section 308 �a ass adopted by the City of Costa Mesa ceresthatat�the time offs issuance the building structure herein below described was inspected and�app ve'&o---vccupancyas,f %- V. 3333 MI9 STREET #1078 B70792 Building Address _ Bldg. Permit No. Use INTERIOR TEN=/IMPROVEMMr ,r 1 B-2 T T r I—FR Use Zone C1—S Group ypeof. Construction Fire+Zone B HARBOR ERE � fel rc�l Owner of Building C. J 4 SF3GERST ++1 Tenant �� -FFIELDS SKIES Address 3315. FAIRVIEW R 4 ,, C05TA Aw=CAS=92626 V", , BUILDING OFFICIAL-toiYp Te>— ° ',��' DateMARCii 3 1995 . REQUIRED TO, BE POSTED IN A.CONSPICOUS PLACEe000 pp AlSr•.R�'r.- r�r .w ��!'3 �!-...-:?-?1-Y s3�a. �:�d.LB::�kr fir[. ?.rr{�'k �.�1 .'a} -w iut ::i}i�=r:xlfi{'21�,1Ait. r-...��i:.h,. 1,.I S.�-. -.�5 �...� �.:�,.o. ..i...:.- ,.. )t':. City of Costa Mesa Development Services Department Building Safety Division CERTIFICATE OF OCCUPANCY No. 0 01 J 3 5 P. O. Box 1200 Costa Mesa, California The Building located at 3333 Bristol Street - Sparo:0078 has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group A2.1Occupancy. Use of Building ilestaurant Legai Description 412--501-02 " iSee reverse side for Metes and Bounds) 827017 Building Permit NoB27217i B25.174Electrical Permit No.E277491 E301(0%mbing Permit No. Mechanical Permit No. M27752, M28102 Number of apartments and/or guest rooms ISSUED TO: Building Official William Howard Birri� Poretti rs jj J3.1313istol Street, #2078 by Costs Mesa, CA 92626 Date A This. Certlfic tesof:Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the BulldingC�Off clai sof theiCity;of Costa Mesa under Sec. 307 (e) U.B.C. CMF ,NU' 6 Yev lh/8,3 m Wli,ite -Owner; Cariary,- Numerical' File; Pink - Bldg. Permit File t CITY OF COSTA MESA r� BUILDING SAFETY DIVISION GAS OR ELE1CTRICAL UTILITY RELEASE FORM TRACT LOT ADDRESS 1 i GAS E LEC. NO, UNITS NO. METER OUTLETS O. RE METERS RELEASED i THESE INSPECTIONS ARE A RESULT OF: (CHECK ONE) C� ❑NEW CONSTRUCTION D REWIRING � 'OTHER IEXPLAIN} "4� �U %! �Q Date Releated /% ff� ""' Signed CMF 0771-46 [/ �/ _ 'Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations. CITY OF COSTA MESA - - P RMIT.NO. - TRACT NO. LOT NO. BLD Transformer ❑ 15-50 iCW ❑ 501+ KW t 'CONSTRUCTION PERMIT �'- --. j.. V _ . L: _ - ,. ,. • - - t _ Project Addfess A3A.3 Bri-stol -- .S e • 78 -ADD TYPE OF CONSTRUCTION NEW ALTERATION REPAIR. Appfica'nt's Mailing Address OLl OaS Plaza ❑ CONVERSION ❑ DEMOLISH OTHER A P 4E Birra Orettls Owner's Name. p Phone DESCRIPTION -OF WORK NOTICE: If, after making this declaration, you should become subject to the Workers'. 'Compensation provisions' of ;the Labor Code, you must -forthwith , comply with such provisions or, -this, permit; shall ,be deemed revoked. CONSTRUCTION, LENDING- AGENCY. ` Ma in Building: ' Address 1333 BriSt01 Ste. 2078 - TYPE.OF PERMIT GRADING - FOUNDATION ❑ STRUCTURAL E T Front s - ""- "- - • - '— ,- Arch/Eng. License No. ❑ TENANT':0 ELECTRICAL ❑ PLUMBING ❑. MECHANICAL B ' _ Address ❑ OTHER ". A Rear ector's Name Master'; Protection -Phone 990-347 Conv F PROJECT DESCRIPTION SQ. T. OCCUPANCY C Right Address (mailing) i 621 Lunar $red C CONSTRUCTION TYPE VALUATION $ 2290 _ ❑0 g Left City License No. 36367 ! ZONE GRADING CU.YDS. ACRES Ping. Ref. LICENSED CONTRACTOR DECLARATION Remarks: Install Fire protection. S Stem lIn Parking Req./Provided ; 1 hereby affirm that I am licensed under provisions of Charier 9 (commencing Trash Compactor 4 P Reins coon Fee pe with section 7000 of Division 3 of the Business and Professions Code, and Kit' cheri H.00ds. " & Ducts -'"P.C. F.ee 2 5.03 Use of Building: 1 ' g' my Ilcense,is In full f ce8� effect. ' ��I Issue Fee' $' 3 MECHANICAL FEES license as LI se No.- 327907 _ PLUMBING FEES Planning Notes: i Date - - Signature Bar Sink t Showers - ' WORKERS' COMPENSATION DEC ATI agree comply with'all clty'andcountyordinances and' tate laws relating to building construction, and hereby authorize repre- sentatives Of t ' ' city to'Iyer upon the Above-mentioned property for Duct - Under Ground ' s 81-46 5/19/87 39.0ta TE. a Zone. Accessory Building: Z N i - E. Park -,Fees $' Q U i ( E E I E T x I hereby affirm that i have a certlflca a of consent to self -Insure or a certificate 1 I I 1 I �. of Warkers'�-Com a ati n_syrance,;-or a certlfled�-copy thereof -(Section Backflow Preventer Service Sink S 3800, Lab. Z �Cv} Backflow Irrigation Sewer Cap I ; ELECTRICAL FEES Policy No. Company United Pati, i -C i BCertified copy is hereby furnished. i CertIV 70p81filed with the'city din Divl �p I = S Date 7 I O I Applicant �� f Bathtubs Sewer Connection Application Issued By Automatic Washer Constr_uctio_n P_o_le Sub. Transformer ❑ 15-50 iCW ❑ 501+ KW t Clarifiers Sojer Collectors EXEMPTION ThisFROM WORKERS',C SATI DECLARATION section a permit Is for one hundred ($100) or less ; need not be completed if 1 certify thatin the performance of the work for which this permit is issued, I shall not employ any person In any manner so as to become subject to the Workers'• Compensation Laws of California.; I Date Signature I --. DisFivvas her e - Solar Pi Pin 9 Cooking Unit,, Meter ❑up to�100 amps Drinking Fountains Solar Tank _ " Dishwasher Meter ❑over 100 amps t' 1 Floor Drains r Swimming Pool w/5pa Dryers ❑Gas' ❑Electric ' sub Panel - Floor Sinks Urinal I builds or improves thereon, and who contracts for such projects with a can- FanMotors ❑01 HP ❑1%z B - - NOTICE: If, after making this declaration, you should become subject to the Workers'. 'Compensation provisions' of ;the Labor Code, you must -forthwith , comply with such provisions or, -this, permit; shall ,be deemed revoked. CONSTRUCTION, LENDING- AGENCY. ` BUILDING PERMIT Gas Service ;Outlets Water Closet ' " $ , F.A.U. Inc. Solar'09-i5 HP ❑1fr15+ - Interceptors - Water Heater Fixtures Microwave I > 1 hereby affirm that there is a construction lending agency for the performance- of the work for which; this permit pis •issued: (Section '3097 Civ, C.) Lender's Name' - Lender's Address ` OWNER BUILDER DECLARATIONLavatories' I hereby affirm that I am exempt from thel Contractor's License Law for the following reason {Section' 7031.5 Business and Professional Code: Any city or county which requires a permit -to construct, alter, improve, demolish or repair -any structure, prior to Its Issuance, also requires the applicant for such permit to file a signed statement that he/she is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division' 3 -of the 'Business and Professions Code) or that he/she Is' exempt therefrom 'and the basis for the alleged exemption. Any, violation of Section 7031.5 by any applicant for a. permit subjects _the applicant to a civil enalty of not more than five hundred dollars ($500). 1, as owner of the' property or -my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered ' for sale (Section 7044, Business and. Professional Code: The Contractor's , License Law does not apply to an owner of a property who'builds or improves thereon, and who does such work himself/herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement Is sold'within one year of com- I Kitchen Sink Water Service t Device Boxes ' Pole Lighti - _ Outlets Range P -Trap - Switches Sign Roof Drains Garbage Disposal Stand ing,Sections > r Generator ❑0 5 KW ❑5-15 KW Trash Compactor 4 P Reins coon Fee pe $25 Issue Fee _ $ 3 PLAN CHECK $ Reinspe+:tian Fee $25 Issue Fee' $' 3 MECHANICAL FEES PUBLIC SERVICES REQUIREMENTS: Zoning Approved By" Application Approved By Date ' Date - a,,. Boiler $ , Hood or Type I ❑ ' - Canopy. Type II El $ agree comply with'all clty'andcountyordinances and' tate laws relating to building construction, and hereby authorize repre- sentatives Of t ' ' city to'Iyer upon the Above-mentioned property for Duct - Under Ground ' s P etion, the owner will .have the burden of proving he/she did not build or im- rove for the purpose of sale). Duct - Structural Refrigeration System Application Issued By at tI , as owner of the property, am exclusively contra cting,with licensed con- tractorsto construct the project (Section 7044, Business and Professions Code: Ddct - Ventilating i ❑0 100,000 BTU ❑100,000 BTU SUMMARY OF FEES The Contractor's License Law does not apply to an owner of property. who -38.50 50 1 50 builds or improves thereon, and who contracts for such projects with a can- Exhaust System ❑ Multiple El System- Repair/Alteration 1 BUILDING PERMIT $ SMIP $ , tractor(s) license pursuant to the Contractors License Law). ❑Tam exempt under Section B. & P. C. for this reason Firepl/Fact. Blt. ICBO PLANCHECK $ PERMIT PLUMBING $ I ISSUANCE $ Date Owner Heating System & Ducting = `-' PLAN CHECK $ ENERGY P.C. $ _ I hereby,certify that I have read this a ppHc'all and state that the above Informaton Is'correct. l' to - ❑0-100,000BTU ❑100,00067 - - a,,. ELECTRICAL $ GRADING $ agree comply with'all clty'andcountyordinances and' tate laws relating to building construction, and hereby authorize repre- sentatives Of t ' ' city to'Iyer upon the Above-mentioned property for ;„ ,,. _- i.,. PLAN CHECK $ MICROFILM $ Inspection pur - 5_7-87 Signature '"- MECHAMCAL $ TOTAL FEE 39 00 F $ --�._ _ Date Drivers' �icens r,55'•;- i • �1 . Reinspection Fee $25 issue Fee $ 3 PLAN CHECK $ t ` _ CMF 0865-46 rev. 7/83 White - Building; Canary - Applicant; Pink -'Accounting; Goldenrod -Assessor - APPROVALS 'Permit 'APPROVALS Permit t7 1. Temporary bectrical Servi 53. Steel Reinforcement 3. Electrical- Conduit.Utility-Undrgrnd. 54. Forms� Steel Reinforcement 56. olu Rough. mbing & Pressure Test, 6. Electrical UFER Grnd. 7. Footings 58.,,,Electrical Co.nduit-Undrgrnd. 8: Foundati(5n Gas Pipe, 0 Undrgr d., 59. n, Test Pro�eriy Sewer Lin -e'& House Conne`cii07 12'. Sewer Cap 63. Heater & Vent -Final 13. Roof Drains 64. Plumbing System'- Final - 14. Rough Plumbing 65. Electrical -Final 151', Rough Electrical-Conduiv- 6. El�ctric Wiring _167. Fehcing & Access Approval 18. Rough Electrical -T Bar Ceiling I �9. -P 19. Rough Heating & Air Conditioning 71 FIRE DEPT. REQUIREMENT APPROVALS Permit 20. Rough Factory Fireplace 21. Ducts, in Structure 70. Underground kydeo 22: Ducts, Ventilating 71. Produci Piping 0 Gas- 0 Oil 23. Gas Pipe:Rough.'& Tes'l, 72. Underground Flush 24. Roof Framing. 73..-Und'ergrnd:Storage-Tank.-OGiis 00il thing 25Roof Shea' 74.. Overhead Hydro 26. T -Bar Ceiling (Structural)!.& Mon 75. Dry Chemical 27, Frame and Flashing 76. bry'Standpipe' 28' , Lathing & Siding 77. FIXED SYSTEM FINAL,* 29"' Insul6tion 78. FIRE PREV. FINAL 30.7 Drywall �Milinq HEALTH DEPT�REQUIREMENT 31 � Plaster 6�own% Coat 79. FINAL INSPECTION 32. Electrical Power Meter-Firial,- .80. FOOD CERTIFICATEISSUED 33'. Final Electric-. Notes: 36. Hood or C�anopy 37. Final Factor'y Fireplace 38. Final Plumbing 39. Water Service -Final 43. Backflow lr�rigation I 44. Landscape IrriqationSyst&m' 45..Sbund Attenuation 46. Handicip Regulations 48. -S'peci al RequirementsiCompleted 50. das Release to Southern California Gas Go 51. CERTIFICATE OF.00CIUPANCY No. Date CMF 0865.46, rev. 10/84 White - Building; Canary - Applicant; Pink • Accounting; Goldenrod - Assessor • Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations. 4292 3/ 17/67 r � 249;:15 , TL CITY OF.COSTA MESA CONSTRUCTION P RMIT � Project Address 5 PE NO. ,� 7 TRACT NO, LOT NO, UNIT NO. � TYPE F CONSTRUCTION NEW ADD ALTERATION REPAIR CON% ERSIONi ❑ DEMOLISH ❑ OTHER _ :,y „f)ESCRIPTION OF WORK/US OF BLDG. 's 1 Applicant's Mailing Address+7 M� p�� moi.` Owner's Name 1 Phone.f�= — ! -s Address % A.P. # _ Zone S Main Building: Accessory Building: Arch/En �f�t�-� C»� Arch/Eng, �L License No. �" Address �' TYPE OF PERMIT GRADING FOUNDATION STRUCTURAL r❑ TENANT ELECTRICAL ❑ PLUMBING ❑ MECHANICAL ` " ❑.:% , OTHER r - - -- • PROJECT DESCRIPTION 5 FT. OCCUPANC`! s < CON STRUCTI'ON TYP VALUATION $ ZONE G ADING CU. YDS. ACRES - E T Front Z O B Rear N Contractor's NameARa �+ Phon F1 Address (mailing)/ City'License No. Q�s�C;1 �j LICENSED CONTRACTOR DECLARATION I hereby affirm that I am licensed under provisions of Charter 9 (commencing with section 7000) of Oivislon 3 of the Business and Professlons Code, and my license is in f II force and effect, + / License las License C Right - N K S Lett G R Ping, fief. # Parking Req./Provided E .'Remarks: Z'7 ^Z' Planning Notes: Q (yI - • - t• r T S .Bar =FEES - ELECTRICAL FEES f Date SignaturePLUMBING WORKERS' COMPENSATION CLARATITN I hereby affirm that I have a certificate of consent to self -insure or a certificate Sink Showers y` of Workers' Compensation Insurance, or a certified copy th eof (Section 3800, Laq.kC.){ _ _ E Policy No. V�1_ ny fi ri17 ��--�• � � Certified Co' y� r py is hereby furnished. (I Backflow Preventer Service Sink Automatic Washer Construction Pole Sub. Transformer ❑ 15 50 KW ' _❑ 50 KW Backflow Irrigation Sewer Cap ' Bathtubs ` Sewer Connection Cooking Unit - Meter El up to 100 amps - Certiii{ec is filedwith the city u 1 1p.g Diyisionr 7 . i ,' Date Applicant G �4 GC r� fL� C ' EXEMPT ON FROM WORKERS' COMPENSATION DECLARATION (Thissection need not be- completed if the permit is for one hundred ($100) or, less). ; I certify that In the performance of the work for which this permit is Issued 1I shall not employ any person in any manner so as to become subject to tke Workers' Compensation Laws of California.vto Date Signature - NOTICE:.if, after making this declaration, you should become subject to the Clarifiers _ SOIar Collect Dishwasher Meter ❑Over 100 amps - Dishwasher Solar Pi g Dryers ,❑Gas ,❑Electric Sub Panel '. 3 _ Drinking'Fountains So Tank Fan Motor1 HP h -s 3 0 Floor' Drains wimming Pool v4/Spa + ;�£: ,` F. A': U. '' '' _ Inc. Solar 9-15 HP ❑16-15+ Floor Sinks Urinal!J.t� Fixtures Microwave (q p ' Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm'that there is a construction lending agency for the performance of the work for which this permit is issued (Section 3097 Civ. C.) Lender's 'Name Gas Service Outlets Water Closet rDevice Boxes •, Pole Light Interceptors Water Heater Outlets Range Qb Lender's Address OWNER BUILDER DECLARATION I hereby affirm that 1 -am exempt from the Contractor's License Law for the following reason (Section 7031,5 Business and Professional Code: Any city or Kitchen Sink ° Water Service Switches Sign , Lavatories Auto -Wash Garbage Disposal Standing Sections 0 P -Trap Laundry Trays Generator ❑Q5 KW ❑5-15 KW Trash Compactor county which requires a permit to construct, alter, improve, demolish or repair any structure, prior to its issuance, also requires the applicant for such permit to file a sigri d.Statement that he/she is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Roo rains ~c Division '3' of ,the Business and Professions Code) or that he/she is exempt therefrom and the basis for the alleged exemption. Any violation of Section ' 7031.5. by any applicant for a permit subjects the applicant to a civil Reinspection Fee $15 I I Issue Fee $ 3 I . enalty of not.more than five hundred dollars ($500). 1, as owner of the property or my employees with wages as their sole compensation, will 'do the work, and the structure is not intended or offered forsale (Section 7044, Business and Professional Code: The Contra cfor's License Law does not apply to an owner of a property who builds or improves thereon, and who does such work himself/herself or through his or her own employees, provided that such improvements are not intended or offered for safe. If, however, the building or improvement is sold within one year of corn- pletion, the owner will have the burden of proving he/she did not build or im- _ prove far the purpose of sale). ❑ I; as owner of the property, am exclusively contracting with licensed con- tractors to construct the project {Section 7044, Business and Professions Code: The Contractor's License Law does .not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a con- tractor(s) license pursuant to the Contractor's License Law). I am aware thatBUILDING proof of their Worker's Compensation insurance should be provided to me. L1m I am exept under Section B. & P. C. for this reason Reinspection Fee $15 Issue Fee $ 3 MECHANICAL FEES DEVELOPMENT SERVICES REQUIREMENTS: ' Zoning Approved By nate Building Approved By Date Application Issued By oat - Boiler Hood Or Type I ❑ Canopy Type I I ❑ - Duct- Under Ground - Duct - Structural Refrigeration em Duct - Ventilating 1:10-100 BTU ❑ 100,000 BTU r SUMMARY OF FEES .. PERMIT $- SMIP $ PLAN CHECK $ PERMIT PLUMBING $ ISSUANCE - '$ Exhaust System ❑ Multiple ❑ ystem'Repair/Alteration Firep1/Fact. Bit. ICBG # Fire Dampers Date Owner I hereby certify that •1 have read this application and state that the above information is Correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize repre-MICROFILM. sentativant.- is city enter upon the above-mentioned propert for Inspection Dur a 1 r Signature .9'w" � Date �✓".�✓L- Heating System & Du g ❑0 100,000 ST 100,DDOBT Registers PLAN CHECK ' 2590 ELECTRICAL PLAN CHECK 50% MECHANICAL PLAN CHECK 25% $ $ $ $` $ ENERGY P.C. $ �.7 ( GOADING $' $ - J TOTAL FEE $ _ Reinspection Fee - $15 Issue Fee $ 3 _ � �+ - - Driver cense or SSS_ _. = CMF 0865.46, rev. 10/84 White - Building; Canary - Applicant; Pink • Accounting; Goldenrod - Assessor A'' CONSTRUCTION AND PLANNING APPROVALS Permit # Date i Inspector POOL & SPA - APPROVALS Permit # v Date Inspector 1. Temporary Electrical.Service or Pole 52. Pool & Equipment Location :t 2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. 54. Forms 4. Electrical Conduit-Undrgrnd. 55'_ Electrical, Bonding 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test a 6• Electrical UFER Grnd. 57:..'APPROVAL TO COVER-GUNITE' 7. Footings 58. Electrical Conduit=Undrgrnd. B. Foundation 59. Gas Pipe, 0 Undrgrnd., Test 9. Water Pipe-Undrgrnd. 60. Backwash Lines, P -Trap,© Undrgrnd. 10. Structural Floor System 61. APPROVAL TO DECK 11. Property Sewer Line & House Connection 1 62• Backwash & Receptor -Final ,12. Sewer Cap .icr„ 63. Heater & Vent -Final 13. Roof Drains 64. Plumbing System - Final 44. Rough Plumbing 65. Electrical -Final 15. Rough Electrical -Conduit Solar System -Final 16, Rough Electric Wiring Fencing & Access Approval 17. Rough Wiring Sign ' APPROVED FOR PLASTERING " 18. Rough Electrical -T Bar Ceiling 15!. POOL/SPA SYSTEMS:FINAL ` 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT . APPROVALS Permit # ; 20. Rough Factory Fireplace 21. Ducts, in Structure 70. Underground Hydro , 22. Ducts, Ventilating 71. Product Piping 0 Gas D Oil 23. Gas Pipe -Rough & Test 72. 'Underground Flush 24. Roof Framing 73. Undergrnd. Storage Tank 0 Gas 0 Oil 25. Roof Sheathing 74. Overhead Hydro 26. T -Bar Ceiling (Structural) & Monocoat 75. Dry Chemical 27. Frame and Flashing 76. Dry. Standpipe 28. Lathing & Siding 77. FIXED SYSTEM FINAL 29. Insulation 78. FIRE PREV. FINAL 30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat 79. FINAL INSPECTION ' 32. Electrical Power Meter -Final FOOD CERTIFICATE ISSUED - 33. Final Electric N� Q d 34. Final Heating & Air Conditioning25-3147- PIMiki. 35. Final Gas Pipe -Test f " 36. Hood or Canopy d ie`t f`te, 37. Final Factory Fireplace 38: Final Plumbing i 39. Water Service -Final 40. Gas Service -Final y41. Solar`Domestic-Final u 42. Backflow Preventer ' X43. Backflow Irrigation 44, Landscape Irrigation System r' A 45. Sound Attenuation 1 x'46. Handicap Regulations 47, FINAL STRUCTURE & BUILDING 48. Special Requirements Completed , 49. Electric Release to Edison t •50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY No. Date m._..�,.�R,.. :sa l�.fii.:.....iPk - - ._....ri..aa.`:'sd.... a... �' _y.rE� 3. 3_•--- ... Y-.�°a�d.._,,.t Tat�il�ltiY!'�ealil� Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations CITY OF COSTA -MESA 22 CONShhRU�CyTI+ON P P T NO. TRACT NO. CMF 0865-46, rev. 10/84 White - Building; Canary - Applicant; Pink - Accounting; Goldenrod - Assessor � LOT NO +UNIT NO. : 1 ^• ' Project Address _3�3J d • rJ� "cif OI i >7652? I /2/87 i 93033 TL Applicant's Mailing ddress �I-:90 V) 77Y� "` ". TYPE OF CONSTRUCTION NEw ADD ALTERATION REPAIR j + ❑ CONVERSION 1:1 -DEMOLISH ❑ OTHE A.P T_. T lona_ Owner's Name Phone 3 .# { __-r_._ _ _ . - Address f DESCRIPT OF WORK/US F BLDG. { S Main Building: ( ) ' Accessorg Building: Arch/Eng; License No. TYPE OF P RMIT 4131NG El FourIDATI?O�fTY STR TURAL T Front I t p Address ! I ❑ TENANT ❑ ELECTRICAL: ❑ PLUMBINGMECHANICAL B N 2 • Contractor's 3'2 lac. ❑ OTHER,: td /_ _ 4 Rear _• + _ _ __ _ - t. 1 . Nam Phone C Right { { N { Address Address (mailing) PROJECT DESCRIPTION SQ. FT. - l r G City License lVo. d CONSTRUCTION TYPE / /yam VALUATION $ 1 /. yyt/ .K S Left 1 R —" —z LICENSED CONTRACTOR DECLARATION , ZONE GRADING CU. YDS. ACRES , - Ping. Ref. # l , Parking Req./Provided E I hereby affirm that I am licensed under provisions of Charter 9 (commencing Remarks: t Planning Notes: M with section 7000). of Division 3 of the BusinesS and Professions Cotle, and _ r my license is in full to e. n effect. &6.32-1 _ + ,•. T License Class Lieen a M- ET7 PLUMBING Date-_' Signature ;u : WORKERS' COMPENSATION DECLARATID I hereby affirm that I have a certificate of consent to Self -insure or•a certificate Bar Sink - Showers: 1 ELECTRICAL t _. FEES of Workers' Compensation Insurance, or a certified copy thereof (Section 3800, Lab. c.) 1�7 Backflow Preveriter I. i Service Sink _ Automatic Washer ' Transformer ❑ 15-50 KW lI Policy No, Company Certified copy is hereby furnished. +� Backflow Irrigation - - Sewer cap, - P ConStruction•Pole Sub. l ' •_ ❑ 50 + KW, ., - ' Certitied cjA�py 's.rf�led with the city B 'I in Ivi on. Bathtubs sewer Connection Cooking Unit _ , Meter ❑up t0 100 amps ` Date /' ZfJ^ /_ Applicant • • -_ EXEMPTION FROM WORKERS' COMPENSATION DECLARATION Clarifiers Solar Collectors - Dishwasher Meter over 100 amps (This section need not be completed if the permit Is for one hundred ($100) or ~` - - less), Dishwasher Solar Piping Dryers ❑Gas ❑Electric = Sub Panel l .' I certify that in the performance of the work for which this permit is issued I - - - shall not employ any person In any manner so as to become subject to tyre Drinking: Fountains y Solar Tank i Fan Motors El 0- 1, HP 01 h 8 { Workers' Compensation Laws of California. Date Signature Floor Drains I Swimming Pool w/Spa' F,A,U. Inc. Solar ❑9 15 HP ©16-15+ NOTICE: It, after -making this declaration, you should become subject to the - � - - w � a - 1v \] Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall . be deemed revoked. - Floor SirikS ( Urinal 1 Fixtures '- f - Microwave - i .- CONSTRUCTION 1 CONSTRUCTION LENDING AGENCY ; I hereby affirm that there is a construction lendingagenc for the y performance _ Gas Service Outlets t Water Closet 1 ? Device Boxes Pole Light! 9 , i of the work for which this permit is Issued (Section 3097 Civ. C.) Lender's Name Interceptors Water Heater + Outlets l Range , ' Lenders Address — Kitchen Sink - Water Service, - - - Switches • I Sign OWNER BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractor's License Law for the Lavatories Auto -Wash l Garbage Disposal Standing Sections ! i • following, reason (Section 7031.5 Business and Professional Code: Any city or 1 county which >equire$ a permit to construct, alter, improve, demolish or repair any structure, prior to Its issuance, also requires the applicant for such permit P—Trap Laundry Trays I Generator 1:10-5 KW ❑5-15 KW Trash Compactor ; l to file a signed statement that he/she is licensed pursuant to the provisions of Roof Drains ; the Contractor's License Law (Chapter 9 (commencing with Section 7000) of _Dl vision 3 of the Business and Professions Code) or that-he/sheds exempt therefrom ano the .basis for the alleged exemption. Any violation of Section 7031.5' by any applicant for a permit subjects the applicant to a Civil S penalty -of not more than five hundred dollars ($500). j L.1 I, as owner of the property or my employees with wages 'as their sole Reinspection Fee $15 Isue Fee $ 3 compensation -will do the work, and the structure is not Intended or offered for Professional Reinspection Fee S75 Issue Fee I ` $ 3 sale (Seci on 7044, Business and Code: The Contractor's MECHANICAL _FEES ; License Law does not apply to an owner of a property who builds or improves thereon, and who does such work himself/herself or through his or her own for - Boiler -- Hood or Type I ❑ < DEVELOPMENT SERVICES REQUIREMENTS: I ! employees, provided that such improvements are not intended or offered sale.- If, however,'the building or improvement Is sold within one year of Com- I Canopy Type I I ❑ _ Zoning Approved By Bate pletlon, the owner will have the burden of proving he/she did not build or im- Duct - Under Ground Building Approved B 8 pP y - Date prove for the purpose of Sale). � � I, as owner of the property, am exclusively contracting with licensed con- � Duct -Structural Refrigeration System Application Issued By J✓� � at tractors to construct the project, Section 7044, Business and Professions Code: The Contractor's License Law Res not apply to an owner of property who Duct - Ventilating ❑0-100,000 BTU ❑100,000 BTU SU RY FtFEES. builds or improves thereon, and -who contracts for such projects with a con- - tractor(s1•ucense pursuant to the Contractor's License Law). I am aware that, Exhaust System ❑ Multiple ❑ System Repair/AlteratiOn I BUILDING PERMIT $ SMIP $ f proof o their Worker's. Compensation insurance should be provided to me. ❑ lam exempt under Section B. & P. C. for this reason PLAN CHECK $ PERMIT Firepl/Fact. Bit. ICBG # Fire Dampers PLUMBING $• ISSUANCE ,$ Date Owner Heating System 8l Ducting Registers' PLAN CHECK - 25% $ -+ ENERGY P.C: $ I hereby certify that -1 have 'read this'application and state that,the above 'correct, ❑0-100,000 BTU ❑100,0006 GRADING, $ information is .1 agree to comply with all city and county ordinances - _ + ELECTRICAL $` C _ and state laws relating to building construction, and hereby authorize repre- - _ PLAN CHECK 50°% $ MICROFILM" �$� of this i y to enter u on the above-mentioned property for inspection inspection purposes. /]� / j MECHANICAL $ TOTAL FEE $ `93 Signature - lad7 Date 1'2 - _, 'Drivers"License dr SS r' T Reinspection Fee $15 Issue Fee $ 3 PLAN CHECK 25% $ CMF 0865-46, rev. 10/84 White - Building; Canary - Applicant; Pink - Accounting; Goldenrod - Assessor ,CONSTRUCTION AND -PLANNING ,APPROVALS Permit # Date Inspector POOL &SPA APPROVALS Permit # Date Inspector 1. Temporary Electrical Service or`'Pole 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement' e 3. Electrical Conduit Utility-Undrgrnd. 54. Forms_ _ ir 4.. Electrical Conduit-Undrgrnd. 55. Electrical Bonding y 5. Steel Reinforcement -56. Rough Plumbing & Pressure Test - 6. Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE + 7. Footings 58. Electrical Conduit-Undrgrnd. 8. Foundation 59. 'Gas Pipe,'❑ Undrgrnd., Test i 9. Water Pipe-Undrgrnd. -; 60. Backwash "Lines, P -Trap, ❑ Undrgrnd. 10. Structural Floor System 61. APPROVAL TO DECK 11. Property Sewer Line & House Connection 62. Backwash & Receptor -Final' r e 12. Sewer Cap 63. Heater & Vent -Final 13. Roof Drains 64. Plumbing System - Final 14. Rough Plumbing 65. Electrical -Final r 15. Rough Electrical -Conduit 66. Solar System 'Final 71 16. Rough Electric Wiring 67. Fencing & Access Approval 17. Rough Wiring SignF68. APPROVED FOR PLASTERING 18. Rough Electrical -T Bar Ceiling' ", . 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit # _ 20. Rough Factory Fireplace 21. Ducts, in Structure 70. Underground Hydro, 22. Ducts, Ventilating 71. Product Piping ❑ Gas ❑ Oil 23. Gas Pipe -Rough & Test 72. Underground Flush• 24. Roof Framing 73. Undergrnd. StorageTank ❑ Gas ❑ Oil 25. Roof Sheathing 74. Overhead Hydro 26, T -Bar Ceiling (Structural) & Monocoat 75: Ory Chemical 27. Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding 77. FIXED SYSTEM FINAL .Z�7 iC,V►. 29. Insulation 7 ' 30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat 79. FINAL INSPECTION ' 32. Electrical Power Meter -Final 80. FOOD CERTIFICATE ISSUED 33. Final Electric Notes:, 34. Final Heating & Air Conditioning { �' 35. Final Gas Pipe -Test 36. Hood or Canopy 37. Final Factory Fireplace = .38. Final Plumbing `39. Water Service -Final , " z 40. Gas -Service -Final ' 41. Solar.Domestic-Final r42. Backflow Preventer ' 43. Backflow Irrigation i 44. •Landscape Irrigation System x'45: Sound Attenuation - 46. Handicap Regulations ' -47. FINAL STRUCTURE & BUILDING k ;• '. 48. Special Requirements Completed ,49. Electric Release to Edison _ 50. Gas Release to Southern California Gas Co Sl. CERTIFICATE OF OCCUPANCY No. Date �._R:_ +a�r�sa'• x. .. ..�.-. "lia`+u.'� _ .�__iw _.-...r.iLaa ori w1 �''.ari�.. .'.lir _ _-_- .,wy�d.:s�.,._.fi�.a M 044 CO NST R LICT 10 N" AND'P'I?ANN I NG �:_ -_ / Date inspector APPROVALS Permit POOL & SPA 4 -Date APPROVALS Permit #-,. I lnspvc�or .. . 1. Temporary Electrical Service or Pole 43. Pool & Equipment, Location:- ., _21.. Soil ?'!pe.-Undfgrn. 44. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrn 45. Forms 4. Electri.cal.Conduit.-Undrgrn 46. Electrical Bonding 5. Steel Reinforce- 47. Roqh' Pl6mbin' & Pressure Test 6, Electrical UFER Grn 48. APP ROVALTO COVER-GUNITEI 7. Footings 49. Electrical 'Conduit-Undrgrn B. Foundation 50.- Gas Pipe, 1:1 Undrgrn;Test 9. Water Pipe-Undrgrn 51. Backwash Lines.'P-Trap, El UndrOn 10. Structural Floor System 52. APPROVAL TODECK` 11. Property Sewer Line & House Connection 53. Backwash & Receptor -Final 12.. Street.Sewer Connection 54. Heater & Vent -Final 13. Rough Plumbing 55.- PluMbmna Systema.-_Fmnal 14. Rough Electric -Conduit .56.. Electrical -Final 15. Rougli Electric -Wiring nz, 57, -. Solar System -Final 16. Rough Heating.& Air Conditioning 7-SK-Te-ncing & Access Approval -Ducts, in Structure 59. APPROVED FOR PLASTERING, -17'. 18. Ducts, Ventilating 60. POO L/SPA_ SYSTEMS FINAL 19. Gas Pipe -Rough & Test 20. -Roof Framing 21. Roof Sheathing NOTES: 22. Frame and Flashing 23,- Insulation *e or _4__z41AV_, 24. Lathing & Siding An .25. Drywall. Nailing . 26. Plaster. Brown Coat 27.r -Electrical Power Meter -Final 28. Final -Electric d _A� - 161.. 29. Final Heating & Air Conditioning 30. Final Gas Pipe -Test 31. Final Plumbing '32t- Water Service -Final 33. Gas Service -Final 34. Solar Domestic -Final 35. Landscape Sprinkling System 36. Sound. Attennation 37. Handicap Regulations. 38. FINAL STRUCTURE & BUILDING 39. Special Requirements Completed 40. Electric Release to Edison 41. Gas Release to Southern California Gas Co. 42, CERTIFICATE OF OCCUPANCY No Date Applicant I . 0 fill In all spaces within heavy border tines and sign all appropriate declarations. -,--CITY OF COSTA MESA PERMIT NO, w TRACT NO. f LOT'NO.' `BLDG rNO:•` CONSTRUCTION PERM_ IT L� ' / 2'3' - "'`( ( ' :3 8993 12/03/. f 9.00 QrArth/Eng.­ Address ',� �(cj• r+ TYPE OF CONSTRUCTION"'Phone' ❑NEW ❑ ADD'��ALTERATION" "' " " " ❑ REPAIR ❑ CONVERSION ❑DEMOLISHng. __...----.-- License No.' - - A.P.5P ZONING REGULATIONS • OTHER.RIPTION OFWORK - `,_ ,__ZONE PLNG. REF: slt�tor�'G IU"l�}i ; ;jD6e'Phone VJ. 2ij ,ITTYPEOF PERMIT �._ sBUILDING E C ��leRy, +�9NE fi ;' w; t- ❑GRADING -❑ 'FOUNDATION ❑STRUCTURAL I YARD'ED C NTRACTOR• DECLARA ON ❑TENANT ELECTRICAL'❑PLUMBING ❑MECHANfGA 5affirm that I am licensed under provisions of Charter.9,(com-, ,.I s t. RIGTmenng' with '-section 7000) --of Division 3 of - the -Business --and ❑ OTHER - - - {n Professions Code, and • my license f In full f a an J; effett.l 'r t r i REAR YARD (TO P/L) .• r -•- s , �' -Z - .PROJECT DESCRIPTION t� License Class Lic nso, „ , i -"PRG. SPACE REGI. PROVIDED Data - 3lgnaturo n: - - STREET WIDTH' PARR FEE S, - WORKERS'COMpENSAT10M0 CLARATION '.00CUPANCY' CONSTRUCTION TYPE. I herebyaffirm that I have a certificate of consent to self -insure -or, a VALUATION' ZONE ZONING APPROVED BY "DATE y,. M�. Pa - .-J •a r certificate of Workers' Compensation' Insurance; or a -certified copy -• _ thereof (Section 3800, Lab. C.).' �- 16RADING CU.: YDS. ACRES SPECIAL CONDITIONS. Pollcy No. Company Certified copy is -hereby -furnished. ,- = -« -. _•- -n -a•REMARKS6+ '= ; '_ .s. ._',�.FOO „, '. •1,; Fv' ,Certlfled copy is filed with the'tlty Building Division. aX`EMPN F TIOROM WORKERS' COMPENSATION DECLARATION - Thls-soctlon need not be. Completed if the permit is for one hundred (($100) I.Cert(fy-that i� the performanco,of,t ark_for_w is h �}+e�rmit 13 _ Issuetl, !shall notamQloy any pars i y man s �a b.tsecama •PLUMBING•'�it,: -PLAN'CHECK -ELECTRICAL -« - PLAN'CHECK -7 subjec to th. Work rs ompensatl9 w5 of. Call, _ Date "� Slgnaturel iBATHTUBS SHOWERS I-Livyr; - NOTICE: If after.jmaking this deClaratlon, you should be co subjoctj ;TOILETS ,r {tri (?,j URINALS �' -GENERATOR 0.1 KW 1-10 FC1N to the Workers' Compensation provisions of the Labor Code, you must TRANSFORMER t•+ '' M a ' forthwith comply with such provlslons or this permit shall be deemed LAVATORIES DOUBLE LAVS APPLIANCE 10.50'KW 50 +-KW' _ revoked.-. - CONSTRUCTION LENDING AGENCY - KIT. SINKS- -DISHWASHERS "MOTORS '0.1' HP 1=1'0 HP,s ' I hereby affirm that there is a construction lending agent for the per- .-, - - y SERVICE SINKS , .. } � SUMPS i -(CNC: SD LAR) -10.50 HP •• -50 +IHP� � - formance of the work for which this permit is Issued (Section 3097 + Cl v; C.)'. `FIXTURES' OUTLETS SWITCHES' _ _' Lender's Address r t ISM iklNG FOUNTAINS I _ T - ; '- - GAS'TUBE IGNS' the 'fdl dBU "reason` Section 7 a.�� .� .e z.... _+�.r.�_ -- ' OWNER BUILDER DECLARATION'"" • s, t. INTERCEPTORS CL'AgIFIEgs � " '- POLE'I;;IGHTS- - -- I hereby affirm that l am exempt from the Contractor's License Law for I g { 031:5''Business and-Professlons Cade: SWIMMING POOL -YPjTRAP - .--r.-_ r-� - .� _. Any city or county which requires- a permit to construct, alter, _ __ POLES µ METERED SUB •. lrnfrove, demolish -or repair any -structure, prior to-its'issua-reaISO-re= - - ' gges the apt Ij;ant for such permit_ to file a signed statement that he WATER SERV ICE ALTERATION PANELS- - MAIN' I'''�Ty:SUB ' is'licensed pursuant to the provislons bfi the Cont ractor's`L'Icense'-Law GAS SERVICE OUTLETS ` E i SERVICE' - 'AMP (Chapter 9, (commencing with Section 7000) of'Divlslon 3 of the Business and' Prolessions'Code)-cir that -he Is'exampt'therefrom-and'the-WATER'HEATERS'µ BTU OUTPUT basis for the alleged exemption. Any violation of Section 7031.5 by ' ^• -o' applicant' -for a perinit :subjects the appllcant"to "a tivll' penalty' -SEWER CONNECTIONS ,ot more than five hundred dollars ($500). as owner of the property, or my employees with wages as their �SOLRR; TANK- ---COLLECTORS-- Sole -Compensation, will do the work, and the structure Isnot Intended.. __ or offered for sale. (Section 7044, Business and Professions Code: The SOLAR PIPING SYS. „ ISSUE FEE' Contractor's Llcense:.•Law doesnotapply to an owner of a.property. =_,. - .._ APPLICATION APPROVED'BY` •' DATE" who builds or Improves thereon, and who does such work himself or ISSUE FEE r y., through his.ownemployees, provided thatsuchImprovements.are-not Intended or offered for sale. If, however, the building or improvement MECHANICAL PQ'AN CHECK SUMMARY DF, FEEsr _ $.sold within one year of completion, the owner -will, have the burden __ ,L of proving he did not build or improve for the purpose of sale). BUtL'DING ` C1 PAND-DUCTING ,-as owner -of -the -property, -am-excfuslvety contracting with HEATING SYSTEM 0-100,000 BTU T Y PERMIT - S - 4' w «I :�SMIP .• �. S licensed contractors to Construct'lhe project (Section 7044, Business 100,000,+ BTU PLAN CHECK S 1't'+'-•l,n •,;,,� 'and`Profass Ions -Code: The Contractor's-titense•L:aw does•not apply to - -i an owner of property who builds or Improves thereon, and who con- REFRIGERATION 0-100,OOD BTU PLUMBING 3 tracts-irom'such projects with a contrattor(s) licesned pursuant to -'SYSTEM"=:' -' - I— - - - - GRADING -3 the Contractor's License taw). 100,000 + BTU r PLAN CHECK; $ ❑ I am exempt under Section B. & P. C. for tHis BOILERS BTU ELECTRICAL S -� 7h� $ „ ,- ml S reason -- '-' ” ' � - PLAN CHECK -MECHANICAL - Si � '"' - _ SYSTEM REPAIR, ALTERATION ! TOTAL FEES'' Date-.._ . _. _..w. ._ Owner - . _ _ - - - fYIGAI S _I hereby certify.that.l have read -this application and state that the above EXHAUST SYSTEM MULTIPLE _ _ _ _ _ � � �. ­LESS--AD-;A01:' inforglation is rect. I agree o c with all city and county PLAN'CHECK -8 VANCE PC S. ordinances,a sta laws relati nstr ction, and hereby authorize representat es this c o' ' ter on the above mentioned property spection.� _.- Slgnatur �_ Date 3- _ FINAL FEE Drivers' License or SS 9y --' ISSUE'FEE'-'- GMF 0865-46 White-Building;_Canary-Applicant; Pink -Accounting; Goldenrod -Assessor Applicant to fill in all spaces within heavy border lines andsign all appropriate declarations. CITY-O� COSTA MESA NO. TRACT NO. LOT NO. [W�§IT CONSTRUCTIONPERMIT /if D 0 J,BLDG.NO.­ 8520 I I /20/81 I 0.58 Address ,' TYPE OF CONSTRUCTION'T Phone ❑ NEW ❑ ADD ALTERATION t!?`�y t ,9�� ❑REPAIR- ❑_CONVERSION ❑DEMOLISH ❑ ZONING REGULATIONS. ng. License No. OTHER rdd DESCRIPTION OF WQ�K t R S �� A.P. � ZONE' PLNTTGOp. REF.-# tor Mone n;73 YPEOFP MIT ❑GRADING ❑ FOUNDATION XSTRUCTURAL SETBACK LS `IDE YARDED FT PROPEIRTVNLINE CONTRACTOR DEcLA ATION- - affirm that I am licensed under Charter 9 ❑TENANT ❑'ELECTRICAL ❑PLUMBING ❑MECHANICA SIDE YA provisions of (cam- 'section 7000) of Division 3 of the Business and, ❑ OTHER - RIGHTmencngwith REAR YARD P/L) % Professions Code, a • rr7y license Is in full force and effect. /PROJECT DESCRIPTION . _- � � (TO License 55 LI nse NoL Date Signature . FT. ' ,.- RL PKG. SPACE REQ. _-_- :STREET WIDTH ,�� PROVIDED PARK FEE $ WORK RS' COMPENSATION LARATION -- OCCUPANCY' CONSTRUCTION TYPE DATE I hereby affirm that I have a certificate of consent to self-Insure or a -Workers' n OQ'� VALUATION ZONE ,ZONING APPROVED BY Certificate of Compensation Insurance, or a certified Copy thereof (Section 3800, Loh. C.). GRADING.-CU.iYDS. ACRES SPECIAL CONDITIONS: �bllcy No. Company t- ,rtified-copy Is hereby furnished. - -- - REMARKS: artifled copy Is filed with the city Building Division. EXEMPTION FROM WORKERS' COMPENSATION DECLARATION (This section need not be-completed-if the permit is for one hundred _ 1 } ' (8100) or less). i y _ - - - ` I certify that In the performance of the work for. which this permit is _ issued, I shall not employ any person In any manner so as to become PLUMBING-1. .,'PLAN CHECK ELECTRICAL PLAN.CHEC.K subject to the Workers Compensation Laws of California.LINU Date Signature BATHTUBS SHOWERS _ sem_ FT__ NOTICE: If after making this declaration, you should become subject TOILETS. "' URINALS _ `' ',GENERATOR- 0-1 KW 1-10 KW. - to the Workers' Compensation provisions of the Labor.Code, you must TRANSFORM_ ER forthwith comply with such provisions or this permit shall be deemed LAVATORIES DOUBLE LAVS APPLIANCE -" 10-50 KW_50 + KW' - revoked,-- _ CONSTRUCTION LENDING AGENCY __ _ KIT.51NK5 DISHWASHERS MOTORS­ 0-1'HP 1-10 HP I hereby affirm that there is a construction lending agency for the per- SERVICE SINKS "'' SUMPS" 'f(INC. SOLAR) 10-50 HP - 50 + HP -'- - --- - - formance of the work for which this permit is Issued (Section 3097 Civ. C.). Lender's Name FLOOR SINKS' ti FLOOR DRAINS FIXTURES OUTLETS SWITCHES' ' Lentler's-Address" s DRINKING FOUNTAINS - -�GASTUBE-SIGNS _ OWNER_BUILDER DECLARATIONINTERCEPTORS hereby affirm that Pam exempt-from"the.Cont}aCtor'S License'Law for �t . CLARIFIERS -POLE LIGHTS -" -,SWIMMING.POOL P TRAP - POLES METERED SUB the fallowing reason (Section 7031.5-Business and Professions Code: 'Any-`city or -county which -requires _a permit -%to•construct, alter, WATER SERVICE E J ALTERATION PANELS'-- MAIN- SUB - improve, demolish or repair. any structure; prior to its'Issuance, also re-' quires the applicant for such. permit-to file a signed'statement.that he _ OUTLETS SERVICE AMP is licensed pursuant to the provisions'of the Contractor's License Law�GAS'SERVICE (Chapter•%g-(commencing with Section. 7000) of, Division 3yoLthe WATER HEATERS BTU OUTPUT Business and Professions Code)` or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by SEWER CONNECTIONS a' applicant for a permit subjects the applicant to a civil penalty e t more than five_ hundred dollars ($500): SOLAR TANK COLLECTORS " L , as owner of the property, or my employees with wages as thele Sole compensation, will do the work, and the structure.is not intended SOLAR PIPING SYS. k ISSUE FEE or offered for sale. (Section 7044, Business and Professions Code: The Contractor's License Law does not apply-to an owner of a property who builds or improves thereon, and who does such work himself or ISSUE FEE APPLICATION APPROVED BYDATE through his own employees, provided that Such-improvements are. not_ MECHANICAL PLAN CHECK SUMMARY OF FEES Intended or offered for sale. If, however, the building or Improvement is Sold within one year of completion, the owner will have the burden of proving he did not build or improve for the purpose of sale). HEATING SYSTEM 0-100,000 BTU BUILDING' •PERMIT g r^ r •� SMIP S O.-� E) I. as -owner - of the property, am exclusively contracting with _ AND DUCTING _ licensed contractors to Construct the project (Section 7044, Business 100,000 + BTU - PLAN CHECK $ PERMIT- and Profession$ Code: The 'Contractor's License Law does not apply to ISSUANCE $ an owner of property who builds or improves thereon, and who con- REFRIGERATION 0-100,000 BTU PLUMBING $ tracts from such projects with a contractor(s) ilcesned -pursuant to SYSTEM GRADING$ the Contractor's License taw). 100,000+BTU PLAN CHECK S ❑ ! am exempt under Section B. & P. C. for this BOILERS BTU ELECTRICAL $ $ , ea son PLAN CHECK $ MICROFILM S ' Date------- Owner - SYSTEM REPAIR,ALTERATION _' TOTAL FEE S MECHANICAL`$' ,I hereby certify that I have read.this application and state that the above, - EXHAUST SYSTEM MULTIPLE LESS AD- I" information is correct. I agree to comply with all city and county ,PLAN CHECK ` $ VANCE PC 'S ordinances and state laws relating.to construction,, hereby authorize "+ �,• i� representatly of this city to en upon"t above mentioned g _ '* - propert�l f Inspectio ur $ate L•. 'w :�', tt }^ ,1 ri: y? �i� FEE $ Signatu, , - ate��� - `� -FINAL Drivers' cense or SS -r ISSUE FEE _ ` CMF 0865-46 White -Building; Canary -Applicant; Pink -Accounting; Goldenrod -Assessor TL CONSTRUCTION AND PLANNING APPROVALS Permit # . Date :Inspector POOL'& SPA ' " APPROVALS Permit # DateInspector 1. Temporary Electrical Service or Pole 43.• Pool & Equipment Location 2. Soil - ipe Un rgrn 44. Steel Reinforcement . 3. Electrical Conduit Utility-Undrgrn •1 45. Forms 4. , Electrical Conduit-Undrgrn 46. Electrical Bondin' 5. Steel ein orce 47. Rough Plumbing & Pressure'Test " 6. Electrical UFER Grn 48. APPROVAL TO COVER-GUNITE - 7, Footings - 49. Electrical Conduit-Undr rn .8. Foundation 50. Gas Pipe, ❑ Undr rn Test 9. Water Pipe-Undrgrn 51. Backwash Lines,.P-Trap, ❑ Undrarna 10. Structural Floor System 52, APPROVAL TO DECK 11. Property Sewer Line & House Connection 53. Backwash & Receptor -Final 12. .Street Sewer Connection 54. Heater & Vent -Final 13. Rough Plumbing 14. Rough Electric -Conduit '56. Electrical -Final 15. Rough Electric -Wiring 57. -Solar System -Final 16. Rough Heating & Air Conditioning- 58. Fencing & Access Approval 17. Ducts in Structure' 69. APPROVED FOR PLASTERING 18. Ducts, Ventilating 60. POOL/SPA SYSTEMS FINAL 19. Gas Pipe -Rough &Test 20. Roof. Framing 21. Roof Sheathing NOTES: 22. Frame and'Flashin S 7 -b d 23. Insulation „T •--- 24. Lathihg & Siding 16,15 S 4T.er 25. Drywall Nailing �' 00Av77i o u7 1;7- e% X/7,;., - A/& V^,?e 26. Plaster Brown -Coat P~.a - 1R^er_ f 1111CI"I" 'e.,w; ag 27: Electrical Power Meter -Final Lz 28. Final Electric G o T J&G rS'rTy+oSaxuL CVP 29. Final Heating & Air Conditioning 3.0. Final Gas Pipe -Test �of 31. Final'Plumbing 32. Water Service -Final A Gas Service -Final 34, Solar Domestic -Final 35. ' UndscapeSprinkling System 36. Sound Attenuation 37. Handicap Regulations 38. FINAL STRUCTURE & BUILDING 39. Special Requirements Completed 40. Electric Release to Edison 41. Gas Release to Southern California Gas Co. 42. CERTIFICATE OF OCCUPANCY No.sd a:LoL Date DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: A�� '7 g 9 Z S D Carrier: F -r G+M C w + � !h , o _ Policy Number: rY (This section need not be completedlif the permit is valued at one hundred dollars ($100) or less.) ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, i shall forthwith comply with these pro ' ons. 1 O /-Z G Applicant Signature: Date: WARNING: FAILURE TO SE ORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMSNAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($1 , ),IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic. # Z Class # �c, _ Contractors Signature: Date: _ IL-) Z 9 CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lenders Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($5(30).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License Na. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, Califomia Administrative Code). ❑ As owner -builder, 1 will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? [:]Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this 8a�plication appermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency/? LJ Yes LJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits), 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). r 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (If `yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. S' tura Of mega! Owner(s)10/ zs/�g AndlOr Authorized Applicant Date CODE f. INSPECTIONTYPE DATE I_NTmAL5 CODE# INSPECr10NTYPE PAN IMMAL5 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Root 210 Final Electrical 201 Final Block/Retaining Wail 212 Final Fire Prevention L3-qj _ 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy 24x6-46 CITY OF COSTA MESA BUILDING DIVISION f 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 www.ci-costa-mesa. .us ". FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER' BC07-00072 . PERMIT TYPE: B_COMBO Sub Type: COM ALT JOB ADDRESS: 3333 1417 BRISTOL ST CM APN: 41250107 Zoning: PDC, Vicinity: MIKIMOTO Const Type: I -FR t- STATUS: ISSUED DATE ISSUED. 08/09/2007 = f` ISSUED BY: RMD Suite[Uriit: 417 _ i=Primary Occ. 5Q. FT: 1185 ��yValug - SCOPE OF WORK: � ca=" 1,185 SF INTERIOR T,l FOR "MIKIMOTO", SPACE-1,41T.—WORK TO INCLUDE:'NEW PAR: 'I, :I FRONT, FINISHES, ELECTRICAL AND MECH WORK- NO*W16RK IN RESTROOM. `�`� �S; SOUTH COAST PLAZA CA Phone: 4'Add asw,a%-.l APPLICANT: IM6RlALE !AT' r Phone: '714.857S? Citylstate/Zip: ;.3315 FAIRVIEW.R0,4D', • , . .fir ;':. �,,.. C4NTRACTORt : DEVELOPMENT' SUM Phone: 7.14457.62ti0 r "y5; :i •'; r:r"":: ,,• ""` ' a • ` SERV I CESI lNC'.• l / r.'. '' Addnas:�"$187 AIRWAY AVEbnit: ARCHrmcT: ATLASCHI AND HA IELD`'� EJYS#1Nt:t:R:' ��'' $21.00 TOTAL -FEES: -h $2,076.65 y. -' -`v 3 ` • f^, .c�1 r; r.�' 4 F',s}-"11 .'�"•,_ a •Crr, . i �' 4'Add asw,a%-.l 'tk[( :Building Fees: �%�.� —``f t� �.�'*-� •'rt�� Citylstate/Zip: ;.3315 FAIRVIEW.R0,4D', Electrlcalr Fees: ;' x '. Address:?'` �+ �x. , City/Stati1&p: __z-"1 r:r"":: ,,• ""` ' a • ` SERV I CESI lNC'.• License No. 748448 Addnas:�"$187 AIRWAY AVEbnit: Clty/State: `-COSTA MESA, -CA $0.00 1r 'k1P Commercial:: 203 final Sig _ _'' a f x '' 4 204. Final Demolition . -* �P lMt $21.00 IV I M I wig r�tr[m1 t, It-c>c auirlmmir%11If Building Plan Check: �' �_` _ `° -, $845.94;; :Building Fees: �%�.� —``f t� �.�'*-� •'rt�� 7' "x$993: 5�` Electrlcalr Fees: ;' x : =` $27716 - Mechanical Fees: ' �r; `�: $44`87 P.lbmbing.Fees: ; 200 Finale Re -Roo! ` 4� ^H $O,aa SMTP Residential: r' , :;' - ' X. ''! 212 Final Fire Prevention $0.00 1r 'k1P Commercial:: 203 final Sig _ _'' a f x '' 4 204. Final Demolition . -* �P lMt $21.00 TOTAL -FEES: -h $2,076.65 Refer:to•tei recelpta for. pl! fees paid for project l: $100;000.00 WALLS, CEILING, -STORE !lint: - COSTA MESA Unit: . STE G ZipCode 82626 PHONE:310.827-5815 PHONE: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE at "� •. Un f x i �4$ CODE f QISPECiIOM TYPE r -' ^ ,. A INTn1Al5 1616' Fixed System Finat Fire Prevention ;% y ' - ` 208 , Final Mechanical �� lolgF N /A4C 1266 Pool Spa Fina!'• , A•. ! ` �T- : -' 1, 208- `Flnal Plumbing , 200 Finale Re -Roo! ` 4� ^H 21p': • Final Electrical Y 07 1, 207 - �t Final BlocklRetaining Wal! ;;� ' " , 212 Final Fire Prevention = 202 i Final Factory Fire Place _ } �� 2202 FinalPlanning Approval 203 final Sig _ _'' a f x '' 4 204. Final Demolition . -* �P lMt 222. ,Final Site , 250 FinaltBuildinglOccupancy WORKERS' COMPENSATION DECLARE` I hereby affirm under penalty of perjury one r-. ng declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation l� Insurancecarrierand policy numberli,ii S:, 51UfI T�_;;..:1,� Carrier: (This sector need nol ee eomprered A the permit a valued at one hundred dollars (5700) or less.) Policy Number: ❑ I certify that in the performance of thei%work for -which this permit is issued, I shall not employ any personiin'any;manner so as toibecome'subject to the workers' compensation laws of Californiaiand,agree•that,if I -should become subject to the workers' compensation- provisions of'Section 3700 of the Labor Code, t shall forthwith comply with these provisions. "i, At :1:.i+_JlW*m1a Applicant's Signature Date WARNING: FAILURE TO SECURE WORKERS' COMPENSATION' COVERAGE IS UNLAWFUL ANDtSHALL'�.SUBJECTi(6N,lEMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS r � Owner ID verified by drive rise. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is requited to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial'Safet'y, as nvled._A6 e, unlei' i such person has a permit to do such work from the division. I' `�� :{Lt - Applicant's Signature Date Division of Industrial Safety Permit Number; I i.G.t'-i ":R f4(a.7 x HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1, Will the applicant or present or future building occ_upant,need lo•filetand" certify;a. Business,Plan for emergency response to release or,threatened, release of a hazardous material? ❑ Yes ❑ No `'ti ` " ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS (Section 25505 of the California Health and Safety Code requires, -with some: PROVIDED FOR•IN,SECTION 3706 OF, THE LABOR CODE, INTEREST, AND exceptions, that Business Plan be filed with the Costa Mesa -Fire-' ATTORNEY'S FEES - "' ^� ,a Department'by every•business wtiicli has at•any one time during a reported quantity of hazardous materials ii tGb tb:or.gnibC6r than a v`eightrof: LICENSED CONTRACTORS DECLARATION: 500 pounds, or a volume of 55 gallons, or 200 cubic feel of compressed gas I hereby affirmjthat I,am licensed under provisions of Chapter 9 (commencing at standard temperature and pressure). :. r }4 : • r r with Section 7000) of Division 3 of the Business and Professions Code, and 2. Does or will the applicant or present or future building occupant need to file' my license is in full force and effect. � • •„ :� •1, � a registration form_ for acutely hazardous materials? ©Yes ❑Non- :'r. Lic. # Class # (Section 25533 of the California Health and Safety Code, with some exceptions;., requires registration with the Costa Mesa, FiretDepartment ,by. each business which at any one time has on :hand; a quantity 'of' acutely Contractor's Signature Date hazardous materials equal to or greater than a weight bf 500 ponds, or a s� .., volume of 55 gallons, or 200 cubic feet of • compressed gas at standard CONSTRUCTION LENDING AGENCY: "'"' �' ' fr- temperature'and pressure). +"'a t - a.• 6: ❑ I herebyaffirm that there is a constn,ction lending agency for the ng 9 y � r' r' ` 3, hoes, or will the applicant or present or future' building occupant need to performance of the work far which tTiis permit is issued. (Sec. 3097, Civil Code). A� PreM Prepare an'RPP (Risk Management and Prevention Program for acutely' Lender's Name: hazardous materials)? ❑ Yes ❑ No - • " r (Section 25534 of the California -Health and 'Safety�Code provides that• the' Lender's Address: Costa'Mesa Fire Department may require the preparation, certiF6kbn.andl filing with the Fire Department of an RMPP by businesses which are required to register acutely_ hazardous. materials with the Fire Department. Signature Date a A ! 11 [ ' 1 ., r s -r +t ^ � .: w l i-; 0 ' d► r ( r r 4. If an RM PP_ is, presently::required, 'has-Section.25534-.of- the -California" OWNER -BUILDER DECLARATIONS: Health and'Safely.Code been fully complied with? ❑ Yest:, []'No ' 3 I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE 5. Does or -will the applicant or present or future building occupant regtiire fog CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, the work which is the subject of this application a permit for such construction' Business and Professions Code! Any city or county which requires a permit to or modification'from the South Coast Air Quality Management Dislrictlor from, cvnNn-N cher, imprnun edemolich nr rannir ?nu gtnrrtrirP nrinr to itc .,!tier -;r .- .,r-t ���..;C! .7 n YC. k1D issuance, also requires the applicant for such permit to file a signed statement (Section 65850.2 of the California Government Code requires that the requested. that he or she is licensed pursuant to the provisions of the Contractors inforrnation,be furnished on applications for non-residential building permits): • � •._ License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the . • - Business and Professions Code) or that he or she is exempt therefrom and 6. Will any,partof the facility to be constructed under this permit-,be•vathin- the basis for the alleged exemption. Any violation of Section 7031.5 by any 1000 feet from tha outer boundaries of a school? ❑ Yes ""' ❑'Na r applicant for a permit subjects the applicant to a civil penalty of not more than (if 'yes", the facility must meet the requirement of Sections -25534 and 42303 five hundred dollars ($500).): of the California Health and Safety Code). ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORE(, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason! Signature 3057-45 (31071 Date 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No. 8. (If "yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct, t agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature of legal Owner(s) Date And)or Authorized Applicant Date CITY OF COSTA MESA BUILDING DIVISION a 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 www.ci.costa-mesa.ca.us vck,o FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: E07-00904 PERMIT TYPE ELEC STATUS: ISSUED DATE ISSUED: 11/15/2007 ISSUED BY: RMD I•. 17 JOB ADDRESS: 3333 1417 BRISTOL ST CIM Suite/Unitt:, '.;- .1417 Vicinity: SPACE 1417 SCOPE OF WORK: ELECTRICAL'-, PERMIT FOR THEINSTALLATION OF10LIGHT FIXTURES FORT"MIKIMOTO", SPACE 1417 .� OWNER: SOUTH COAST PLAZA, •Address: Unit:COSTA MES -T'= PHONE: : ' CitylStatelZip: 3315 FAIRVIE? �t 1101 d• i `" �P APPLICANT: MEDEL, MIKE _ �;,. "�',"-`' � � "; f`'-." Address:' .- 3187 AIRWAY AV nit:ST.�J PHONE: 714-957-8250 k.,-, Tr+ CitylState/zZip: COSTA MESA CONTRACTOR: DEVELOPMENT.SUPPORT SERVICES -INC License No. 7,48446- Address: 3187;AIRWAY AVEUnit: STE G: ' . -PHONE: 714-957.8250 City/State: COSTA MESA, CA ZipCode:.92626, .- ;. _ ,,:,CELL: ELECTRICAL PERMIT FEES' - - Electrical Plan Check Fee- ' $0.00 Electrical Permit Fee: , $34.50 _ NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE R. INSPECTION TYPE DATE INTmALS CODE N INSPECTION TYPE DATE INTITIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final BlocklRetaining Wall 212 Final Fire Prevention 202 Finat Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy WORKERS' COMPENSATION DECLARATION.-` I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: r ��, I� Ca ? k"w DEL L f r (This section need not be corroeled if the permit is valued alone hundred dodars (3100) or fess,) P610Y`y—Number: o I u ICS n� x 0 0 0 3 ❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' mpensalion laws of California, and agree that if I should btome subject t the workers' co pensation provisions of Section 3700 of th Labor Code, I hall forthwith co ly with these provisions l� U� Applimnl's Signature WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATtON, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. ' LICENSED CONTRACTORS DECLARATION' I hereby affirm that I am jicensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force jand effect. L. 4 L r s5 11R _ tractor's Signature Dale CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5. Business and Professions Code: Any city or county which requires a permit to construct, after, improve, demoligh, or repair any structure, prior to its issuance, also requires the applicant for such permit to rile a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature Dale 3057-46 (3107) Owner ID verified by driver's fi,_ .d. j] Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Ari 2, Sec. 341, Title 8, California Administrative Code). 0 As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Date Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be fumished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code), 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If "yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: t certify that under penally of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. &gnature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: i certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occup or allow occupancy of any building authct zed by this p�rTr�it until final inspec Ii n. 'Andlor Authorized Applicant (_Dale__ --J IVl AS CITY OF COSTA MESA ,D BUILDING DIVISION f 77 FAIR DRIVE, COSTA MESA, CA 92626 - (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us �• FOR INSPECTION Wfr MWfBER: BX07-00143 PERMIT TYPE B_MISC STATUS: ISSUED APN: 41250107 DATE ISSUED: 09125/2007 Zoning-, PDC, ISSUED BY: CAC JOB ADDRESS: 3333 1417 BRISTOL ST CM Suite/Unit: 1417 Vicinity: 1417 Primary Occ: Const Type :?? SQ. FT: 0 Valuation: $1;500.00 SCOPE OF WORK: SUITE 1417 ILLUMINATED FRONT WALL SIGN FOR MIKIMOTO REF BC07 INCLUDED OWNER: MESA CA City/Stale: Phone: APPLICANT- City/State: Phone: ��� SOUTH COAST PLAZA Address:: - 3315FAIRVI EW. ROAD' Zip Code: 92 KELLY MILLER CORONA, CA 909-734-6275 CONTRACTOR: SOUTHWEST SIGN CO Address: 1696 COMMERCE ST City/State: CORONA, CA Zip Code: 92880 ARCHITECT: Phone ENGINEER: Phone Building'Plan Check: Building Permit: Electrical Permit: SMIP Residential SMTP Commercial $O.00TOTAL FEES 9g' . Address: 1696 COMMERCE ST Unit: Zip Code: 92880 License No. 724929 Unit: Phone 909-734-6275 License No. License No. FEE SUMMARY $35.10 _ $54.00 $0.00 $0.00 $0.00 $89.10 Cell: LECTRICAL Unit COSTA NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE 1. INSPECTtON TYPE OAT£ INTMALS CODE A INSPECTION TYPE D_&TE INTMALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign r l ' 222 Final Site 204 Final Demolition 250 Final Building/Occupancy L\ WORKERS' COMPENSATION OECLARATIO40 I hereby affirm under penally of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the pe ormance of the work for which this permit is issuel have and will maintain workers' compensation insurance, as required by - s lion 3700 of the Labor Code, for the performance of the tivork for which this permit is issued. My workers' compensation insurance carrier and policy nu Carrier: not be completed it the permit is valued al one hundred dollars (E 100) or less ) otic) Numbe ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if i should bete a subjec to the workers' compensation provisions of Section 3700 of the ober G e, i shillhwit a p!y with these provisi s. poi6nt'sSignature D e WARNING: AILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLA PUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTI S AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100, ), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and m ' l in full force and effect, L�,# z C ratter' ore Date CONST U TION LENDING AGENCY: ill I3 1 hereby affirm that there is a construction tending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Cl The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such.work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of Completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). 0 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractors) license pursuant to the Contractors License Laws.). 0 f am exempt under sec. Business and Professions Code for this reason: Signature Date 3057.46(3107) Owner I D verified by deed ❑ Yes [:)No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division, Applicant's S4nalure Division of Industrial Safety Permit Number: Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes Cl No (Section 25505 of the Cafifamia Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gaf)ons, or 200 cubic feet of compressed gas at standard temperature and pressure), 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? []Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on appficatians for non-residential' building permits). f. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safely Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. - (It "yes", attach certificate of compliance from the appropriate air pollution control officer). CERTtFfCATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct, t agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. r tore -i 0,niA / Date / r' A or A`(lthOri2etl cont ie r (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.8ttMLDING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 ,lob Address: 3333 -BRISTOL ST Status: ISSUED Suite: 1415 Applied: 09/06/2005 Vicinity; 1415 Issued: 09/06/2005 Primary Occ: M Display/Sale Merchandise Type of Construction: I -FR Parcel Number: 41250107 Zoning: PDC Applicant: RAQUEL CHRISTENSEN — Address: 1515 W ALTON AV Phone: 714-957-8250 ISSUED BY:ll�r/ SANTA ANA, CA Zip: 92704 Owner: SOUTH COAST PLAZA:, Address t COSTA MESA CA `� "' Phone: " 3315 FAIRVIEW ROAD Zip: 92626 4 Contractor: DEVELOPMENT SUPPORT.. SERVICES:INC.`:::' ""' Address: 1515 W ALTON AV Phone: 714-957-8250 SANTA ANA, CA Zip: 92704. ;" License: 748446 Arch : Eng. Address: Address: Phone: i°s Phone Zip: License: , License: - .. SCOPE OF PERMIT INTERIOR STORE.DEMOLITION TO;NON BEARING WALLS FOR FUTURE TENANT IN SUITE 14157- ' FEE-SUMMARYx l Plan Check: $72.31 Calc Valuation $4,606:00 Permit: .x$1.11.25;• . µ'_ Claim Valbation $4,600NSMTP Res: } ' , $0.00 . . SMIP Corn: $0.97 r - Other: $0.00 - Inspection:. $0.00 Total: $184.53 PLANNING & ZONING SETBACKS MAIN STRUCTURE Front 0- 0 } ;. Rear,''�; 0- 0 A ` �� "Left w:: 0 0 : Right 0- 0 ACCESSORY' Front.: , 0 0 ,: -Rear, 0- 0 ,, k'Left` _'- ,0- D.- � , Righ4> e .0-01 . PARKING Existing: o Required:, 0 Proposed: 0.- NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 244648 {6=00) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and *ill maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which'ihis permit Is Issued, have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit Is Issued. ork rrlpensatlon surance ca r nd policy umber are: w arrier; r olicy bar: D K-¢� I�! 2h 3 l� 4 action not be mpfe t the pe it is valued at one undrad dollars ($100} or less,} ❑ I certify that in tine performance of the work for which this permit Is issued, I shall not employ any person in any manner so as to become subject to the workers' Cpm nation I o a an agree the i should become subject to the workers' compensation provisions of Section 3700 of the labor Code, I shall forthwith mK App of O SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN F1!=0 CFMNk PEAALTIES AND CIVIL FINES UP TO ONE HUNDRED ($100,000), IN ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I here that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of ss and Professions Code, and my license is In full farce t. Lie. 0 C C fact s Signature: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: _ _ Lenders Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business .and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for safe. If, however, the building or Improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors Uconse Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: _ _ _ _ Date: Owner ID verified by driver's license. ❑ Yes ❑ No Drivers License No, Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet In depth Into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsowork, or demolition or dismantling thereof, will be more than thirty-six (36) feet high, (Chap. 3.2, Grp 2, Art 2, Sec. 341, Tltle 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do succi work from the division. Signature: _ _ Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ...... ............................•--..................... ...................................................................................................................................... ,,.................................................................. ........................................... ............................................. I'll ............ 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous matedals? ❑Yas ❑ No (Sectlon 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 50D pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ._ ........................ —................._ p .................._.__...............................---......................_—................ —...... .............. .»»............................................................... »........... _........................................ ..... .`.................................. 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑Yes ❑N Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. — .................._............_..............................................................._........................................aa-l............_..... f',e, t, C-,— ..... _ __.. . w—..... ............ �_................. �........ ............ ..................... ...... 4 If an RMPP is presently required, has Section 25534 of the California Health end Safety Code been fully complied wish? ❑Yes ❑ No ......................... ..................................................................................................................................................................................._..............................--....._............................__...................._............................................... 5 Does or wig) the applicant or present or future building occupant require for the work which is tha subject of this a plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ....... .............. ................................. ............1__....................................................................................................... .............................. .,..,,,............ ......................................•.................................................................................................... 8 Will any part of the facility to be constructed under this permit bo within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). .................................. -._..................................................................................... ................................................................................................................................................ ........................................................................................... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by Califomia Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (if yes-, attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: t certify under penalty of perjury that t have read this application and state that the information given is correct. I agree to comply with at] state laws and city ordinances rotating to building construction, and aulhorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. fur ner(s) ate And/Or Au nzed Appl nt ate CODE f. INSPECTION TYPE UR INTrrJ6L$ CODE I INSPECTION TYPE Q j 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 206 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final BlocklRetaining Wall 212 Final Fire Prevention 202 Final f=actory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition m �` 250 Final Building/Occupancy N v PLUMBING PERMIT Job Address: 3333 BRISTOL ST Suite No 1415 Vicinity: Parcel Nunmber: 41250107 i Applicant: RAQUEL CHRISTIANSEN.:, ,. Address: 1515 W ALTON AV SANTA ANA, 'CA" .` Phone: 714-957-8250, Zip; 92704 ISSUED BY: Status: ISSUED Applied: 09/26/2005 Issued: 09/26/2005 COMMENTS'! SPECIAL.CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 190 days. W INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codeafiand all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of tilF it. FOR INSPECTIONS CALL: (714) 754-5626 2448-48 (8100) rnone.,, n4-aor-awU SANTA ANA, CA .. Zip: 92704 H • License: 748446' 3 SCOPE OF PERMIT INTERIOR,1176 SF STORE TI FOR "GIUSEPPE ZANOTTI DESIGN' IN SPACE 1415. WORK TO x. ; INCLUDE NEW NONBEARING PARTITION WALLS, NEW FINISHES, CEILING LIGHTING AND NEW STORE ~h{ FRONT, ELEC, MECH,:PLUMBING WORK TO BE.DONE. REF.: B05-01540,,,: ` <'K € PLUMBING TO INCLUDE: 1 FLOOR'DRAIN, 1 SEWER CONNECTION, 1'WASH BASIN, AND 1 WATER CLOSET... t` FEE SUMMARY AMT QTY ~ `i AMT. QTY .' AMT QTY ISSUE FEE $23.50 Laundry Tub I Washer $0.00 0 Sump Pump $0.00 0 Backflow irrigation $0.00 `0. Landscape Irrigation $0.00 0 Swimming Pool, .$0.00 0 Backflow Preventer $0.00 0 P -Trap $0.00, 0 Trap Primer $0.00 0 Bathtub $0.00 0 Pressure Regulator $0.00_ 10 Urinal $0.00k. D Clarifier System $0.00 0, Process Piping (per 10 ft) $0.00 0 Vacuum Brkr Bkflow(1-4) $0.00 0 Connect (Ice,Soda,etc) $0.00 0 Receptors $0.00 0 Vacuum BrReE kflow(5+) • $0.00 0 Dental Units $0.00 0 Septic Tank $0.00 0 Wash Basin $9.80 1 Dishwasher $0.00 0 Sewer Cap for Demo $0.00 0 Wash Basin Set $0.00 0 Drain, Floor $9.80 1 _ Sewer Connect $24.65. 1 Waste and Vent System $0.00 0 Drain, Rainwater $0.00-. 0. Sewer Private Line $0.00' .'0 _~ Water Closet (Toilet) '$9,80 1 Drain, Roof $0.00 0 '" s,k v Shower.. $0.00 0 Water Heater 1 vent $0.00 0 Drinking Fountain $0.00 0, Sink, bar 2 $0.00 0 Water Piping (Inst or Rep.) $0.00 0 Expansion Tank $0.00, 0"'` "• Sink; commercial $0.00 0 Water Re -pipe $0.00 0 Gas Earthquake Valve $0.00 0 Sink; Floor $0.00 ` . 0 Water Service $0.00 0 Gas (1-4 outlets) $0.00, 0 . Sink. -kitchen ,'_... $0.00: 0 Water Softener $0.00 0 Gas (Over 4 outlets) $0.00 0 -Sink, service/mop: $0.00", '0 OTHER $0.00 Gas Repipe $0.00•0•. Spa.(private) $0.00 0 VIOLATION $0.00 Gas Service $0.00 0" Spa (public) $0.00" 0 PLAN CHECK $0.00 Interceptors (Grease, Oil) $0.00 - 0 ,REINSPECTION $0.00 0 Interceptors (Sand Auto ) $O.OD 0 TOTAL CALCULATED FEES: $77.55 COMMENTS'! SPECIAL.CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 190 days. W INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codeafiand all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of tilF it. FOR INSPECTIONS CALL: (714) 754-5626 2448-48 (8100) DECLARATIONS WORKERS' COMPENSATION DECLARATION:, I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 1 have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' corn tion Insor ce carrier and policy number are: „ Carrier: _ 03 (�d0��..7Policy Number: ! T (This section need na completed If the permit is valued at one hundred dollars ($100) or fess.) � I certify that in the pert oft ork for which th. permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws Galifomi d r that if 1 sh become subject to the workers' compensation provisions of Sec 'on 3700of he Labor Code, I shall forthwith comply with these PIP" ,1 Applicant Signature: Date:Ky�_ WARNING: FAILURE TO SECURE WORKE PENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed undo provisions of Chapter 9 (commentwith Section 7000) of Division 3 of the Business Professions Code, and my license is In full force and effect. Lic. q Class 4 %Contractor's Signature: Date: o�lt d CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lenders Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not intended or offered for sale. 11, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a cnntractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than Ihirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 6, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure), ...............................................................................................................................................................""I'....................................................................................................................................................................................................... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Deparlment by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ...........................................................................................................................................................................................................................................................................................................- ............... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ......................................................................................................................................................................................................................................................................................................................................................................................... 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? [I Yes ❑ No ................................................................................................................................................................................................................................................................................................................................1........................................ 5 Does Or will the applicant or present or future building occupant require for the work which is the subject of this a�pplication a ermit for such construction or modification from the South Coast Air quality Management District or from any other air pollution control district or agency? L l Yes ( No (Section 65650.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ............................................................................................................................................................................................................................................................................................................................................................................................ 6 Will any part of the taci[ity to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). .......................................................................................................................................................................................................................................................................................................................... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No fj"I'll'-, ­­­ .................. ............................................................................................................................................................................................................................................... 6 (I1 es", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signf Legal IjDale ;AL Authorized Applicant Dat6 CODE A. INSPECTION TYPE IHTmAL5 CODE t INSPECTION TYPE jM INTrrtAL 1616 f=ixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 206 Final Plumbing 200 Final Fie-Roof 210 Final Electrical 201 Final Block/Retaining Wail 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 MECHANICAL PERMIT .lob Address: 3333 BRISTOL ST Status: ISSUED Suite No 1415 Applied: 09/26/2005 Issued: 09/26/2005 Vicinity: Parcel Number: 41250107 :. ISSUED BY: Applicant: RAQUEL CHRISTIANSEN = ` Address: 1515 W ALTON_AV Phone:, 714-957-8250 SANTA ANA, CA Y Zip: 92704 Owner: SOUTH CbAST'PLAZA Address: COSTA MESkCA Phone: 3315 FAIRVIEW ROAD Zip: 92626 Contractor: DEVELOPMENT SUPPORT SERVICES INC Address: 1515 W ALTON AV Phone: .714-957-8250 SANTA ANA, CA Zip: 92704 License: 748446 SCOPE OF PERMIT INTERIOR .1176 SF STORE Tl FOR "GIUSEPPE ZANOTTI DESIGN -'IN SPACE 1415: WORK, TO INCLUDE NEW NONBEARING PARTITION WALLS, NEW FINISHES, CEILING LIGHTING AND NEW, STORE FRONT. ELEC, MECH, PLUMBING WORK TO BE DONE. REF.: B05-01540 MECHANICAL TO INCLUDE: 1 REPAIR/ALT COOLINGIHEAT AND 1 VAV BOX. FEE SUMMARY \<; Quantity _ µ .-Quantity ISSUE FEE $23.50 Repair/ Alt Absorbtion Unit: . $0.00 „,:01, Inst FAU <100 k BTU:` $0.00 0 Repair/ Alt Refrigeration Unit $0.00 0 Inst FAU >100 k BTU...$0.00 .0 Ventillation System $0.00" •0 Repair/ Alt Cooling/Heat' $13.70: 1 " Evaporative Cooler $0.00 0, Inst / Rep. Recess Wall Htr $0.00 0 Commercial Incinerator $0100 0 Refrib Sys <100 k BTU: $0.00 0 Domestic Incinerator $0.00: 0 Refrig Sys >100 k BTU,, , $0:00 0 Compressors 1 Absorpt]on'Svstems - 3 Gas Piping $0.00 0 Up to 3 hp /,100 k BTU $0.001, 01 Factory Fireplace $000 0 3 To 15 hp 1500 k f3TU$0 00 0, Hood w[Mech Exhaust $0.00 0 15 To 30 hp 11,000 k BTU $0.00 0 VAV Box $10.65 1 30 To 50 hp 11,750 k BTU $0.00 0 Vent Fan 15ingle Duct $0.00 0 Over 50 hp 1 Over 1,750 BTU $0.00 0 Appliance `; ' $0.00 0 Boilers Fire Dampers `. `=` .:$0.00;.; 0 f•;: .. .' Up to 3 hp $0.00 0 Smoke Dampers $0.00 "0 k s :. 3 To 15 hp $0.00 0 Inst or Relocate App] Vent .: , ,- $0.00. • ` 0' 15 to 30 hp $0.00 0 Air Handlers < 10000cfm .::` "' " . $0.00 "` 0 .: '>:' 30 to 50 hp . > ,> .$0.00 0 Air Handlers > 10000cfm ,' $0.00 0 Over 50 hp $0.00 0 Floor Furnace $000,_. 0 Other. Mechanical Fee, Floor or Suspend Heater $6,0{), '.0 lnvest]gation Fee $0.00 Plan Check Fee, , $0.00 F Reinspection`=Fee, t $0.00 .TOTAL CALCULATED FEES $47.85 COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this.permit. FOR INSPECTIONS CALL: (714) 754-5626 2446.46 (6=) DECLARATIONS WORKERS' COMPENSATION DECLARATION:, I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. I have and maintain workers' Compensation Insurance, as required by section 3700 of the Labor Code, for the performance of tthee work for oorr,/w�hi'ch} this permit iss Lnuod. My works c pensatio9 Insurance carrier and policy number are: ��C_--'l�-�V[f�•��T Carrier: TCL✓I/]i+l Policy Number: (This s on need not be completed It the permit Is valued at one hundred dollars ($ t 0D) or less.) certity that in the performance of the work for which this permit is issued, I shall not employ any person In any manner so as to become subject to the workers' compensation la o gree that if hould become subject to the workers' compensation provisions of Section 3700 c; the Labor Code, I shall forthwith comply with the provl io Applicant Signature: Data: aG % WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTI AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE CAST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed 4A d4 provisions of Chapter 9 (comma%ifing with Section 7000) of Division 3 of the Business Professions Code, and my license Is in full force and effect. Uo. q 74Ad 4 !1— Class ri Y Contractors Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code), Lender's Name: Lender's Address: Signature: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a Civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or Improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). • ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more foot in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .........................................................................................................................................,......................... -•__.............................. ........................... .�............................. �.... ._......... ................ _...................._..................__................ 2 boas ar wltl the applicant or present or future building occupant need to file a registration term for acutely hazardous materials? ❑ Yes 0 No (Section 25533 of the California Health and Safely Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one lime has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .............................................................................................................................................................................................................................................................................................................................................................. 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an FIM PP by businesses which are required to register acutely hazardous materials with the Fire Department. ................... ... ....... ................,..................... .............................................. ............................................... ....................................................................................................... .......................... ................. ................................... 4 11 an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? [3 Yes ❑ No ................................. .........._........................................................................................... ............................................... ...----............................................................. ..................... ...................................... --.................................................... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication aEgermit for such construction or modification from the South Coast Air duality Management District or from any other air pollution control district or agency? LJ Yes LJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). .......................................................................................it-h-i....................................... -•--.........................................................................e...................................................................................... 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries 4t a school? ❑Yes ❑ No (If yes", the facility must moot the requirement o1 Sections 25534 and 42303 of the California Health and Safety Code). ................. .............. ..................................................................................... ......-............----..................................... .....-----......................................................................................................................................... --............................... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No _.........................—..............................................................._...�_.......................... _..................... —.................... —_.................................... ----..... _..... _........................ _.................... _...................... —.................... 8 (if "Yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all stale laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of penury that I have read this application and state that the information given Is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-doscribod property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection, p 41 g lure Of L 1 0Wner(s) QaIPJ.� And/Or Authorized -Applicant Dile ;,POE>>. INSPECTION TYPE 2AR INTITIA CODEI_I INSPECDONTYPE } 2AR IflTITIA9 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1 I - IS= 05 a(y 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolitlon 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesad?CTRICAL PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Suite No 1415 Vicinity: GIUSEPPE ZANOTTI DESIGN Parcel Nunmber: 41250107 Applicant: MARK HUNTER Address: ... ^^ ISSUED BY: Contractor: HARBOUR ELECTRIC Status: ISSUED Applied: 10/0612005 Issued: 10/06/2005 `, Address:' 5445'OCEANUS DR Phone: 714 373-3055 HUNTINGTON BEACH CA Zip: 92649 License: 707899 SCOPE OF PERMIT, n A:INSTALL 119FIXTURES; 12 OUTLETS, 3 SWITCHES FOR "GIUSEPPE ZANOTTI:DESIGN";STORE TI: RE305-01540. FEE SUMMARY Quantity : - Quantity ISSUE FEE $23:50 Temp Dist System 1 Lighting $O.OQ 0 <>"Temp service test `° $0.00 Busway 1100 ft- _ ;, $0.00 <0. Res: alc package $0.00 Standing Section "' $0.00' 0 New Res (f-2 units) . $0.00, 0 Misc Electrical Equipment $QAO. 0 ' New Res (3+'units) `, �. `"$0.00 0 .r Transformers up to:l"kvalkw $0.00 ;:. 0 Pool I Spa $0.00 4 - . ; .......up to 10 kvalkw $0.00 0 a Lighting Fixts .$94.27 119 '• °`_ .................up to 50 kvalkw $0.00 : 0 Recept Outlets x,$13.20 >:.:; 12 .................up to 100 kvalkw $0.00 0 Switches - $9.30 3 ..................over 100 kvalkw $0.00 0, Non Fte's Appl ; < $0.00 0 Low Voltage Equipment $0 00 0 Res App] $0.00 0 Low Volt Wiring System I Ckt $0,00, 0 Service to 200a $0.00.: 0 Misc. Conduit $0.00 10 Service to 1000a $0.00 0 "Misc. Conductor $o.00.. 0 Service over 1000a $0.00 ' 0 Circus (gen or ride) $0.00_.: 0 Motors to 1 h .$0.00 0 Circus (mech ride or lights) $0.00 0 :. Motors to 14hp' $0.00 " 0 _'?` Christmas Tree Stand $O.OQ 0 Motors to 50hp $0.00 0 .. Fireworks Stand . $0.00 ,. 0 Motors to 100hp $0.00 ry ff Other Electrical Fee $0.00 Motors over 100hp $0.00 0 , Communication drops , $0.00 0 Investigation Fee ,. $0.00 Sub panel to 200a $0.00 ' 0'^;..,.Plan Check Fee •,, $0.00 Pole Light Pkg $0.00, 0 Reinspection Fee'='f r $OAO Sign Circuits $0.00 g'0 x Temp Pwr Pole $0.00 0 . TOTAL CALCULATED FEES $134.27 Intermed Pole $0.00 0" 0- 'COMMENTS 'COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 1130 days, or if work Is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446-46 (sroo) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to salt -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. ❑ I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Cade, for the performance of the work for which this permit is issued. My work rs' compensation Ins carrier carrier and policy number are: 0� �(�6 Carrier: �* r /� r�.rs ��f _ Policy Number: (rhis section need not be completed if the permit is valued at one hundred dollars (Sf0 )OD or less.) ❑ 1 certify that in the performance of the work for which this permits Issued, I shall not employ any person In any manner so as to become subject to the workers' compensation laws of California, ago agree that if I should b a subject to the workers' compensation provisions of Section 370G of the Labor Code, I shall forthwith comply with these ovisfons. Applicant Signature: Date: lll� WARNING: FAILURE TO 9&RE WO S' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE {5100,0001, IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3700 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am fico ed under provisions of Chapter 9 (commencing with Section 7 ) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic. qQ Class N C r� Contractors Signature: 4 Date: _ .,:fa — CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Cade). Lenders Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis tot the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($50G).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or Improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. It, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ' ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. Q Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth Into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, fatsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 6, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the Cafifomia Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ..... . ................................................_................. .............................................................................................. ....... ........... -......... ....... ............... .......................................... ......................................... ........... .................. ---.......... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant Head to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials}? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. _................------.........-----._._...._..._..—..........................._—...._........._.......—_.......................--••-----....................................................----...... .........---..............---..._......_-- 4 It an RMPP is presently required, has Section 25534 of the Califomia Health and Safety Code been fully complied with? Q Yes ❑ No ............................................................................................................................-............................,......................................................................................................................I............................. .......................................... 5 Does or will the applicant or present or future building occupant require for tho work which Is the subject of this a plicatlon a rrnit for such construction or modification from the South Coast Air Quality Management District or from any other all pollution control district or agency? Ll Yes �No (Section 65850.2 of the California Government Code requires that the requested Information be tumished an applications for non-residential building permits). 6 Will any part of the facility t0 be constructed under this permit be within 1000 feet from the outer boundaries at a school? ❑Yes ❑ No (if 'fres", the facility must meat the requirement of Sections 25534 and 42303 of the California Health and Safety Code). _..........................-- _... _...... T_ ........................ _.—....................... ---.............. .................. ._.._............................................................... .._._...-....................... —_................ — ................. — 7 If a permit from the South Coast Air Quality. Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes Q No upvi __................................................................. —...___.._..................... .................... ..................... — 8 Qf yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certity that under penalty of perjury the Information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree t0 comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes, I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Si at Le al Owner(s) U Date OV And/O Authorized Applicant Uate COPE 1. INSPECTION TYPE un ISL$ CODE.I INSPECTION TYPE JET JNTITIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Root 210 Final Electrical {/J'T�d�/ 201 Final Block/Retaining Well 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 ' Final Demolition 250 Final Building/Occupancy r (714) 754-5273 • Fax (714) 754-4456 • www.cl.costa-mesa.61MILDING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Suite: 1415 Vicinity: STE1415 GIUSEPPE ZANOTTI DESIGN Primary Occ: M Display/Sale Merchandise Type of Construction: I -FR Parcel Number: 41250107 Zoning: PDC Applicant: RAQUEL CHRISTIANSEN Address: 1515 W ALTON AV SANTA ANA, CA Owner: SOUTH COAST PLAZA Address Phone: 714-957-8250 Zip: 92704 ' Status: ISSUED Applied: 09/07/2005 Issued: 09/26/2005 ISSUED BY: s1 �i r COSTA MESA CA Phone: $231.a6 3315 FAIRVIEW ROAD Zip: 92626 Contractor.. DEVELOPMENT SUPPORT SERVICES INC $0.00 Address: 1515 W ALTON AV ". $37.04 Phone: 714-957-8250 SANTA ANA, CA $0.00 Zip: 92704 License: 748446 , Arch : PIERLUIGI SONVICINI ARCHITECTURE INC Eng: Address: 2901 W MAC ARTHUR Address: SANTA ANA, CA Zip: 92704 Phone: 714-957-8250 License: C17303 Phone: License: SCOPE OF PERMIT INTERIOR 1176 SF STORE TI FOR "GIUSEPPE ZANOTTI DESIGN" IN SPACE 1415. WORK TO INCLUDE NEW NONBEARING PARTITION WALLS, NEW FINISHES, CEILING LIGHTING AND NEW STORE FRONT. ELEC, MECH, PLUMBING WORK TO BE DONE. Plan Check: $231.a6 Permit: $1,424.95 SMIP Res: $0.00 SMIP Com: $37.04 Other: $0.00 Inspection: $0.00 Total: $1,693.55 SETBACKS MAIN STRUCTURE Front 0- 0 ACCESSORY Front 0-0 PARKING Existing: 0 FEE SUMMARY Calc Valuation: $176,400.00 Claim Valuation: $176,400.00 PLANNING & ZONING Rear 0-0 Left 0-0 Right 0-0 Rear 0-0 Left 0-0 Right 0-0 Reouired: 0 Proposed: 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become vold if work is not commenced within 180 days, or if work Is suspended/r abandoned for a period of 180 days. INSPECTION& In order for the work authorized under this permit to be considered legal, such work must comply with all applica codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiratio f this permit. FOR INSPECTIONS CALL: (714) 754-5626 2aa8-4e (6100) DECLARATiONS WORKERS' COMPENSATION DECLARATION:' hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Mbar Code, for the performance of the work for which this permit is issued. `};have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. My workers' compensation insurance carrier and policy number are: Carrier sem` 1~PoSEy:Ntanber [Th is ssection need not be completed if the permit is valued of one hundred dollars ($100) or less.) ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation lawsr, ' , gree that i should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these o gpplicantSfgn#atu^-=Y ,! Dated•ds _ WARNIN[i' FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUEUECT AN EMPLOYER TO CRIMINAL PE TIES AD CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereeby_affirn•that l•am-licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business a8Professions Code, and my license is in full force arld effect.-L'Ic-H" CCfi3ss .may Cont'actoes•Si99ature: Qate:. CONSTRUCTION LENDING AGENCY: ❑ t hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Londer's Name: Lenders Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty o1 perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professlons Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or Improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Cade for this reason: Signature: Date: Owner ID verified by ddvees license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, Califomla Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Pian for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be tiled with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form far acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with soma exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). —..........................................-.........................._._........................................._........................._.__.................._—.............._............................-•-•--•--__..._............................. ....._......................... — ................ . .._.. 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ................................................................................................................................................—........................... _ .........................•.................................. _—...................... _—_....... ........ 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No _............................................................................................................................._..............................................._.._.................................._.._..................................._............................_....... — .. 5 Does or will the applicant or present or future building occupant require for tha work which Is the subject of this a plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes � No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). .......................................................r;. i.-----..w-iti..-in...............................................1a.;............d- .d - i.o-f-....s ---o -1--iis.-............---....................................................................... 6 Witl any part of the facfiiry to be constructed under this permit be within 1000 feat from the outer boundaries of a school? ❑Yes ❑ No (If 'yes", the facility must moot the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ............................................................................................................. 1­11.­­1 ...................................... 1111"I'll ............................................... ..................................................... . ....................... 7 li a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all 01 the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (If "yes", attach cer1ificate of compliance from time appropriate air pollution 0Onlr01 officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Data: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. lure Of L er(s) �AndlOr Autho zad Applicant',— CODE f. INSPECTION TYPE PAI)i INTMAL CODER INSPECTION TYPINTITIA 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing I 200 Final Re-Roof 210 Final Electrical ` ! 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Mace 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 a Fax (714) 754-4856 a www.cl.costa-mesa.00LHLDING PERMIT ,lob Address: 3333 ~BRISTOL ST COSTA MESA CA Suite: 1415 3315 FAIRVIEW ROAD Vicinity: Contractor:' . 'SOUTHWEST SIGN -CO Primary Occ: M Display/Sale Merchandise Type of Construction: I -FR Parcel Number: 41250107 Zoning: PDC Applicant: BECKSTROM, REBECCA CORONA, CA Address: 1540 COMMERCE ST - r License: 724929 UNIT G Phone: 909-734-6275 Eng: CORONA, CA Zip: 92880 Owner: Ad SOUTH COAST PLAZA Phone: 77 FAIR DRIVE, COSTA MESA, CA 92625 1 Status: ISSUED Applied: 10/11/2006 Issued: 10/11/2006 ISSUED BY: ress COSTA MESA CA Phone: 3315 FAIRVIEW ROAD Zip: 92626 Contractor:' . 'SOUTHWEST SIGN -CO Address: 1540 COMMERCE ST' UNIT G,,,' Phone: 9AW-734-6275 CORONA, CA .; Zip: 92880 License: 724929 Arch :. Eng: Address: Address: Phone: Phone: Zip: License: License: SCOPE OF PERMIT INSTALL 2 ILLUMINATED STOREFRONT SIGNS AND 9 NON -ILLUMINATED STORE FRONT SIGNS FOR "CARTIER" IN SPACE 1415. 5- 6'11" S.F. SIGNS" ' 2 - T5" S.F. SIGNS 2 - 2'9"S.F. SIGNS 2 - 3'6" S.F. SIGNS FEE SUMMARY Plan Check: $267.77= - Calc Valuation: $26,s85.00 Permit:• $411.95 , _- Claim Valuation: $26,885.00 SMIP Res: $0.00 ' SMIP Com: $5.65 ' Other: $0.00 _ Inspection: $0.00 Total: $685.37 �•� PLANNING & ZONING - SETBACKS MAIN STRUCTURE Front 0-0, 'Rear 0-0 Left 0-0 Right 0-`0 ACCESSORY l Front 0 / 0 Rear ' 0- 0-.' Left 0-0 Right '0'0 f l PARKING Existing: 0' Required: . A _ Proposed: 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void it work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 348-46 (6400) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is Issued. �� have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit Is Issued. My w erecompensation Insurance carrier and policy number are: Um r: �O A-,- _---_ _---_-- Palicy,Number. b d3 3 17 section need not be completed If the permit is valued at one hundred dollars ($100) or less.) ❑ I certify that in the performance of the work for which this permit Is Issued, I shalt not employ any person in any manner so as to become subject to the workers' compensation laws alifornla, and agree the f I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these r I 'ons. IR TA Stgnaturer - WARNING .FAILURE SECURE WORKERS' COMP SATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPEA TO CRIMI PE IES AND CIVIL FINES UP TO ONE HUNDRED T1�OUSAND {5100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR DE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed and r pfovisions of Cha ter 9 (commencing with Section 7000) of Division 3 f thoGusing s and Professions Code, and my license is in full force and effea C7a7! '_vonUaators'/ ala "a. f" J✓' .. � CONSTRUCTION/EN DING AGENCY: ❑ I hereby affirm that there is a construction rending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter. Improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner o1 the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement Is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's Ucense No. Expires: Verification of Ownership by (type of document, I.e. - property tax bill or dead): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsawork, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industria! Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). bu,iI'd-I'........................................."'I'l'.....................r-a"'t..................io"'r,..........................a' r' ..................a"d, "I's".................-e .................----...................... ................... ........... 2 Does or wi11 the applicant or present or future building occupant need to IIIc a registration form for acutely hazardous materials? ❑Yes ❑ No (Section 25533 o1 the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal 10 or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). __ .........................._......................................................................._._.................................................... _..................... ......................................... _.._.......... _.—_.._......................... _............... _.._............................................... 3 ❑oe 8or will t© applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. .....___......._........................._................................................................................alif...rnia......................._.... t"o".............ie -......... f'u"'ll'y'.._...._.Ilo'-d.w,ii........_.............................................. _................ ....................... ............. 4 If an RMPP is presently required, has 5action 25534 o.. the California Health and Safety Code been fully complied with? ❑Yes ❑.No 5 Does ar will the applicant or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency?Yes No (Section 65850.2 of tho California Government Code requires that the requested Information be fumished on applications for non-residential building permits). ...­­_W'a'n � _......'a'n..............................................................................................................................................................................................................._.................s...............„......................................................................................................... fi Wiany part of the fadlity to be constructed under this permit be within 1000 teat tram the outer boundaries of a school? ❑Yes ❑ No (it 'yes'. the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). --................................._........th............—..................................... �....................................................... ............................... _ .................................................................................................. 7 If a permit from e South Coast Air Ouality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes [I No --._.............. — ...._ _....... ............ _ ...........-_............. -... ___...-... _.-...... _............. ..._---................ _..�...�............... .._........... 8 (It jres", attach certificato of compliance from the appropriate air pollution control officer), CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described roperty for Inspection pu . I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature al Ow (s Da Arrdfl7r A �ocrli�dlApjillesyt'i�`a,�:a. �_ . I a e ',;:.. �. INSPECTION TYPE 2M CODE 1 , IRSPECTION TYPE IKTMAL 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing. 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign b 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 - Fax (714) 754-4856 - www.ci.costa-mm9tj sCTRICAL PERMIT .lob Address: 3333 BRISTOL ST Suite No 1415 Vicinity: Parcel Nunmber: 41250107 Applicant: BECKSTROM, REBECCA Address: 1540 COMMERCE ST UNIT G CORONA, CA , Phone` 909-734-6275 Zip 92880 - 77 FAIR DRIVE, COSTA MESA, CA 92626 Status: ISSUED Applied: 10111/2006 Issued: 10/11/2006 3 ISSUED BY: t NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 160 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446 -as (6=) Owner: SOUTH COAST PLAZA Address , /COSTA'MESA CA , Phone: - 3315 FAIRVIEW ROAD - Zip: 92626 Contractor. SOUTHWEST SIGN CO Address: 1540 COMMERCE ST UNIT G Phone: 909-734-6275 CORONA, CA Zip: 92880 . License: 724929 -- -- ' SCOPE OF PERMIT 'INSTALL 2 ILLUMINATED STOREFRONT SIGNS AND 9 NON -ILLUMINATED STORE FRONT SIGNS FOR "CARTIER" IN SPACE 1415. REF.: B06-01724 ELECTRICAL TO INCLUDE: 2 SIGN CIRCUITS. FEE SUMMARY Quantity - Quantity ISSUE FEE 523.50 Temp Dist System ! Lighting $0.00 0 ' Temp service test $0.00 Busway 1100 ft $0.00 0 Res. alcpackage $0.00 Standing Section r $0.00 0 .New. Res (1-2 units) $0.00 0 ` Electrical,0 - "_ _ Misc Electrical Equipment $0.00 ' New Res (3+units) $0.00 0 ' ': Transformers kvalkw ,' $0.00 0 Pool 1 Spa $0.00 0 .................up to 10 kvalkw $0.00 0 .` Lighting Fixts $0.00 0....... .......... up to 50 kvalkw $0.00 0 Recept Outlets $0.00 0 ....... .....up to 100 kvalkw $0.00 Switches . $0.00 0 ................... over. 100 kvalkw $0.00 0' Non Res Appl $0.00 0 Low Voltage Equipment $0.00 11"1:0-1 - Res Appl $0.00 0 ,= * ".. Cow Volt Wiring System 1 Ckt $0.00 0 Service to 200a $0.00 0 Misc. Conduit $0.00 0 Service to'1000a "$0.00 0 Misc. Conductor;-_ $0.00' , 0 Service over 1000a $0.00 , 0, ` ~ Circus ( gen or ride) .*,$0.00. 0 Motors to 1hp . $0.00 6, Circus (meth ride or lights) '$0.00 0 ' Motors to 10hp $0.00 . , 0 Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 01- - ` Fireworks Stand $0.00 0 Motors to 100hp $0.00 _ '0 _ Other Electrical Fee .$0.00 Motors over 1 00h $O.DI)- o-- '1 , 1'- Communication drops $0.00 0 Investigation Fee $0.00 Sub panel to 200a .$0.00 0 Plan Check Fee $0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $49.20' 2 Temp Pwr Pole $0-00,' 0 TOTAL CALCULATED FEES .$72.70 Intermed Pole $0.00 0`' : COMMENTS 1 SPECIAL CONDITIONS t NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 160 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446 -as (6=) DECURATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations, ❑ I have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the labor Code, for the performance of the — work for which this permit Is Issued. IR Chave and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit Is Issued. my-W9 cgmpensation Insurance carrier and policy number are: ary Cer. / Q/J orcyN`um`ber-_99iC/4 O Do�,zr _ �fhis section need not be completed r1 the pemut is valued at one hundred dollars ($100) or less.) ❑ I certify that in the performance of the work for which this permit is Issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that i1 I should become subject to the workers' compensation provisions of Section 700 of he Labor Code, I shall forthwith Comply with these provisions. �A O[ate r� -WARMNG�FAMURE'TO-SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMI ENAL S AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE (Si 00.0001, IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I herebfrn.ihat l.am.licens d under r io of apter 9 {co ening with Section 7000) of Division 3 of,,1th,Bu6inass nd Professions Code, and my license Is in full force and effect. fac.J, ass p C�ontracto 68r' 6gnature:-r••-,- — - [Dale:, 199y CONSTRUCTION LEND# G AGENCY: ❑ f hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or Improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Seo. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No, Expires: Verification of Ownership by (type o1 document, #.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more loot in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, An 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signalure: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .....................•.-...........--...-•----...........................................................................................................................................................................................................................................-........,..................................................._............... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater then a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ............................................................................................................................................................................................................................................................................................... •................................................1..............I............... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and tiling with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ....................._..........-......_.....-..-....................._ _.-......................................................................................_..........................,........................ __.................... __........ 4 If an RMPP is presently required, has Section 25534 of the Califomia Health and Safety Code been fully complied with? ❑ Yes ❑ No ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------_...........................................................................------................. 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this a plication a ermii for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? 8 Yes No (Section 65850.2 of the California Goverment Code requires that the requested information be furnished on applications for non-residential building permits). 5 Will any pari of the facility to be constructed under this permit be within 1000 foot from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes . the facility mustmeet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ...... ...................................................................................... ...- .......-.. 7 if a p It from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which Is the subject of this application, have all of the disclosures prescribed by California Haaith and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (it "yee, attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of pedury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-do scrib roperty for inspection purpose . groe not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature Of 01 Owner{ r ate L,` AndlOf Au onze .Applicant, `"'� Da1e CODE A, INSPECRONTYRE INTITI6LS CODE! INSPECTIONTYPE QBIE 1NTITAL$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical S a 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final BuildinglOccupancy (714) 754-5273 - Fax (714) 754-4856 - www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 BUILDING PERMIT Job Address. 3333 BRISTOL ST Suite: 1520 Vicinity! Primary Occ: M Display/Sale Merchandise Type of Construction: I -FR Parcel Number: 41249102 Zoning: PDC Status: ISSUED Applied: 07112/2005 Issued: 07/12/2005 Applicant: JEFF REICH Permit: ISSUED BY: Address: 12439 MAGNOLIA BLVD SMIP Com: $0.84 Other: SUITE 113 Phone: 818-764-1909 Total: N HOLLYWOOD,'CA Zip: 91607 Owner: SOUTH COAST PLAZA Address 3315 FAIRVIEW AVE MISC. Phone: COSTA MESA, CA Zip: 92626 Contractor: MALL SIGNS AND SERVICE Address: 12439 MAGNOLIA BLVD SUITE 113 Phone: 818-764-1909 N HOLLYWOOD, CA Zip: 91607 License: 811074 Arch = Eng: Address: Address Phone: Phone: Zip: License: License: SCOPE OF PERMIT . INSTALL 1 ILLUMINATED WALL MOUNTED SIGN AND 2 NON -ILLUMINATED SIGN ON EACH SIDE OF THE MAIN ENTRY FOR WALENTINO" SPACE 1520 Plan Check: $63.21 Permit: $97.25 SMIP Res: $0.00 SMIP Com: $0.84 Other: $0.00 Inspection: $0.00 Total: $161.30 SETBACKS MAIN STRUCTURE Front, 0- 0, / ,' Rear 0-0 ACCESSORY Front, 0-0,.- Rear 0-0 PARKING Existing: 0 Required: 0 FEE SUMMARY , Calc Valuation: Claim Valuation PLANNING & ZONING Left 0-0 Right 0-0 Left 0-0 Right 0-'0 Proposed: 0 $4,000.00 $4,000.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, g 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 244046 (8=) 771 DECLARAVONS WORKERS' COMPENSATION DECLARATION: 1 I hereby affirm under penalty of perjury Otis of the following doclaratlons: ❑ I have and will maintain a cortificato of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued, `f flava and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit Is Issued. My wo ars' compensation Insu cantejnd policy number are: ��'� ']�ry,.,� �Cerrier �� C%A) Policy -Number: L�L�-4�` C. 00_, __ (This sactian 1 be completed if tho p�ermf is valued alone hundred dollars ($100) or less.) {_� N ❑ 1 certify that in the performance of the work for ich this permit is issued, I shall not employ any person In any manner so as to become subject to the workers' compensation laws of Call}Omla, a agree that ii hould beco a subject to the workers' compensation provisions of Section 3700 Of the Labor Code, I shall forthwith comply with these 0slops. nature: Date:--- - �. WARrJING; FAILURE TO SE RS' T10N COVERAQE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CR MINAL PENALTIES AND CML FINE$ UP TO ONE HUNDRED THIOUS,W D DOLLAAE (SIOO, , IN ADDITION TO THE COST OF C.OAI ENS4T1ON. DA.%4GES AS PROVIDED FOR IN SECTION 37DO OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: hereby affirm that I am licensed der rovislons o Chapter 8 (commencing with Section 7000) of Division 3.of•the Business and Profess) Code, and my license is In full ,fOrce'andeffect­Lic: sk ` "', C a� C� Gonlractors,SSIgna star -7 Date: �! CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is Issued. (Sec. 3097, Civil Code). Lenders Name: Lenders Address: Signature: Data: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of podtlry that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors license Law (Chapter 9 (commencing with Section 7000) of Dtvfslon 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($.500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or Improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. It, however, the building or Improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose Of sale.). - ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Coda: The contractors License law does not apply to an owner of property who builds or Improves thereon, and who contracts for such p"e t with a conlractogs) license pursuant to the Contractors License Laws.), ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: _ _ _ Date: Owner ID verified by drivers license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet In depth Into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffotding, falsewcA. or damoblion or dismantling thereof, will be more than thirfy-slx (36) fear high, (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release Of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Pian be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater then a weight Of 500 pounds, or a volume of 55 gallons, or 200 cubic feat of compressed gas at standard temperature and pressure). _.................. _.__.. _........._...---......_—................_...._....------- .. _............ _ ............m -. 2 Doas or will the applicant or preentOrsfulure building occupant need to file a registration form for acutely hazardous materials? ❑Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity 4f acutely hazardous materials equal to or greater than a weight of 50O pounds, or a volume Of 55 gallons, or 200 cubic fest of compressed gas at standard temperature and pressure). _........_._............. .......................___.............................................. ,...... ...................... ............. ..................---....................... _........................... ............-.-..-..,-,...............,--....._...._....----............. __............................ 3 Does or will the applicant or present Or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Hettith and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. Yes ❑ No 4 if an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ .. ... -1 ...... �..._....... ....................................._._.........-....,—..............................,...................... 5 Does or will the applicant Or present or Futu..ro..._.bultding.....—_.......occupant....... raqulr_a for the work which is the subject of this �ppplication a�ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes LJ No (Section 658.50.2 of the California Government Code requires that the requested information be fumished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If yes-, the facility must meet the raquirement of Sections 25534 and 42303 of the California Health and Salary Code). 7 if a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disdosurgs prescribed by Celifomia Health and Safety Cade Section 42303 been made? ❑ Yes ❑ No _ _ .............................. _ _ ....... _........................_.. ...... _..._........................ __ _........ 8 (If yes', attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the Information given above Is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: _ Date: CERTIFICATE OF COMPLIANCE AND AVTHOR¢ATION OF ENTRY: 1 certify under penalty of porjury that I have read this application and state that the Information given Is Correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signattire Of Legal O er ) 1 �pate� 6 z9&-roptrcant-•- Orr .� CODE 0, INSPECTION TYPE 2M IKIWA $ CODE / INSPEOON TYPE 2&M fNTITIA�$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.cl,costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT Job Address: 3333 BRISTOL ST Suite No 1520 Vicinity: Parcel Nunmber: 41249102 Applicant: JEFF REICH Address: 12439 MAGNOLIA BLVD ' SUITE 113 - " - ' Phone: 818-764-1909 N HOLLYWOOD, CA (_ - Zip 91607 f Owner`: SOUTH COAST PLAZA Address '3315 FAIRVIEW AVE misc. Phone: COSTA,MESA, CA Zip: 92626 Issued: 071`1212005 'FEE SUMMARY.;, Contractor: MALL SIGNS AND SERVICE., f _ Address: 12439 MAGNOLIA BLVD . �.- SUITE 113 Phone: 818-764-1909 N HOLLYWOOD, CA Zip: 91607 $23.50 License: 811074 Status: ISSUED Applied: 07/12/2005 Issued: 071`1212005 ISSUED BY: ` SCOPE'OF PERMIT._- ' INSTALL 1 ILLUMINATED WALL MOUNTED SIGN AND 2 NON -ILLUMINATED SIGN ON EACH SIDE OF THE MAIN ENTRY FOR "VALE NTINO" SPACE 1520. REF.: B05-01153 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 2"648 (6100) ELECTRICAL TO INCLUDE: 1 SIGN CIRCUIT., 'FEE SUMMARY.;, Quantity Quantity ISSUE FEE $23.50 Temp Dist System / Lighting $0.00 0 Temp service test $0.00 Busway 1100 ft $0.00 0 Res. a/c package $0.00 Standing Section $0.00 0 New Res (1-2 units) $0.00 0 ~' Misd Electrical Equipment $0.00 , 0 New Res (3+units) $0.00 0 Transformers up -to 1 kvalkw $0.00 ,-" 0 Pool 1 Spa `$0.00 0 .. .........up to 10.kvalkw $0.00 0 Lighting Fixts $0.00, -0 ..........up to 5o kvalkw' - $0.00" 0 Recept Outlets $0.00', 0 ..........:......up to 100 kvalkw $0.00, 0 Switches ,' $0.00 ;- 0 ..................over 100 kvalkw $OAO 0 Non Res App] _ $0.00 0 , �,_ Low Voltage Equipment, : $0.00 0 Res Appl $0.00 O`__ Low Volt Wiring SystemI Ckt - $0.00. 0- Service to 200a ��� $0:00 0 Misc. Coridu]t - $0,ob- ` 0 Service to 1000a \ -.�' .$0.00` /0 Misc. Conductor - -',-$0.00,,, l 0 - Service over 1000a ` ' ^-$0.00 -0 ' ', r Circus ( gen or ride) '10.00"1'' 0 Motors to 1hp ''-$0.00 - 0 Circus (meth ride or lights) $0.00 0 Motors to 10hp $0.00 0 Christmas Tree Stand ;' $0.00 0 Motors to 50hp $0.00 0 -- Fireworks Stand _ .-"$0.00 $0.00 0 Motors to 1 00h $0.00 0 Other_ Electrical Fee ` $0.00 Motors over 100hp $0.00 0 Communication drops $0"00 0 lrivestigation Fee $0.00 Sub panel to 200a $0.00 0 Plan Check Fee $0.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 2"648 (6100) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the fallowing declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensatlon, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. I have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. --My workers' co_ mpensation urance carrier and policy number are: a O �- Cam'er Y25 Polley Number. -- `(.This s'Bcilal need not be completed if the permit is valued at one hundred dollars ($100) or less.) ❑ 1 certify that in the performance of the work for which this permit Is issued, I shall not employ any person In any manner so as to become subject to the workers' compansatlon laws of California, and agree t ' shoul ecome subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these sio , .Applicant Slgnatura:'`x ll l Date; ;-7 4 Z 0 S WARNING: FAILURE TO SE TION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPWYER TO CRIMINAL PENALTIES AND CIVIL FINES UP 70 ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby afflrm'that l am licensed under revisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Prof scions Code, and my license is In full force and effect. L C: # C� Cmtractots Signature: Date; c --' r CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is Issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any pry or county which requires h permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License taw does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his Or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors license laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license- ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more toot in depth Into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, AA 2, Sec. 341, Title 6, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: — ____ Date: Division of Industrial Safety Permit Number. HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume o1 55 gallons. or 200 cubic feet of compressed gas at standard temperature and pressure). .... ............................................................................................................... ._................................................... ............................................................... ................................ _................................. _.._.............................. 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant ent or fut or presure building occupant need to prerepaan RMPP (Risk Management and Prevention Program for acutely hazardous materlats)? ❑ Yes ❑ No Section 25534 of the Califamia Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. _...................._.................---•-•--......._._...._...._._....._—....................—.................. _........................ ............... .................................................. _......... ...............�............. � ._.. 4 Ilan RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No .....................-.................._ -- ---._.—........-...............—.................................--....----.....-...................................................................-................._..._.....—............_.—...........-- 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication armit for Such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes IggeNo (Section 65850.2 of the Califomia Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will an an of the facili to be conwructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'fres", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ...................................._....._----................. _..... -....................... ...--................ ----................... _...... _.................................................. ..........---...................................................... _...................... ................. ........ -...-... ..-...... ------- 7 ff a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No _....... _._...._....._ . _... .......................... _............ ...._....-- - - 8 (If yes", attach certificate or Compliance. ...... from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Smissions. Signature: _ Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances rotating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. I tura qt e a n1r(s) Data ,%AnVr0j. Applicant • �; w._ Data ' CODE f:, INSPECTION TYPE JIM IlilIIllACODE r INSPECTION TYPE 2AR fNMIALS 1616 Fixed System Final Fire Prevention 2D6 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Root 1 Final Electrical ��- 201 Final Block/Retaining Wall Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Flnaf Sign 222 Finaf Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 - Fax (714) 754-4856 - www.ci.costa-mFIRE SUPRESSION PERMIT i7 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Suite: 1520 Vicinity: STE 1520 (VALENTINO) Parcel Number: 41249102 Zoning: PDC PDC Applicant: APODACA, DENNIS Address: 1200 RIDLEY AV Phone: 323-626-0043 HACIENDA HEIGHTS, CA Zip: 91745 Owner: SOUTH COAST PLAZA Address 3315 FAIRVIEW AVE MISC. Phone: COSTA MESA, CA Zip: 92626 Contractor: APODACA, DENNIS Address: Status: ISSUED Applied: 05/23/2005 Issued: 06/03/2005 ISSUED BY: UjJ Phone: Zip: License: 676834 SCOPE OF PERMIT RELOCATION OF 45 HEADS AND ADDITION OF 3 HEADS IN CONJUNCTION WITH THE 2.940 S.F. INTERIOR TENANT IMPROVEMENT " VALENTiNO" SPACE 1520. REF# 805-00531 FEE SUMMARY, Plan Check: $81.41 Permit: $125.25 Other: $0.00 Total: $206.66 r Calc Valuation: $6,000.00 Claimed Valuation: $6,000.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days, or If work Is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result In the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 A46-8 (SW) DECLARAVONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate o1 consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 3,;-1 have and will maintain workers' compensation Insurance, as required by section 3700 of the labor Code, for the performance of the work for which this permit is issued. *-f -My workers' Compensation Insurance carrier and poilcy number are: Camgr �]2� �� U� �0- _ Policy Number: & �a 7 -2— (This Z I , (This section need not be completed if the permit is valued at one hundred dollars ($ 100) or less.)�- ❑ 1 certify that in the performance of the work for which this permit is Issued, I shall not employ any person In any manner so as to become subject to the workers' compensation w f California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with dase pr sions. Applica'I Signatu !:• : Date: WING, FAIy LURE ECURE WORKS ' COMPENSATION COVERAGE IS UNLAWFUL AND SWILL SUBJECT AN EMPLO EFi TQ CRIMINAL PENlILT1ES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLL ARE (S100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNIErS FEES. LICENSED CONTRACTORS DECLARATION: hereby affirm that I am licensed andr provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Businea and Professions Code, and my license Is In full force anndQIAL;eHect effect- ClassM �4 — / � --- Contraclors Signatur.. Date:.ffj 3 - U S� ,- - —. CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lenders Name: Lenders Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to Its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (SSW).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professlons Coda: The Contractors license Law does not apply to an owner of property who builds or Improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or Improvement Is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or Improve for purpose of sale.). • ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec, 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractors) license pursuant to the Contractors License laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet In depth Into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thlrty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -bulkier, 1 will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Data: Division of Industrial Safety Permit Number- HAZARDOUS umberHAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Pian be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ....._................... .._ ._._ — --._._.......... ---........................................... _.................... ...... 2 Does ar will the applicant or present or future building occupant need to file a registration farm for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requites regfstratlon with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 DoeYs or will th❑e applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? No (Section 25534 of the California health and Safety Code provides that the Costa Masa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. _............................................... ........-..................... _. _ --- -- _ 4 I1 an RMPP ispresentlyrequired, has Section 25534 of the California Health and Safety Code been fully compiled with? ❑ Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this a plication a�ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes Mile (Section 65850.2 of the California Government Code requires that the requested Information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries o1 a school? ❑Yes ❑ No (if yes", the facility must meet the requirement Of Sections 25534 and 42303 of the California Health and Safety Code). 7 if a permit from the�South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (if -.attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: i certify that under penalty of perjury the Information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given Is correct. I agree to comply with all state taws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature Of Legal Owner(s) _ Date And?Or Authorized,Appllcani Data— coot. INSPECTION ?IPE QAEB NTrn844 CODE i INSPECTION TYPE Q1,jE KTITIA 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final BlockfRotaining Wall 212 Final Fire Prevention 7't -x -o 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Buflding?Ocouponcy (714) 754-5273 • Fax (714) 754-4856 • www.ci-costa-mesa.ca.us NG PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST FEE SUMMARY Status: ISSUED Suite: 1520 Calc Valuation: $75,000.00 Permit: Applied: 03/17/2005 Vicinity: SPACE 1520 SMIP Res: $0.00 Issued: 04/11/2005 Primary Occ: M Displayl5ale Merchandise Type of Construction: I -FR Parcel Number: 41249102 Zoning: PDC Inspection: Applicant: HURST, SCOTT Total: ISSUED BY: [ A-0 Address: 2377 S. EL CAMINO REAL PLANNING & ZONING SAN CLEMENTE, CA Phone: 949-361-0111 MAIN STRUCTURE Front 0-0 SUITE 103 Zip: 92672 Front 0- 0 Owner: SOUTH COAST PLAZA PARKING Existing: 0 Required: 0 Proposed: 0 Address 3315 FAIRVIEW AVE Misc. Phone: COSTA MESA, CA - Zip: 92626 Contractor: HURST AND SIEBERT Address: 2377 SO EL CAMINO REAL SUITE 103 Phone: (949) 361-0111 SAN CLEMENTE, CA Zip: 92672 License: 622681 Arch : PAUL J RUFFING, AIA Eng: _..._. Address: 1101 DOVE STREET Address: SUITE 140 Phone: 949-660-8062 Phone: NEWPORT BEACH, CA Zip: 92660 License: C4264 License: SCOPE OF PERMIT 1,440 S.F, INTERIOR SHELL MOI)IFICATIONS ONLY FOR TENANT IMPROVEMENTS TO CREATE A SPEC SUITE FOR FUTURE TENANT. WORK TO INCLUDE: DEMOLITION, CONVERT 2 EXISTING SPACES INTO 1, AND DEMOLISH EXISTING MEZZANINE. NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work Is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-6626 2"6-46 (OM) FEE SUMMARY Plain Check: $133.05 Calc Valuation: $75,000.00 Permit: $818.75 Claim Valuation: $75,000.00 SMIP Res: $0.00 SMIP Com: $15.75 Other: $0.00 Inspection: $0.00 Total: $967.55 PLANNING & ZONING SETBACKS MAIN STRUCTURE Front 0-0 Rear 0-0 Left 0= 0 Right 0-0 ACCESSORY Front 0- 0 Rear 0-0 Left 0-0 Right 0- 0 PARKING Existing: 0 Required: 0 Proposed: 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work Is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-6626 2"6-46 (OM) DECLARATIONS WORKERS' COMPENSATION DECLARATION: hereby affirm under penalty of perjury one of the following declarations: I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, IOT the performance of the wa for which this permit is issued. I have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I h workers+' j oompensation Irtsu ca caviar and policy number are: [� Q (this section Head not be complAlrk Witte valued at one hundred dollars ($f00) or less.) ❑ I certify that in the performr which this permit Is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Catihat if I ould become subject to the workers' compensation provisions of Section 3700 of the Labor Coda, I shall fdrthwith comply with these pro+daioO Applicant Signature*- � Date: WA NING: FAILURE I; SECURE WORKERS' COM ATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLAAE (SI 00.000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PgOVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm a a13•am•i' sed under proviso s at Ch er 9 (commencing with Section 7000► of Division 3 of the Business and Professions Code, and my license is in full force and effect'CfC,Class fP.-ti Cotmacto�s Signature: -=--r-: {A � , 44 - I CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code), Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct. alter, Improve, demolish, or repair any structure, prior to its issuance• also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sola compensation, WILL DO THE WORK, and the structure is not intended or offered for We (Sec. 7044, Business and Professions Code: The Contractors License taw does not apply to an owner of property who builds or improves thereon• and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ t, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License taw does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type o1 document, Le. - property tax bill or deed): DIVISION OF INDUSTRIAL. SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, Califomia Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety as noted above, unless such person has a permit to do such work from the division. Signature: Data: Division of industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present Or future building Occupant need to file and cerlity a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ........ .......................................... .............................................._..........................---.......................__............................................................................................................. ................. .,.............. .............. ..._ ......._—. 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 at the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ......................... __...................... _............ _......... --•--............__._.._...............-........................ __....................................... _..................................................................... _....................................... ..._............. .._.........- ....... .......... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutety hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation• certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ....................1, _ — ...__....................—......................._...._..............._.............................. .. ... 1111............. _ ................ --------........... 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code bean fully complied with? ❑ Yes ❑ No 6 .............- ..................- .............. _._.... -.............. —....................... _._............. _........................................................................................... ......... ............•..........1111...... - 1111...................... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of thisa plication a germil for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Byes L_] No (Section 65850.2 o1 the California Government Coda requires that the requested information be furnished on applications for non-residential building permits). ....... ......._..... ...... 1— .. .......1111.. .............. T._................._. --- ......... -....... .................... _............. ..1111. _ .......—............_-........_....._.-... 6 Will any part o1 the facility to be constructed under this permit be within 1000 foot from the outer boundaries of a school? 0 Yes ©No (if -yes', the facility must meet the requirement Of Sections 25534 and 42303 of the California Health and Safety Code). ......................1111.__....._.................. --...- ........ -- -- -- - 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have allot the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No -- ---• .................................._-••-•-_ . _ ............................. _............................ ...............................................................................-----------....---.._................_....................._._ 6 (ff yes', attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: 1 certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE ORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to oc mpfy with a i ws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described propert 4 � U purposes. I. I Aee not to occupy or allow occupancy of any building authorized by this permit until final inspection. egalOwne s) L , _Q mate An rtze W 1- pie CeDE f. III(SPE •TION TYPE am If'�IbORE a lH§?EQTIO f rjF R&U wrm 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 206 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 - Fax (714) 754-4856-0www.ci.costa-mesa.ca.us 77 FAIR'DRIVE, COSTA MESA, CA 92626 MECHANICAL PERMIT Job Address: 3333 BRISTOL ST Suite No 1520 Vicinity: Status: ISSUED Applied: 05/04/2005 Issued: 05/04/2005 Parcel Number: 41249102 e _ ISSUED'BY:' Applicant: BILL KREISL- ' '3 Address: 4065 YOSEMITE/PL Phone: 530-642-8858. PLACERVILLE, CA Zip: 95667- Owner: SOUTH ,COAST' LAZA \ Address: 3315 FAIRVIEW;AVE E'N' �misc. �f .;Jr Phone: �; ✓ COSTA MESA. CA Zip: 92626 Contractor:, OAKSTONE CONSTRUCTION=INC,_ Address: /!4065 YOSEMITE PL Phone.-- 530-642-8858 PLACERVILLE,CA_ Zip: 95667 \ i ✓ `\ /� License: 682535 \ ,,- •„- - -- SCOPE OF=PERMIT 2,940 S.F. INTERIOR TENANT IMPROVEMENT' VALENTINO".SPACE 1520; REF.: B05-00531 ,`.. MECHANICAL TO INCLUDE: 1 REPAIR/ALT COOLINGIHEAT, 5 VAV BOXES, AND 3 VENT FANSISINGLE DUCTS. r-' FEE SUMMARY ,j` . Quantity % * _ - -Quantity ISSUE FEE $23.50 Repair I -Alt Absorbtion Unit $0.00- ,0 1, Inst FAU'<100 k BTU $0.00 0 Repair I Alt Refrigeration Unit ,$0.00 0,' Inst FAU >100'k BTU $0.00 0 1, Ventillation System ! $0.00 0 Repair 1 Alt Cooling/Heat $13.70 1 Evaporative Cooler $0.00 0 Inst I Rep -Recess Wall Htr $0.00 0 Commercial, incinerator $0.00 '0 Ref rig Sys <100 k BTU v 50.00 _ 0 _ Domestic Incinerator+ „-�. �.:ystems , .,, '� - $0.00 0 Refrig Sys >100 k BTU $D,DO" "0 ` Compressors I Absorption:S' Gas Piping �.A $0;00;' 0 •Up to 3 hp 1100 k BTU"�. / $0.00 0 Factory Fireplace. 50.00 \�0' , ` r 3 To 15 hp / 500 k BTU y �j/� 50.00 0 Hood w/Meth Exhaust�fS0.00�0 15 To 30 hp 11,OD0 4c BTU �r <� $0.00 0 VAV Box $53.25-�,5 30 To 50�hp 1.1 T50�/ k BTU� � ; ,$0.00 0 Vent Fan 1 Single Duct -$21:75 ; 3 _ Over -50_ hp /Over 1,750.BTU,, $0.00 0 Appliance $0.00: 0 `~ r� Boilers Fire Dampers $0.00 " /0' _ r Up to 3 hp-" + , >> i $0.00 0 Smoke Dampers $0.00 0 3 To 15 hp __= ',i _ $0.00 0 Inst or Relocate Appl Vent $6,06- 0. 15 to 30 hp. _ �J.% j" $0.00 0 Air Handlers < 10000cfm $0.00 _0 - 30 'to 50 hp. �;=, $0.00 0 Air Handlers > 10000cfm $0.00 0 _ - Over, � 50 hp,-�. T $DAO 0 Floor Furnace $0.00 0 _ _Other Mechanical Fee Floor or Suspend Heater $0.00 0 investigation Fee $0.00 NOTICE:.- The: work•authorized-by this permit shall comply with -all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12721-92) EXPIRATION: -This permit shall automatically expire and become vold.if work Is not commenced within 180 -days, or if work is suspended or abandoned fora period of 180 days. INSPECTIONS: In -order for the.work•authorfzed-under. this:permit to.be considered: legal; such•work•must comply,with all applicable c and all required inspectiona.and.tinel approval must be obtained.. Failure to obtain Inspections and final approval will result in the expiration of t permit. . FOR INSPECTIONS CALL: -(744) 754-5626 2446.46 16!001 DECLARATIONS If--\ I WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to sell-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the perforina Ica of the work for which this permit 15 issued. E've and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is'issued. _ �My wo alrs,'.c —4m enation Insurance carder and policy n bar ora �Carr�^� // 1'r 1 1�7G Ct oTicy Number! ,(f 119 sect on need not be cornp4ted if the pwfrnif Is valued or one hundred dollars ($ fOO) or less.) ❑ I certify that In the performance of the work for which this permit is Issued, I shall not employ any person in any menriar so as to become subject to the workers' compensatlan laws of California, and agree that If I should become subject to the workers' compensation provisions of $action 3700 of the Labor Code, I shall forthwith comply with these- provisions, pkant'S nnature:• T Date: _ WA�3MN0`FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UrMWFUMP L AND SHALL SUBJECT AN ELOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED SAND DOLtARE ($100,000)• IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed der r0 ' lor�t Chapter 9 (commencing with Section 7000) of Division 3 of the BusInW and Professions Cafe, and my license is In full force anti affect: Lle:'1I -}- Glass it _Co Irev's•slgneture:Y Date "CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lenders Address: Signature: Data: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a perrrdt subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own amployeos, provided that such Improvements are not intended or offered for sale. If, however, the building or improvement Is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contraclor(s) license pursuant to the Contractors License Laws,). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, Le. - property tax trill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet In depth into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) foot high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 6, California Administrative Cafe). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division, Signature: Onto: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building Occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 o1 the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas of standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a rogistratlon form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which a1 any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ...........................................................................................................................................................................................................................................................................................................................................................- 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department, 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication armit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ EEe Yes L,f No (Section 65850.2 of the California Government Code requires that the requested Information be fumished on applications for non•rosidential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (11 'yes', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ...._.....................................•. -..—............. ......................__._...................... ,............................ _..............----........ _................... _._...----.— ........... _...... .._...... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (if 'yes", attach certificate of compliance from the appropriate air pollution control officer]. CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions, Signature: Dale: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I cenity under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for Inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature L i ner(s) ate VA �AnnilOr A 1 d.Applicant ate-,� CooE 1. SECTION TYPE DhIE INMLS CODE f INSPECTION TYPE 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical " 201 Final BlocktRetaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 1 204 Final Demolition 250 Final BuildinglOccupancy (714) 754-5273 • Fax (714) 754-4856 www.ci.costa-mesa.ca.us 77 FAIR DRIVE; COSTA MESA, CA 92626 ELECTRICAL PERMIT Job Address: 3333 BRISTOL ST Suite No 1520 Vicinity: Parcel Nunmber: 41249102 Status: ISSUED Applied: 05/04/2005 Issued: 05/04/2005 1/10" Applicant: BILL KREISL ✓ /-�'=/r "% ISSUED 13Y Address: 4065 YOSEMITE PL -Phone:-5307642_-8858, • f%r! Plicne�: 530- 2-885 t��\,�� 1�Zip PLACERVILLE�CA 95667 PIACERVIL\L<E, CAnn+�0, Zip: 95667 AZA—,, - Dwner.�=SOUTH-COAST: '4' .vim' Addis l'-' 3315 -FAIR IEE AVE __, MISC. Phone: 1' COSTA�MESA,,CA Zi 92626 SCOPE OrPERMIT lo, fel% �' 2,940 S.F. INTERIOR -TENANT IMPROVEMENT" VALENTIN_O" SPACE 1520,'REF.: B05-00531 Contractor: OAKSTONE CONSTRUCTION]NC :,r -- Address:. 4065 YOSEMITE PL r........ ELECTRICAL TO INCLUDE: 185 LIGHT FIXTURES, 57 OUTLETS, 1A�VITCHES; 1 SERVICE TO 2fl0 FEE'SUMMARI(� Quantity..�1I Quantity ISSUE FEE ,i $23.50 Temp Dist'System'! Lighting $0.00 0.`"/ ' Temp service test', t ' $0.00 Busway 1100 ft- $0.00 0': _.E C -) Res. a/c package �;\ $0.00 '4Standing Section $0.00 �`0"j New Res (1-2 units)-" ' $0.00 0 -"?''".' Misc Electrical Equipment $0.00 =','0 New Res (3+units) x$0.00 0 j'. Transformers.up to 1 kvalkw $0.00, f -0 Pool 1 Spa'-, r `$0.00 0 „;.`;; '' '. , ..'...up to 10;kva/kw� - $0.00, 0 A. Lighting Fixts, -_ $142.45`x, 3 �185.�`,-'t o, ':'` ....up to 50 kvalkw�V $0,00 0 Recept Outlets, ` . ...... .° i' $49.01 1 57 ftC� 0� o f...1....up to 100 kvalkw �r$0:00 �0 Switches �` .� - /-13:20 ~\ 12 o oL ,,: over 100 kvalkw $0.00 <�0 Non Res Appl .��� Cif $0:00 0 . �� jow Voltage Equ pment'' $O:Oay. 0� f Res Appl ^ '� x_$0:0O 0 ,�, _ ' Low V_olt'Wiring:Systeiri I:Ckt $(]:00� ° �0 Service to 200a 'K` \ $30.50 1 ' 1 1 ' `Misc: Conduit= �" - C $O OO i� ,0j;; Service.to 1000a f -Mis;0 0$�0.000' Service over 1000a $0.00Circus(.gemorride) Motors to 1hp $42.75 `tea < 9 ; ? , -, Circus (mech'ride-or lights) $0.00' , 0 Motors to 10hp $0.04 �� ;`�,0 Christniae Tree`Stand'` x$0.00 0 Motors to 50hp $0.000 s �.. " ` ' ' Fireworks Stand �/ $0.00 0 Motors to 100hp $0.00 0- -'L ,•- - __ .._Other- Electrical, Fee:;' $0.00 Motors over 100hp $0.00 fl -,�-r Communication drops $8.80 8 Investigat Fee $0.00 Sub panel to 200a $0.00 0 Plan Check Fee $0.00 NOTICE: The-work•authorized by this permit shall comply with all applicable handicap access -requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12721-92) EXPIRATION: This. permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In,order-for the work authorized- under this permit to be considered legal; such work must comply -with all applicable codes, andraill required inspections and.final approval must be obtained. Failure to obtain inspections and final.approval will result In the expiration of this pefr FOR INSPECTIONS CALL: - (714) 7545626 2446416 (6=) -Phone:-5307642_-8858, , �" c- �" X/x PIACERVIL\L<E, CAnn+�0, Zip: 95667 License: 682535 e. SCOPE OrPERMIT lo, 2,940 S.F. INTERIOR -TENANT IMPROVEMENT" VALENTIN_O" SPACE 1520,'REF.: B05-00531 ELECTRICAL TO INCLUDE: 185 LIGHT FIXTURES, 57 OUTLETS, 1A�VITCHES; 1 SERVICE TO 2fl0 ;• { -'' 3, `' ,AMPS, 9 MOTORS TO 1,HF;-AND &COMMUNICATION DROPS. FEE'SUMMARI(� Quantity..�1I Quantity ISSUE FEE ,i $23.50 Temp Dist'System'! Lighting $0.00 0.`"/ ' Temp service test', t ' $0.00 Busway 1100 ft- $0.00 0': _.E C -) Res. a/c package �;\ $0.00 '4Standing Section $0.00 �`0"j New Res (1-2 units)-" ' $0.00 0 -"?''".' Misc Electrical Equipment $0.00 =','0 New Res (3+units) x$0.00 0 j'. Transformers.up to 1 kvalkw $0.00, f -0 Pool 1 Spa'-, r `$0.00 0 „;.`;; '' '. , ..'...up to 10;kva/kw� - $0.00, 0 A. Lighting Fixts, -_ $142.45`x, 3 �185.�`,-'t o, ':'` ....up to 50 kvalkw�V $0,00 0 Recept Outlets, ` . ...... .° i' $49.01 1 57 ftC� 0� o f...1....up to 100 kvalkw �r$0:00 �0 Switches �` .� - /-13:20 ~\ 12 o oL ,,: over 100 kvalkw $0.00 <�0 Non Res Appl .��� Cif $0:00 0 . �� jow Voltage Equ pment'' $O:Oay. 0� f Res Appl ^ '� x_$0:0O 0 ,�, _ ' Low V_olt'Wiring:Systeiri I:Ckt $(]:00� ° �0 Service to 200a 'K` \ $30.50 1 ' 1 1 ' `Misc: Conduit= �" - C $O OO i� ,0j;; Service.to 1000a f -Mis;0 0$�0.000' Service over 1000a $0.00Circus(.gemorride) Motors to 1hp $42.75 `tea < 9 ; ? , -, Circus (mech'ride-or lights) $0.00' , 0 Motors to 10hp $0.04 �� ;`�,0 Christniae Tree`Stand'` x$0.00 0 Motors to 50hp $0.000 s �.. " ` ' ' Fireworks Stand �/ $0.00 0 Motors to 100hp $0.00 0- -'L ,•- - __ .._Other- Electrical, Fee:;' $0.00 Motors over 100hp $0.00 fl -,�-r Communication drops $8.80 8 Investigat Fee $0.00 Sub panel to 200a $0.00 0 Plan Check Fee $0.00 NOTICE: The-work•authorized by this permit shall comply with all applicable handicap access -requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12721-92) EXPIRATION: This. permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In,order-for the work authorized- under this permit to be considered legal; such work must comply -with all applicable codes, andraill required inspections and.final approval must be obtained. Failure to obtain inspections and final.approval will result In the expiration of this pefr FOR INSPECTIONS CALL: - (714) 7545626 2446416 (6=) EC DECLARATiONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of thi work for which this permit Is issued. 1'tlnve and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. TLy�` y w rkers' compensation Int u once carrier and policy number are: �} (y cerrfer:., L�21 G�4 A 1 D►�)dr ft.T.T uQ A-N G I�. gar" Number_. � - -7 �:s' Non need not be completed it the permit is valued at one hundred dollars (S foo) or less.) ❑ 1 certity that in the performance of the work for which this permit Is issued, I shall not employ any person in any manner so as to become "subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, ! shall forthwith comply with these provisions. Appji ant. Signature WA IAI 0A1CURE'TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SURJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: 40 I hereby affirm that I amlicensed nder rovisl f Chapter 9 (commencing with Section 7000) of Division 3 of lh Business nd Professions Code, and my license is In full 1 e end effect.`Lic: #'3 r (. antra bei Slgnaturs:'-'= 4EA41 CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency tot the performance of the work tot which this permit is Issued. (Sec. 3097, Civil Code), Lender's Name: Lender's Address: Slgnature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) Of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement Is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sate.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of properly who builds or Improves thereon, and who contracts for Such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet In depth Into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, fatsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, Califomia Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 WIII the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .............................................................................................................................................................................•---........................................................................................................................................................................................... 2 Does or will the applicant or presort or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater then a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ......................_..—_...................__....................... --............. ......_.................... ..................................................... .._.............. _............. --_............. _—........ 3 Does or will theappplicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No {Section 25534 of the Califomia Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. .... ............................................................................................. 4 li an RMPP is presently required, has Section 25534 of the Cel€lornia Health and Safety Gode bean fully complied with? ❑ Yes ❑ No .....................PP_............................................................_ ........ ........_q.................... __....................... _................... ;.P........................_"..................._._................ --............. ................ _.... 5 Daes or will the applicant or resent or future buildingoccupant require for the work which Is the subject o1 this a licat€on apperm'd for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes LJ No (Section 65850.2 of the California Govamment Code requires that the requested information be furnished on applications for non-residential building permits). ........................................................................................................................................................................................................_...............,................................................................... 8 WIII any part of the Facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ---................. e,r'.........._..._..h,_e,_............._..............................................................._............id, c - o'_ro...__............_.._...................._.-........... *c"t..........................._...................................._................................................_ . ............... 7 If a permit from the South Coast Air Quality Management District or ocher air pollution consrol district or agency is required far the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No Of compliance from the appropriate air pollution control8 (It yes", attach certificate officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for Inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signet re Owner D e a c. rfzed Applfcant •_ ' ; . r .gyp '`� CopE R. INSPECTIONTYPE' �r `� p1�IFi IItTIT18LS CQQE! ly$PECTIONTYPE' I?AIF NTITIA:$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical Z S 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy' (714) 754-5273• • -Fax (714) 754-4856• • www.c€.costa-mesa..ca y G PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Status: ISSUED Suite: 1520 Applied: 04/04/2005 Vicinity: SPACE 1520 Issued: 05/04/2005 Primary Occ: M Display/Sale Merchandise Type of Construction: I -FR Parcel Number: 41249102 Zoning: PDC Applicant: BILL KREISL ISSUED BY: Address: 4065 YOSEMITE PL Phone: 530642-8858 OFFICE PLACERVILLE.-CA--l/ 1 Zip: 95667�I Owner: SOUTH COAST'PL-AZA Address /,3315 FAIRVIEW AVE ` MISG. `. ��% �� = Phone:���_ i 1 % \•\� rCOSTA MESA CA�j` r / Zip: 92626 Contractor: OAKSTON&CONSTRUCTION INC ' rddres's 4065 YOSEMITE PL Phone: 530-642-8858 PLACERVILLE, CA ( ;cz -•License:, _Zip: 95667 X _ 682535 _ Arch' . , KARL;SHULTZ Eng:_ Y'. Cr }Address: , ; 39039 PAS EO PADRE PAR_KWA _ �; - '- Address:- _ Phone: 510 796-7801 Phone: FREMONT,,CA Zip: , 94538. License: License: SCOP.E�OF PERMIT 2,940 S.F. INTERIOR TENANT IMPROVEMENT" VALENTINO* SPACE 1520 L' 1 rr FEE SUMMARY - ~ Plan Check: $206.99 -.r' _ - ''`~ -' "�` r c` Calc Valuation: .-$150;600.0 0 Permit: $1,273.75 - - = _ , ^�' -•-- •-CI'aim Valuation: 5150,000.00 SMIPRes: $0.00 `SMTP Com: $31.50 �� ` �•. �' Other: $0.00" ; w - Inspection: ,$0.00 w Total:$1,512:24 PL'ANN-ING1& ZONING SETBACKS MAIN STRUCTURE -Front" 0= 0 fr-.\ Rear_ O.D'- :.�. Left 0- 0 �/` Right 0 0' ACCESSARY Front o-'0 Rear 0- 0 Left w0- 0 '-�'! Right, ,--0; 0 PARKING Existing: 0'`Re `uired: 0 Proposed. NOTES: NOTICE: The:work.authorized by this -permit shall comply �with,all--applicable-handicap access requirements. under California statutes and related regulations. (Ord: No. 92-26, § 1, 12-21-92) .EXPIRATION: This permit shall automatically expire:and become void If work is not commenced w€thln 180 days,.or if work is suspended or abandoned for period of 180 days. /` INSPECTIONS: ln,order,for thee work ' authorized under. this'permit-to.be considered. legal;:such +work must,comply with -all applicable codes; and all required Inspectlons,and,final-approval must be obtained. -Failure to obtain inspections:and finaliapproval will result fn.the expiration of thi ,sperm€t. F.OWINSPECTIONS,CALL: (714) 754-5626 ;e 2448-48 (8100) DECLARATiONS WORKERS' COMPENSATION DIECLARATION: I hereby affirm under penalty of perjury one of the following declaratlons: ❑ I have and will maintain a Certificate of consent to self-Insure for workers' oompensatlon, as provided for by section 3700 of the Labor Code, for the performance of the ark for which this permit is Issued. I have and will maintain worktirs' compensation Insurance, as required by secdori 3700 of the Labor Code, for the performance of the work for which this permit is Issued. My.workers' compensation Insurance carrier and policy numb are:�� ^� ; Ca rs 61610 U40, &1_ Policy Number: J is s ii need at a completed lrtAe permit is va4j&T4Tone hundred dollars ($ 100) or fess.) ❑ I certify that in the performance of the work for which this permit is issued, I shall riot employ any person in any manner so as to becomo'subjoct to the workers' compensation laws o1 California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisions. Applicant Sigriatare; - 1"` =�_ —Date— _-- r 1 ,WARNING:-, FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUaJECT AN EMPLOYEWTO CR a;4L PENALTIES AND CrVIL FINES UP TO ONE HUNDRED }SAND DOLLARE ($100.000 , IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PFCMDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. 'LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed undwyrovi of Chapter 9 (commencing with Section 7000) of Division.3_pf.the .Busina nd Professions Code, and my license is In full _torce•and e�ffect. �l-kip �Class'fi'r'' r `Grxrt�cto"re•Slgneture:Date V D CONSTRUCTION LENDING AGENCY: ❑ l hereby affirm that there is a construction lending agency for the performance o1 the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty Of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to Its issuance, also requires the applicant for such permit to file a signed statement that he Or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (Commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he Or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not intended or offered for sale. If, however, the building or Improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors Llcenge Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractors) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. _ Business and Professions Code for this mason: Signature: Date: Owner 10 verified by driver's license. ❑ Yes ❑ No Driver's Llconso No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation live (S) or more feet In depth into which a person is required to descend, will be made in connectlon with work authorized by this permit, and that no building Structure, scaffolding, talsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Data: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight o1 500 pounds, or a volume o1 55 gallons, or 200 cubic feet of Compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the Callfornia Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, Or a volume of 55 gallons, or 200 cubic toot of compressed gas at standard temperature and pressure). ..................._.................. _........_..,......................—.—......-- --_..._.....�.................. _.._................................................................ — _._.. 3 Does or will the applicant or present or luturo building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes 11N (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ---- .............._-c-ti..._................................_..........................................."a1.1f'• .........................,............... ................. ....................... ........ 4 If an RMPP is presentty required, has Section 25534 Of the California Health and Safety Code been fully complied with? ❑Yes ❑ No 5 Does or w111 the applicant or present Or future building occupant require for the work which is the subject of this a plication a�ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? )j Yes 19 No (Section 65850.2 of the California Government Code requires that the requested Information be fumished on applications for non-residential building permits). Y P tY P .. 6 Wlll an art of the fat;iti to be constructed under this permit be within 1000 favi from the outer twundaries of a schoo11 l? ❑Yes ❑ Na (if "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ................................................._- ... ._............... ....-•----.......................................... "I..................... ................................... .......................... ................................. ............—................. .. _.. 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which Is the subject of this application, have all o1 the disclosures prescribed by Caliiomia Health and Safety Code Section 42303 been made? [3Yes ❑ No __.. , atl .................. _------------.....th_._.....air"..._._.._-..............._..._.."e,'r)............................................................................................................................................................�..._.............. 8 (If "yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the abovo-described property for Inspgotion purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. gngsure O1 al err a f! ,9Eate And/Or Au rued t -' CopE /, INSPECTfON IMTTIA CODE d ` INSPECTION TYPItMnA1S 1616 Fixed System Final Fire Prevention 206 Final Mechanical ' 1266 Pool Spa Fina! 208 Final Plumbing 200 Final Re-Roof ' 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building+OCCupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 PLUMBING PERMIT Job Address: 3333 BRISTOL ST Suite No 1520 Vicinity: Status: ISSUED Applied: 05/04/2005 Issued: 05/04/2005 Parcel Nunmber: 41249102 ISSUED BY: Applicant: BILL KREISL;`J Address: 4065,YOSEMITE,PL'-' �\• -Phone: 530-642-8858 PLACERVILLE, CA : �'� - Zip: 956fi7 �\ Owner: '�SOUTH.COAST,PLAZA ,Address. 3315 FAIRVIEW AVE MISC./, Zle ,/ Phone:,," `•����, COSTAMESA, CA Zip:;, -92626 ` �`:���. -�..- �; �' ^ 4� i fir` ` ° � ` • \ Contractor: / OAKSTONE CONSTRUCTIONANC�'_ ; Address:"4065'YOSEMITEPL C�- `- `' % % Phone: 530-642-8858 PLACERVILLE,,CA'� Zip: 95667 �. =License:.- 682535, , \ Z�'��'7 �- � JY•�"r rrZ rZ r7�7 T� '' �i - - w. - - �, _SCOPE OF PERMIT ` 2,940 S.F. INTERIOR TENANT IMPROVEMENT "tVALENTINO"-SPACE 1520. REF.: B05-00531 PLUMBING TO INCLUDE: -2 FLOOR DRAINS; 4P=TRAPS, .1=SEWER CONNECTION, 1 BAR SINK_j­ ' ` SERVICE/MOP SINK, 2 TRAP PRIMERS;'2 WASH BASINS, VWASTE'AND* VENT SYSTEM, 2 WATER ; CLOSETS, 1 WATER HEATER, 1 WATER PIPING, AND 1,WATER SERVICE. FEE SUMMARY ; �- ',.'AMT QTY } AMT QTY ;, % AMT' OTY ISSUE FEE', $23.50 Laundry Tub [Washer $0 00 0 Sump Pump/ $0.00 0 Backflow irrigation $0.00 0 Landscape Irrigation. $O.l)0�*{0 Swimming Pool %,$0.00 0 Backflow Preventer $0.00. � 0 1„� .� �-'P,-Trap ,,'$39.20 { 4 ''� � Tr'ap,Pnmer 1,$19,60 2 Bathtub�Y SO,00 ,E},`,�, Press ure Regulator c`. " $0.00 0.. _n Urinal' ,11$0.00 0 Clarifier System ` %\ $0.00 0`' \1 �PProcess'Piping (per.10 ft)` yv $0.00 D, Vacuum'Brkr Bkflow(1-4) i $0.00 0 Connect (Ice,Soda,etc), $0.00 :0 Receptors:: $0:00 ' �O `' Vacuum Brkr.Bkflow(5+); $fl.00 0 Dental Units �, $0;00 /,-0, :Septic Tank '� $0.00 O:y��� Wash $19.60 2 r ' $0.00, -"0 Wash Basin Set Dishwasher `� $0.00Demo ti-� ~r- � � j` $0.00 0 Drain, Floor $19,60 �� 2r t j l5ewer Connect. $24:65' " 1 Waste and-Vent,System $9.80 1 Drain, Rainwater x$0:00, o�'-// 3 Sewer Private Line $0.00 0�1 Water Closet (Toilet) $19.60 2 Drain, Roof $0.00 0 .' '� t'Shower�f 1`', �` -,� -_$6-60­,CO " Water 1 eater / vent $12.30 1 Drinking Fountain $0.00_' ^0~' Sink, bar• $9.80 C_ -.1. ,Water.piping (Inst or Rep.) $9.80 1 Expansion Tank $0.00 0 "- - Sink, commercial $0.00 0'Water Re -pipe $O.00 0 Gas Earthquake Valve $0.00 0 _ :,Sink, Floor _$0.00 0.!�� i` Water Service $9.80 1 Gas (1-4 outlets) $0.00 0 `-Sink,. itchen-•_-$D.OD'''"0 -` Water Softener $0.00 0 Gas (Over 4 outlets) $0.00 0 Sink, service/mop- - $9:80 1 OTHER $0.00 Gas Repipe $0.00 0 Spa (private) $0.00 0 VIOLATION $0.00 >' NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work Is not commenced within 180 days, or if work is suspended or abband d for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable cods, and all required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result in the expiration of thi6ermit. FOR INSPECTIONS CALL: (714) 754-5626 d 2446-46 (6100) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declaratlons: ❑ 1 have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the /work for which this permit is issued. �� ►have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Cade, for the performance of the work for which this permit is issued. My wo ars' corn ensation Insurance carrier and pal mb r are: 9 7 aGeirrter: ,," sec need not comp a ed if pe it is va et one hundred dollars ($100) or less.) ❑ I certify that in the performance of the work for whlch this permit is Issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws ofallfomia, and agree that If I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these pr " ns. Applicant Signature: ---Date:""` RNING FAILURE TOWE E WORKERS' COMPENSATION OOVERAGE IS UNLAWFUL AND SMALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE: HUNDRED iDU9AND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby aff3rm.that I am Ilccansed under rovlslan of Che I r 9 (commencing with Section 7000) of Division 3 of-the-Busine and Professions Code, and my license Is In full &fob' r e snd eflact. Llc�tl : '� :." Clads ✓rte"° Contraclors,Slgnatura:— Date; CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Cade), Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby afflrm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement Is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). [] 1, as owner of the properly, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who Contracts for such project with a contractors) license pursuant to the Contractors License Laws.): ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type o1 document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made In connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the Califomia Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ............................................................................................................................................................................................... ........................................................................... 2 Qoes or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feel of compressed gas at standard temperature and pressure). .................................................................................................................................................................................................................... 3 Does or will the appliea*nt or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ............................................................ _...............................................................,......................................... ............................................. ................ .............................................................................. -................................................................. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes [3 No .................................... ... .._............. I'll .......................... ............................................................................................................................................................................. ................................................................................................................. 5 Does or will the applicant or present or luture building occupant require for the work which is the subject of this application armll for such construction or modification from the South Coast Air Ouality Manageman�e l District or from any other air pollution control district or agoncy7 Yes LJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ................................................................................................................................................................................................."I........•............................................................................................................................................... 6 WiII any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (I1 "yes', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). - _ ................... ............ _._.............................._...........................................---..... ............................................................ _...................... _................ 7 It a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this applicatlon, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (If yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to Comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Masa to enter upon the above-described property for inspection purposes. i agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. ignature eg r s) ��yla We k and/0r Authorixidd Appllcsnl* ` As., l `t781�•ta"�"—� CODE #. INSPECTION TYPE - Qom. tinmALS •-T'~`"Zcom INSPECTION TYPE ♦,}�Tf. 1616 Fixed System Final Fire Prevention 206 Final Mechanical _ 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retalning Wall 212 Final Fire Prevention 202 Final Factory Fire Place _ 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy I .':: ;-!,.:..:-:: ,..,]'h..i...4 ^o+i � ' r -:,.,.-..r `�wy+,f "v -- -- - f_ titr of Co,5ta Naa Development Services, Division of Building and Safety CERTIFICATE OF OCCUPANCY This certificate is issued pursuant tlth'e reWiremerits of�the Uniform Building Code, Section 308 adopted by the City of Costa Mesa certifi6s.that_at the time of its.issuance the building structure herein below described was inspected an&appr'_oved f&o6cu5a—&' as follows: Building Address 3333 WkQL�(ST M UNIT 1600 �� z %Bldg. Permit No. B 8096$_ _ i� �1 Group Type of,Con9struction � tit Firelzone" ; 1 Use Zone CI -S Owner of Building C. J.� 5ege_r6tr_o_m — `� 'Tenant "COM $KM & TEA Lam" I Address Iryl ., .a By BUILDING OFFICIALtonv VN Baca ate 30 , 1997 REQUIRED 0 BE POSTEDIN "A CONSPICOUS PLACE ADDRESS of BUIL@NG: 3333 BRISTOL ST OWWIrSNAIIEIFID1D�ffFk C, J11, ;4GERSTROM X3315 FAIRVIEW RD COSTA MESA,CA 92626 546-0110 APDL. MAILING ADDRESS: UNT: 1600 FLOOD: AO -38 ARCHRECTORENf9NEER: CHARLES TERRY uGNo= C11658 ARCH. OR ENG.'S ADDRESS: 3300 IRVINE AV uNT: 235 N.B. CA 92660 CONTRACTOR'SNAME PACIFIC COAST DEVELOPMENT (310)514-0215 owmAmrs max 6603 6603 ABDRESS: SAN PEDRO CA ucNo, 581953 90734 UNIT: LICENSED CONTRACTORS DECLARATION: I hereby affirm uder Penally of perjury that lam Ueerned under prasxiim d Chaptar 9 with 7000) d Divisime a d the Business and Prolnsiom Code, and my liosrhw is in full lace and affect. CITY LIC. O.: c. cuss: B uc. No 819 5 3 EXP: ate: Cordract 111'1_3156 'R BUILDER DECLARATION: I hereby affirm under penalty d perjury Ihel I am exempt from the Contractors License Law for the reason (Section 7001.5 Busmen and Professions Code: Any City or county which requires a pemnd to aormtrhx:L aftor, improve. demolish, a repair any structure, prior to ds issuance, also requires the applicant for such permit to file a signed statement that he or she is boensed pursuant to the Provisions of to Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Busineres and Professions Cadel or that he or she is exempt therehom and the bass for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit suboft the applicant to a civil penalty of not more than five hundred dollars (5500]►. ❑ I. as owner of the property or my employees with wages as their sols compensation, wil do the wont, and the structure is red Wei or offered for sale (Section 704, Business and Protessias Cads: The Contractors License law does rot apply to an owner of property who builds or improves Ihareon. and who does such work himself or hernial or though his or her own employees, provided that such improvements ars not intended or offered for sale. If. however, the building or inprohrenhaeht is sold within ars year d mmpkmion. ere owner -builder wig have the burden of proving hit or she did not build or improve for the purpose d sale). ❑ 1, as owner of the property. am exclusively cwmrooft with licensed contractus to construct the project (Section 7044, Business and Professions Code: The Contractors L kenee Lew does not appy to an owner of property who builds or improves Iherepn and who contracts for such projects with a oonlradorfe) licensed pureusnt to the Contractors License Law). ❑ 1 am exempt under Section: B. d P.C., for this reason: Data: owner: I do hereby caddy that I am aware of and understand the requirements of California Health and Safety Code Sections 25505, 25533. and 25534, and that I or any future building oocupert witl 7 all req (rinds ons) need b campy with said two codes and the mWArements For a permit for aorstruction or modification hos lhne Arty angyemart District. Aasidaraiel omstnxtiion apps catiors ars exempt from these Date: Apdicarit: WORKER'S COMPENSATION DECLARATION: I hereby affirm under penalty of perjury, one of the following declarations: ❑ 1 have and wilt maintain a eartilicale of consul to seHinsurs for workers' eompensatien, as provided for by Section 3700 dthe Labor Coda, for the performance of the work for which this permit is issued. f3 I have and wilt maintain wodrus' oomperselion insurance, as required by Section 3700 d the labor Code, for the performance of the work for which this permit Is issue!. My workers compensation Insurance tender and policy number are: Carrier: Policy Number. rl ion need not be camplered if the pemnk a for ane hundred dayars jSa00j a lees.j ndy that in the performance d the work for which this pen nh is issued, I shell rot employ arty person in anry manner oro as to subject to the workers' compensation laws d Catlomie, and tee slat d I should eoume subject to the workers' pansetionprovisionsdSection 3700 d the tabor Code 4 Shelly 1 copy with=Applicant:FaAurs to secure workwo' conWenestfon coverage to uMawArl, and shall subject art smploya, to cr ngrial penafdss and clvN Rnea up to nuns hhxedrsd thousand dollen (S100, 0WJ, In addlffon to the cwt of eompensatlon, damages as provided for In Secdon 3706 of the Labor Coats, Interest, and attontey's fop. CONSTRUCTION LENDING AGENCY: I hereby affirm under penalty of perjury that there is a construction landing agency for the performance d the work for which this peak is issued (Section 3097. Cir. C). LENDER'S NAME: LENDER'S ADDRESS: I candy that I have read this application and state that the above information is correct. I agree to comply with atl sky end county ordasroes and state laws nelatig to building construction and hereby auggrae represenaatiwes of this city to anter upon the above4row rhed pr'operw for impaction, purposes, WANDA DONCOST Dau: ZI 3 l9 (515116.WP) Whea-Buddi o A Sdaty; Green -File: Caria"Pplcant: Pmk4ievnxue: C+oldertrod-Assessor CITY OF COSTA MESA — BUILDING PERMIT PERM NO: B 080968 PERMIT NO: B 080968 PLAN CHECK NO: 05217-96 A GOVT: N SUPP: N CONSTRUCTION TYPE: I FR PERMIT TYPE: STA PURPOSE: ALT JOB DESCRIPTION : 1345SF STORE TI SQ FT: 1,345 CLAIM VALUE: 30,000.00 CALC—VALUE: 20,766.80 GROUP OCC: B / COMMENTS: "COFFEE BEAN & TEA LEAF" STORE TI Z O N I N G R E Q U I R E M E N T S S E T B A C K S -------------- MAIN BUILDING ------------ --------- ACCESSORY BUILDING--------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN PARKING REQ: PROV: PARCEL: 41250107 ZNE: C1—S REF NO: PLANNING NOTES> INTERIOR ALTERATION FOR COFFEE BEAN AND TEA LEAF RELOCATION. ')E iE iE iE iE iF iE ♦f iE iE FE iE iE iE iE iE iE iE �E iE jF � iE � iF iE irk 1E �E'1E jF- i't• -)F'lE �lE �E iE �E � !E if iE• if• * *'>E iE * iE * * * iE iE if ie !E * !E iE iF ie iE -1E if iE iE �E iE iE iE * iE iF if iE iE � D E V E L O P M E N T S E R V c I,� ` C E S R E Q U I R E M E N T S ZONING APPROVED BY _ V V Rja DATE: BUILDING APPROVED BY : �'�,/a DATE: I -NW -1 �-1 APPLICATION ISSUED BY: DATE: � iE i(• � � iF iF iE * iE � iE * iE iE iF �E fF � i1- iE *�� �E 1E � iE � iE � iE !E !E i6 � LEGALIZATION:N F E E S U M M A R Y STRUCTURAL SEGMENT:Y BLDG PMT PERMIT 299.75 PLUMBING ELECTRIC MECHANIC PLAN 48.71 " '.- ISSUE FEE ' BUILDING -DIV-> PERMIT ISSUE PLAN -CHECK TOTALS ---- > 304.11 0.00 48.71 REVENUE DIVISION TOTALS--> COLLECTED: BLDG PMT PLUMBING ELECTRIC MECHANIC 299.75 FIRE SMIP/RES GRADING SMIP/NON-RES 4.36 TOTAL PAID DUE 352.82 352,82 .00 304.11 OVER/SHORT: .00 FIRE SMIP/TOT GRADING PLAN -CHECK 4.36 �E �F � iE iE iE iE iE iE iE if iE �E'1F �E iE * iE iE �E dE �E �E dF iE �F iE if iF iE * iE'IE'lE * � � iE * 'IE' �E iF # iE }E * �E � iE i� iE iE• iF dE * if iE iE iE iE iE � � -)! ;'E 9E !F iE• iF iF � iF � iF � dE iF �E � I N D I V I D U -A 11 F E E B R E A K D 0 W N TYPE QTY D E S C R I P T I O N r UNIT COST TOTAL COST SFC 1345 STO—INT. ALTER TYPE "I,II F.R. —AVER 14,36 19,314.20 SFC 1345 EQU—ALT COMM, SPRINKLER SYS —AVER .36 484.20 SFC 1345 EQU—ALT COMM, AIR COND —AVER .72 968.40 END OF FEES rM 01 00221442-00221443 TUT 300. i 1 DATE: 12123/75 TIME: 14:47 CONSTRUCTION AND PLANNING- "'APPROVALS Permit # _ Date Inspector F _ &SPA APPROVALS Permit # Date Inspector 1. Temporary Electrical Service or Pole 52. Pool & Equipment location 2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement 413. Electrical Conduit Utility-Undrgrnd. 54. Forms 4. Electrical Conduit -Undrgrnd. a. Steel Reinforcement 55. Electrical Bonding 56. Rough Plumbing & ?Tessure Test 6. Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNiTE 7. Footings 58. Electrical Conduit-Undrgrnd. B. Foundation 59. Gas Pipe, 0 Undrgrnd., Test 9. Water Pipe•Undrgrnd. 60. Backwash Lines, P•Trap, © Undrgrnd. 10. Structural Floor System 61. APPROVAL TO DECK S 11. Property Sewer Line & House Connection 62. Backwash & Receptor -Final 12. Sewer Cap 63. Heater & Vent -Final 13, Roof Drains 64. Plumbing System - Final 14, Rough Plumbing 65. Electrical -Final , 15. Rough Electrical -Conduit 66. Solar System -Final 16. Rough Electric Wiring 67. Fencing & Access Approval 17. Rough Wiring Sign 68, APPROVED FOR PLASTERING 18. Rough Electrical•T Bar Ceiling 69. POOLISPA SYSTEMS FINAL 19, Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit # 20. Rough Factory Fireplace 21. Ducts, in Structure 70. Underground Hydro 22. Ducts, Ventilating 71. Product Piping 0 Gas D Oil 23. Gas Pipe -Rough & Test 72. Underground Flush 24. Roof Framing 73. Undergrnd. Storage Tank © Gas 0 Oil 25. Roof Sheathing 74. Overhead Hydro 26. T -Sar Ceiling (Structural) & Monocoat 75, Dry Chemical 27. Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding 77. FIXED SYSTEM FINAL 29, Insulation 78, FIRE PREY. FINAL 30. Drywall Nailing - HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat 79. FINAL INSPECTION 32. Electrical Power Meter -Final 80. FOOD CERTIFICATE ISSUED 33. Final Electric Notes r _ 34. Final Heating &Air Conditioning 35. Final Gas Pipe -Test 36. Hood or Canopy 37. Final Factory Fireplace 38. Final Plumbing 39. Water Service -Final 40. Gas Service -Final 41. Solar Domestic -Final 42. Backflow Preventer 43. Backflow Irrigation 44. Landscape Irrigation System 45. Sound Attenuation 46, Handicap Regulations 47. FINAL STRUCTURE & BUILDING /_ 48. FINAL PLANNING 2a_(7'1 49. Electric Release to Edison 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY Np Date ADDREss of euLD9rG: 3333 BRISTOL ST UICT: 1600 0MPNIWEIF*M*C. J S&GERSTROM ryJ ,x ,3315 FAIRVIEW RD COSTA MESA, CA 92626 ADPL. MAILM ADGRIA& ARCHITECT OR f3if 41MR: LIC. NG: ARCH. OR DWS &OGRESS: UNT: CONTR,TOR`SKM1EAMERICAN NEONICS (213)875-1815 7075 V I N EL AND AV c" "'NO HOLLYWOODCA S, 520181 91605LICGr,r LICENSED CONTRACTORS DECLARATION: I hereby affirm todr penalty of pa*" Mat I am I" order provisions d Chapter 9 (oomrnerr5y sem 7 ) d Division 3 d the Bumess �L]C. akasiors hrG farce and, * CITY uc. No� 4 4 / uc. cLAss:C 4 No.: ] 1 0 219 7 (2 Date LZ _ _ c«wadw INNER BUILDER DECLARATION: I hereby aft. under paroty d perjury [hal w npt from the Contractors Lioama Law for the Mewing rea40n (Section 70315 Business and Prolesaioft Cade: Arty sty a oouray whidr ragouts a Pencil to oal.rud, after, imW0", demolish, err repair any Srtncmre. Prior 10 m issuance. afro roquirsa the appecare fa suchparmilto Rea signed statement that he orshe ts licensed pursuers to the provisions of the Contractors lirn cense Law (Chapter 9 (oomermV with Section 7000) d d Dwnm 3 the Business and Professions Codej or that M or she is exempt therehom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjeae The applicant to a civil petnelly of not more than Ove hundred ddlars p500D. ❑ I, as owner of the prop" or my empkryeas with wages as their sok mmparhae11 . will do the worse, and the srumre is not 'wended or offered for sale (Section 7044. Business and Prdessiorm Code: The Contractors License Law does nal apply to an uwwner of property who holds or improves thereon, and who does such work himself or here" or thragh his a her own empioyaea, provided then such improvements are not intended or offered for sale. If. however. the building or improvement Is sold within one year of onmplelion, the owner -builder will have the burden of proving he w she did not bu5d or improve for the purpose of sale). ❑ I, as owner of the property, am exdusivety oonlrnaing with Gamed eonInscim m oonstrw the Wood (Section 7044. Business and Profession Code: The Contractors License Law does not appy to an owner of Property who btAft or improves thereon and who contracts for such projects with a comraaor(s) licensed pursuant To the Contractors License Law). ❑ I am exempt under Section: S. b P.C.. for this reason: Date: owner: I do hereby anify that I am aware of and udastand the requinsmCdfontia and Safety Code Sections 25505, 25533, and 25534, and that I or any future building oaaupanl will I will not (circ:, -:—:)need to w!h said *fade coda and IM requirements for a permit for aomtnxtionormodifioni nfromtheAi�iai�i ansosrxt. islmnstnrtion applications are exempt from th provmms- Date: APP+iama: ` WORKER'S COMPENSATION DECLARATION: l hereby atfmn under Penalty of pricy are of the following dsdarafora: ❑ I hew and wl membsin a certifiaade d oonsanl to seuvrsura for wakara' p.rsrion, a provided lot by Section 370Dof the Labor Code, for the performance of the wok for which this permit in issued. r] I haw and will maintain workers' comprrsatjon irduranos, as equh by Section 3700 d the Labor Code, for the performance of the work for which this permit is issued, hty w� jam cwurir and P"lcy number aro: EXPIRES Canisr 12/01/97 Policy fJumbsr: 0780889-96 phis section reed rat be oaahpratad I the pwmA is cern ane hwxkW dollars 151001 or Ism) D I cea y that in the Wormer— of the work for which this Farad is Issued shelf not cry PWFn in aryw mWr eo as to become subject to the workers' oompernr= kers d Cafrfamia. and if I subject to the workam' compamatlon Pry isioi" d Section %3700 d the Labor Cad.. I shat I Applicrd: W&MhV FaRue to secure wofir"' corrtprwtlon enrraga lir reU+wltr; SMr a&/scf an rrtployar to rxfmfrrd penelefes acrd da firms rpt to ate hrstdred drouawd doffens (11040 WA in addlOw to Um cost of eon>Ivsrraatl rk da rwM a pmvkw for In Secdon 3706 of Lha Labor Cods, Interest, and eftorrmy s uses. CONSTRUCTION LENDING AGENCY: I hereby allinn under Penalty of perry Uhat there is a oonstnxxioh lendirg agency for the performance d the work for which this permit is issued (Section 3097. Civ. C). LENDER'S NAME: LENDER'S ADDRESS: I candy that I have read this epPficeson and state that the above information is conga. I agree to oom* with ei ray and county ord'mernoea and state laws relmig to MdWft construction "hereby auO*rca represeraatiwa dihis city to anter upon the above-merdioned Properly for inspectionWrpo*aNARK W LSON Date: - vLh ro rector (5151.46.WP) Whae-Building & Safety: Groan-Fle: Canary-AppicaM: Pink -Revenue: CITY OF COSTA MESA — BUILDING PERMIT PERMIT NO: B 081274 PLAN CHECK NO: 00261-97 L PERM NO:'B 081274 GOVT: N SUPP: N CONSTRUCTION TYPE: I—FR PERMIT TYPE: STR PURPOSE: OTH JOB DESCRIPTION : INTERIOR SIGN / ILLUMINATED SQ FT: 2,595 CLAIM VALUE: 2,595.00 CALC—VALUE: 2,595.00 GROUP OCC: B / COMMENTS: "THE COFFEE BEAN" CHANNEL LETTERS (REVERSE) Z O N I N G R E Q U I R E M E N T S S E T B A C K S ----------- MAIN BUILDING ---------- --------- ACCESSORY BUILDING--------- RNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN EFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN ARKING REQ: PROV: PARCEL: 00000000 ZNE: REF NO: LANNING NOTES> It � iE iE iE iE iE it iE iE * * * * * ?4 iE iE iE iE iE if• iE * * iE * * iE iE iE * 1E � � � * * iE dE � * �E �E !E iE• I{ �E if• 'FE'If 9f iE !f �(' � iE * iE * iE � * iE iE iE if iE If iE it• iE• * * dE iE• D E V E L O P M E N T S E R V I C E S R E Q U I R E M E N`'T-S ONING APPROVED BY DATE: r.ZZ`�/ UILDING APPROVED BY : 5� DATE: -ZZ'97 PPLICATION ISSUED BY: /W DATE: f ZZ dE it• iE �E � iE iE iF �E iE iE iE iF iE * lE'!f *'IE iE iE iE !I' � �f ♦E * iF lfl'E �E iE if EGALIZATION:N F E E S U M M A R Y STRUCTURAL SEGMENT:Y BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMTP/RES GRADING PERMIT 74.75 SMIP/NON—RES PLAN 48.59 .54 ISSUE FEE BUILDING—DTV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE TOTALS ---- > 75.29 0.00 48.59 123,88 123.88 .00 REVENUE DIVISION TOTALS--> COLLECTED: 123.88 OVER/SHORT: .00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK 74.75 .54 48.59 df'IE iE'IE iE �E ii iE iF * * * � ♦E i[• iE #F ii iE !E * * � it � iE�[- * iE iF * * iE � !!� 1f * * * 1E #f 4E * iI• !f� 9E !E * dE �]E 'IE If �lE !f !(� � 1(' dE !E �(- �E iL• #E iE iE �E � * �1E !E lE 9E iE 9E � 9E i(� iE I N D I V I D U A L F E E B R E A K D O W N PE QTY D E S C R I P T I O N UNIT COST TOTAL COST FC 2595 ALTER BY VALUE COMMERCIAL NOZONE 1.00 2,595.00 END OF FEES 81-22-1997/83:38 PM/$123.88 RCPTA:81-8888986 PERMIT:881274 ONSTRUCTION AND PLANNING 7,CPPROVALS Permit# Date Inspector I _ & SPA APPROVALS Permit # Date Inspector 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement 3. Electrical Conduit, l3ti1ity-U1)tdr9rnd. 54. Forms -.4. Electrical Conduit-Mdrgrnd. 55. Electrical Bonding `5. Steel Reinfarcetnent' 56. Rough Plumbing & Pressure Test 6. Electrical UFER:Grnd. 57. APPROVAL TO COVER•GUNITE 7. Footings = 58. Electrical Conduit Undrgrnd. -8. Foundation .:7 59. Gas Pipe, © Ut 0rgrnd., Test 9. Water Pipe-Undrgrnd.S 60. Backwash Lines, P•Trap, © Undrgrnd. 70. Structural Flour System r , 61. APPROVAL TO DECK 11. Property Sewer Lire & House Connection 62. Backwash & Receptor -Final 12. Sewer Cap 63. Heater & Vent -Final 13. Roof Drains 64. Plumbing System - Final 14. Rough Plumbing _ ! 65. Electrical -Final ; 15. Rough Electrical -Conduit 66• Solar System -Final 16. Rough ElectriC.Wiriog 67. Fencing & AcEess Approval 17. Rough Wiring Sign 68. APPROVED FOR PLASTERING 18. Rough Electrical•T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating &Air Conditioning _ _ y 'FIIjE DEPT,..REQUIflEME�IT ,. APPROVALS Permit # - -, 20Rou9h Factory Fdreplace ^ r �< z w 21, Dudts, iri'Str•trctttieL 70._:Underground i'{ydro t 22 -Ducts, Ventilating r Y - : r,, 71, Product Piping O'Gas f0 Oil 1 23. Gar_Pipe Roigh &Test 72. Underground Flash. _y 24�Roof Framing - y x 73. Undergrnd. Storage Tank ©Gas ©Oil G , 25. Roof Sheathing 74..Ov'errhead Hydro.- 26.7T•Bai Ceiling (Structural) & Monocoat 7.5�.-Dry Chemicals _ - 27 -Frame and Flashing 76. Dry Standpipe Fes' r 28. Lathing;& Siding- - r w �, 77. FIXED-SYSTENI FINAL 29. Insulation rx _ 78. FIRE PREV. FINAL ' 30. Drywall Nailing r iHEALT-H DEPT. REQUIIiEMENT 31. Plaster Brown CoatJ 79. FINAL INSPECTION 32. Electrical Power Me"t&'•Fina! `T 80. FOOD CERTIFICATE ISSUED - 33' -Final Electrit- > Notes: 34 -Final Heating& Air,'Coriditioning- _ n. 35.'Final Gas Pipe-T$st* C- 36. Hood o%CanopyT 37. Final Factory Fireplace'" f . r 38.Fi4. PlumbingW. 39 ater Service.Finai - =W •- ;, - } - 40. Gas Service -Final"- ':T - _ -' 1'' ." ; 41: Solar Domestic-FinaI' 42. Backflow Preventers 43. Backflow Irrigation .1-44. _ Landscape 1rTipati6n. system- .7- _-45. Sound Atterivatio[i T �� - - + -46.'Handicap Regulations - ,47: FINAL STRUCTURE & BUILDING 48. -FINAL PLANNING 49. Electric Release to • dison - I f• -50.-Gas Release to Southern Calif ornitt Gas Co -51. CER'TIFICATE OF`OCCUPANCY No Date - '%DDItM (*Al1LDINO: 3333 BRISTOL St UNIT. 1600 M7*IrS WhelFl MFkC J SEGERSTROM FLOOD: AO -38 / ADDRESS:3315 FAIRVIEW RD COSTA MESA,CA 92626 546-0110 'APPL. WILIMADDRESS, ARoTrECT oR ENMEER: LIC. NO.: ARCK OR ENG.'S ADDRESS: UNIT: CWM=T0I?Sm E:TRI—COUNTY FIRE (714)472-3186 cowmAcmnhhuum23881 VIA FABRICANTE ADDRESS:MISSION VIEJO CA uc.No, 659326 92691 uNIT: 517 LIC NSED CONTRACTORS DECLARATION: I hereby effim under beery of perjury that I am licensed under provisions of Chapter 9 with Section 7900) of Division 3 of the Business and Pfglessions Code, and my fioerme is in full force and effect. c1TY . No.O 5 8 7 5 4 uc. cuss:C 16 uc. No.: 6 5 9 3 2 6 EXP: 03/97 f DComranorBUILDER DECLARATION: I hereby affirm under panty of perjury that I am exempt from the Contractors License Lew lot the {krwiog reason (Section 70315 Business and Professions Code: Any city or county which requires a permit to construct. after. improve. smolish, or repel any structure, prior to its issuance, also requires the applicant for with p&m A to file a signed atalament that he or she to licensed pursuant to the provisions of the Contractors License Law )Chapter 9 (oommencirp with Section 7000) of Division 3 of the Business and Profewma Code) or that he or she is exempt tlherelmen and the basis for the alleged exemption. Any violation of Section ' 7031.5 by any applicant for a permft subjects the applicant to a civil penafty, of not mors than five hundred dollars [MI). ❑ I, m owner d the property or my employees with wages as their ado oomperwation, will do the work, and the structure is not Wended or offered for sale (Section 7044. Business and Professions Corfu. The Contractors License Law doe, net apply to an owner of property who bolds or improves thereon, and Who does such work himself or herself or through his or her own w0wees, Provided that surJh improvements are not intended or Offered for sale. 0, however, the building a inprovernem is sold within ane yew of completion, the owoerbkdlder will have the burden of pro+'ing he or she did nol buaki or improve for the purpose of sale). ❑ I. as owner of the properly. ears exdusivdy oonlrectig with licensed eontreaore to comtruG the project (Section 7044. Business end Professions Code: Tike CaunhAas License Lew does ml apphy to an owner of propery who bts7da or inpraves thereon and who contracts for such projects with a corera tors) licensed pursuant to the Contream License Law). I am exempt under Section: B. d P.C.. for this reason: Date: Owner: I do hereby certify that I am aware of and understand the requirement, of Callomis Neath and Safety Code Sections 25505.25533, and 25534, and that I a any Mune &Ailing occupant will! will not (cycle due) now to empty with said state oodes and the requirements for a pemhl for construction or modrfralion from the Air -M ty whsgement District. Residential oonsInKlian appicationa we exempt from trate provisions. Data: Applicant: WORKER'S COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and oil maintain a certificate of consent to self -inure for Workers' compensation, as provided for by Sewn 3700 of the Labor Code, for the partomhence of the wont for which this permit is issued. K❑ I have and wall maintain workaa' compensation insurance. as required by Section 3700 d the Labor Code, ler the performance of the work for which this permit is issued. My workers' comper"lon insurance carrier and policy number we: NO Carrier: GOLDEN EAGLE EXPIRES Policy Number: (anis section creed nal be completed r dw peanut is lex ane kolt'ad Hallam )5100) or fees.) ❑ 1 cantly 00 in the performance of the work for which this Penne is issued. I shall not employ any person in any roamer so as to become subject to the workers' compensation Iowa of Cafdarnia, and agree that lf I ahpedd became subject to the work"' omperoation provisions Of Section 3700 d the Lisbon Coda, I shell forthwith comply with those provisions. Date: Applicant: We ng: Fagtm to secure workers' componsetlon coverage is unisadul, and stall sub*r an employer to hxlmlmal parmOss and fines up to ome hundred rhousand dollars (3!90(000), In aftdon to the cmf of compenuedoA damages as provided for m Secdon 37M of rhe Labor Coco, Interest and attorneys fag. CONSTRUCTION LENDING AGENCY: I hereby affirm under Penglty of perjury that them is a construnion lending agency for the performance of the work for which this permit is Issued ($anion 3097, civ. C). LENDER'S NAME: LENDER'S ADDRESS: I cenity that I have road this application and state that the above infomletion is owed. I agree to comply with all cry end county ordinances and state laws retailing to building construction and hereby authorize representatives of this city to enter upon the above-mentioned properly for inspectionprr'(;RAIG TAYLORLO Print Name -- Date: Signature of Owned A (515146.WP) Whce-Building d , Green -Ale: Canary-Applranl: Pink -Revenue; Goldenrod -Assessor CITY OF COSTA MESA — BUILDING PERMIT PERM NO: F 081067 PERMIT NO: F 081067 PLAN CHECK NO: 05323-9£ L GOVT: N SUPP: N CONSTRUCTION TYPE: I FR PERMIT TYPE: FIR PURPOSE: ALT JOB DESCRIPTION RELOCATE 14 EXISTING SPRINKLER HEADS SQ FT: CLAIM VALUE: 1,400.00 CALC—VALUE: GROUP OCC: B / COMMENTS: "COFFEE BEAN & TEA LEAF" STORE TI REF:B-80968 Z O N I N G R E Q U I R E M E N T S S E T B A C K S MAIN BUILDING ----------- --------- ACCESSORY BUILDING — — FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN PARKING REQ: PROV: PARCEL: 41250107 ZNE: REF NO: PLANNING NOTES> � � * * * 9E )E iE # 3E iE iE 3E 3E 3E iE 3E fE * � 3E � * � 3E �E �E )(• � BF � df 'fE iE iE iE iE iE iE �F iF )E �E )E iE >tiE iE � �E � iE � 3E �E iE iE ui(u1F �E iE iE •1E iE IE iE iE )E iE iE # iE iE iE iE iE iE iF iF iF D E V E L O P M E N T S E R V I C E S R E Q U I R E M E N T S ZONING APPROVED BY DATE: BUILDING APPROVED BY DATE: APPLICATION ISSUED BY: DATE: � * � � 1E � iE iE• iF iF iE iE �E iE jE �E IE'jE IE iE * !E iE iF iE iE iF � iE iF * •ie3E iE LEGALIZATION:N F E E S U M A R Y STRUCTURAL MENT:N BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE $MIP/RES GRADING PERMIT 4665t SMIP/NON—RES PLAN 29.90 ISSUE FEE BUILDING—DIV—> PERMIT ISSUE PLAN --CHECK TOTAL PAID DUE TOTALS ---- > 46.00 0.00 29.90 75.90 ,00 REVENUE DIVISION TOTALS--> COLLECTED:<4. 90 OV R/SHORT: .00 BLDG PMT PLUMBING ELECTRIC MECHANICSM OT GRADING PLAN --CHECK 29.90 If IE 1E 14 a4 # if jE 3F * IE )k ,tiE'iE iE dE �E iE * iE �E 1E 1E �E �F 1F * 14 �E d4 aE iE iE IE iE iE fE iE dE KIM -I N D I V I D U A L F E E B R E A K D O W N TYPE QTY h'�D E S C R I P T I O N UNIT COST TOTAL COST FIR 46 FIRE EQUIP FEE (FROM BLDG VAL TABLE) 1.00 46.00 END OF FEES PERNIT97 UNRI f rt _i • .tet PERNIT97 UNRI ` •CpdSTFIUCTION AND PLAKNING ; PROVALS Permit #; .r Date - Inspector, Pc � &SQA - APPROVALS Permit # Date inspector = 11. Temporary Electrical Service or Poke 52. Pool &Equipment Location 2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement 3. Electrical Condoit Utility-Undrgrnd.. 54. Forms 4, Electrical Conduit-Undrgrnd. 55. Electrical Bonding 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6. Electrical UFER Grnd, 57. APPROVAL TO COVER-GUNITE- 7• Footings 58. Electrical Conduit-Undrgrnd. 8. Foundation 59. Gas Pipe, D Undrgrnd., Test ` 9" Water Pipe-Undrgrnd. 60. Backwash Lines, P -Trap, O Undrgrnd. 10. Structural Floor System 61. APPROVAL TO DECK 11. Property Sewer Line & House Connection 62. Backwash & Receptor -Final 12. Sewer Cap 63. Heater & Vent -Final 13. Roof Drains 64. Plumbing System - Final 14. Rough Plumbing 65. Electrical -Final 15" Rough Electrical -Conduit 66. Solar System -Final 16. Rough Electric Wiring 67, Fencing & Access Approval 17. Rough Wiring Sign 68. APPROVED FOR PLASTERING 18. Rough Electrical•T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 191, Rough Heating & Air Conditioning • FIRE DEPT. REQUIREMENT APPROVALS Permit # 20. Rough Factory Fireplace 21. Ducts, in Structure 70. Underground Hydro 22. Ducts, Ventilating 71. Product Piping ❑ Gas 0 Oil 23. Gas Pipe -Rough & Test 72. Underground Flush 24. Roof Framing 73. Undergrnd. Storage Tank D Gas ©Oil 25. Roof Sheathing 74. Overhead'w,4ss Rea M%% � 26, T"Bar Ceiling (Structural) & Monocoat 75. Dry Chemical 27• Frame and Flashing 76. Dry Standpipe 2$. Lathing &Siding 77. FIXED SYSTEM FINAL �! d?h;p l�, 29, Insulation 30. Drywall Nailing 78. FIRE PREY. FINAL HEALTH DEPT. REQUIREMENT �rCl 31. Plaster Brown Coat 79. FINAL INSPECTION 32. Electrical Power Meter -Final 80. FOOD CERTIFICATE ISSUED 33. Final Electric Notes: 34. Final Heating & Air Conditioning 35. Final Gas Pipe -Test 36. Hood or Canopy 37. Final Factory Fireplace 38. Final Plumbing 39. Water Service -Final 40. Gas Service -Final 41. Solar Domestic -Final 42. Backflow Preventer 43, Backflow Irrigation 44. Landscape Irrigation System -.1 45. Sound Attenuation 46. Handicap Regulstions 47, FINAL STRUCTURE & BUILDING S, 48. FINAL PLANNING r, 49. Electric Release to Edison d .� h •1 50. Gas Release to Southern California Gas Co -: 51, CERTIFICATE OF OCCUPANCY No - _ ___ �� _ Date �. CITY OF COSTA MESA BUILDING DIVISION t �o i e 77-FAIV DRIVE, COSTA MESA, CA 92626 - (714) 754-5273 - Fax (714) 754-4856 vw w.costames�aca.dov FOR INSPECTIONS CALL: (714) 754-5626 •O,pnORFlF4* PERMIT NUMBER: BC12-00011 PERMIT TYPE: B_COMBO STATUS: ISSUED Sub Type: COM—ALT DATE ISSUED: 01/2512012 ISSUED BY: RMD JOB ADDRESS: 3333 1609 BRISTOL ST CM Suite/Unit: 1609 APN: 41250107 Zoning:PDC, , Vicinity: SPACE 1609 Primary Occ: Const Type: I -A SQ. FT: 1996 Valuation: $150,000.00 SCOPE OF WORK: 1,996 SF INTERIOR TI TO UNIT 1609 FOR "DIANE VON FURSTENBRERG", SPACE 1609, WORK TO INCLUDE NEW NON -LOAD BEARING WALLS, CELING AND FINISHES IN ORDER TO RECONFIGURE THE FITTING ROOMS, SALES AREAS, STOCK ROOM AND TOILET ROOM WITH 1 ALT DUCT SYSTEM, 2 VAV BOXES, 102 LIGHTS, 27 OUTLETS, 3 SWITCHES, 5 COMMUNICATION DROPS, 1 SUB PANEL TO 200 AMPS, OWNER: SOUTH COAST PLAZA Address: 3315 FAIRVIEW RD Unit: Phone: CitylState/Zip: COSTA MESA, CA APPLICANT. CALKINS, JAMES Address: Phone: 661-713-5182 CitylStatelzZipl CONTRACTOR: HURST AND SIEBERT Phone: 949-361-0111 Cell: Unit: : License No, 622681 Address: 2377 SO EL CAMINO REALUnit: SUITE 103 City/State: SAN CLEMENTE, CA ZipCode 92672 ARCHITECT: PAUL_ J RUFFING, AIA License No.C4264 ENGINEER: License No. COMBINATION PERMIT FEE SUMMARY Building Plan Check: $206.99 Building Fees: $1,273.75 Electrical Fees: $171.77 Mechanical Fees: $58.50 Plumbing Fees: $0.00 SMIP Residential: $0.00 SMIP Commercial: $31.50 Bldg Std Admin Fund $6.00 TOTAL FEES: $1,748.51 PHONE:949-660-8062 PHONE: ,Refer to fee receipts for all fees paid for project HOURS FOR CONSTRUCTION ACTIVITY: EFFECTIVE 3/18/2010 - PER CMMC Sec. 13-279 Monday thru Friday -7:00 am thru 7:00 pm. Saturdays -9:00 am thru 6:00 pm. Prohibited all hours -Sundays and the following Federal holidays: New Years Day, Memorial Day, Independence Day, Labor_Day, Thanksgiving Day and Christmas Day NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE p. INSPECTION TYPE QATT INITIAL S COPES INSPECTION TYPE DATE INTM4 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final BlocIdRetaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 250 Final BuildinglOccupancy �� ti 204 Final Demolition 4 WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a,certificate, of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy number are: tCarrler.kliV� (This seam need not be completed d the permd is valued alone hundred dollars (5104) or less,) Policy Number: CX'iC)Sq 17 ZO 1 Z ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, Ihall forthwith comply with these provisions. Applrcant's-Signature Date: WAR ING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. C� lass #' 1-7 7 1 f2 _contractors Signature r"Date'*,., CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lenders Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: ,The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion; the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.): ❑ 1, -as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractors) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: r. Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, !.e- prop'grty tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Division of Industrial Safety Permit Number: Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the Califomia Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If "yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE:' I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature o eg wnec(s) Date Signature Date { �7 5 f Zb l Z 3057-46 (3107) 1 I}ndlor.Authonzed App1scant T'Date r CITY OF COStA'MESA BUILDING DIVISION i 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 • www.cl.costa-mesa.ca.us t• �•� FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER:BX07-00134 PERMIT TYPE B_MISC STATUS: ISSUED APN: 41250107 DATE ISSUED: 09120/2007 Zoning: PDC, ISSUED BY: RMD JOB ADDRESS: 3333 1613 BRISTOL.ST CMI ' ±Suite/Unit 1613 Vicinity: STOREFRONT Primary Occ: ` = Const Type :?? SQ. FT: 27 Valuation: $3,000.00,- " SCOPE OF WORK: INSTALLATION OF AN ILLUMINATED (1 SIGN CIRCUIT) CHANNEL LETTER SIGN FOR "DAVANTE", SPACE 1613. OWNER: SOUTH COAST PLAZA Address:: Unit COSTA MESA CA City/State: 3315 FAIRVIEW ROAD Zip Code: 92626 Phone: _ APPLICANT: TURNER, TIM Address: 801 W 17TH ST_ Unit: City/State: SANTA ANA,.CA s Zip Code: 92706' Prone: 323-440-4491' CONTRACTOR: MANUEL GODINEZ license No: 773804 Address: 801 W 17TH ST" ` Unit: City/State: SANTA ANA, CA Zip Code: 92706 Phone -323440-4497 .Cell: ARCHITECT: License'No.. y' , Phone ENGINEER: License No.' ' Phone FEE SUMMARY Building Plan Check .` $54.11 Building Permit: $83.25 - Electrical Permit: i $0.00 - SMIP Residential - .$0.04 SMIP Commercial $OAO $O.00TOTAL FEES $137.36 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE I• INSPECTION TY DATE INTmALS CODE = INSPECTION TYPE DATE INTMAL� 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final BlOcklRetaining Wall 212 Final Fire Prevention b2 Final Factory Fire Placa 220 Final Planning Approval 203 Final Sign C ` — 222 Final Site 204 Final Demolition 250 Final Buildingl0ccupancy i WORKERS' COMPENSATION DECLARATION:' . I hereby affirm under penalty of perjury one of the following declarations: a I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. Q I have and will maintain workers' compensation insurance, as required by' section 3700 of the Labor Code, for the performance of the work for which this Permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: (This si 0 ion need not be completed dine perml is valued alone hundrecl dUlars (5100) or less) Policv�lVumber: j—l-certify that in;rkers' rformance of i rk for which this permit is issued'I sh p y person in any ma er so as to become subject to the er ' com n laws of Califo a, and agree that if I should bec a su ' ct a compensayofi provisions of Section 3700 of Ih Lab I sha orth�Complyese provisions. pl,-nt's Sigrwture Dale WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. I~ICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. # R~ Cl s # ti �_ �ne�z' rstracl ale L-- CONS�herebyl N LENDING AG (a Iaffirmthat th re is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). (-enders Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to Construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole Compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement Js sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, 7am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who bui]d5 or improves thereon, and who contracts For such project with CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I a contractor(s) license pursuant to the Contractors License Laws.). certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa t on the above-described property for inspection purposes re e of to occu or allow occupancy of any building authorized b er tun final inspectio . Signa f galOwner(s) p `ntl AulhodaedApO Owner ID verified by driv nse. []Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or. deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Division of Industrial Safety Permit Number: Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the Califomia Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to lite a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials aqua( to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department, 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6, Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8: (If "yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date ❑ I am exempt under sec. Business and Professions Code for this reason: Signature 3057-46 (3107) Date NEW DEMISING WALL, INTERIOR NON-STRUCTUAL DEMO, OWNER: SOUTH COAST PLAZA NORDSTROM INC Address:: SEATTLE, WA City/State: P O BOX 2229` Picone: i APPLICANT: LORIOT,-DAN Address: City/State: Phone: 949-361-0111 CONTRACTOR: HURST AND SIEBERT �Odress: 2377 SO EL CAMINO REAL x;03 Qlty/State: SAN CLEMENTE, CA Zip Code: 92672 CITY OF COSTA MESA Building Pian Check: ARCHITECT: BUILDING DIVISION Phone r 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 - Fax (714) 754-4856 } www. costamesaca.gov uA�o FOR INSPECTIONS CALL: (714) 754-5626 SMIP Commercial fi ' PERMIT NUMBER: BX11-00356 PERMIT TYPE B_MISC STATUS: ISSUED APN: 41249108 DATE ISSUED: 12/14/2011 Zoning: ISSUED BY: ' rt: JOB ADDRESS: 3333 1616 BRISTOL ST CM Suite/Unit: 1616 Vicinity: Primary Occ:Const "' Type :?? SQ. FT: 0 Valuation: $15,000.00 ' - SCOPE OF WORK: - _ ; _ ,• NEW DEMISING WALL, INTERIOR NON-STRUCTUAL DEMO, OWNER: SOUTH COAST PLAZA NORDSTROM INC Address:: SEATTLE, WA City/State: P O BOX 2229` Picone: i APPLICANT: LORIOT,-DAN Address: City/State: Phone: 949-361-0111 CONTRACTOR: HURST AND SIEBERT �Odress: 2377 SO EL CAMINO REAL x;03 Qlty/State: SAN CLEMENTE, CA Zip Code: 92672 Building Pian Check: ARCHITECT: LANCE -BROWN Phone 714-427-0370 ENGINEER: SMIP Residential Phone r, ATTN TAX DEPT Unit Zip Code: 92626-1610 [trim Zip Code: License No. 622681 Unit: SUITE Phone 949-361-0111 $163.31 $251.25 $0.00 $0.00 $3.15 $1.00 TOTAL FEES $418.71 License No. C19698 License No. Cell: ;4 HOURS FOR CONSTRUCTION ACTIVITY: EFFECTIVE 311812010 - PER CMMC Sec. 13-279 "Monday thru Friday - 7:00 am thru 7:00 pm. Saturdays -9:00 am thru 6:00 pm. Prohibited all hours - Sundays and the following Federal Holidays: New Years Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day and Christmas Day 2 ZI:- tNOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related re gulations. (Ord. No. 92-28, § 1, 12-21-92) :EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. s`- ,INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all 'required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE /• INSPECIRON TYPE DATE WMAL CODE t INSPECTION TYPE ME SAL 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 206 Final Plumbing j200 Final Re -Roof 210 Final Electrical 261 Final Block/Retaining Wall 212 Final Fire Prevention f202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site, B DA 4 Final Demolition 250 Final Building/Occupancy X 1-51c FEE SUMMARY: J Building Pian Check: Building Permit: .;i. Electrical Permit: } SMIP Residential SMIP Commercial Bldg Std Admin Fund ATTN TAX DEPT Unit Zip Code: 92626-1610 [trim Zip Code: License No. 622681 Unit: SUITE Phone 949-361-0111 $163.31 $251.25 $0.00 $0.00 $3.15 $1.00 TOTAL FEES $418.71 License No. C19698 License No. Cell: ;4 HOURS FOR CONSTRUCTION ACTIVITY: EFFECTIVE 311812010 - PER CMMC Sec. 13-279 "Monday thru Friday - 7:00 am thru 7:00 pm. Saturdays -9:00 am thru 6:00 pm. Prohibited all hours - Sundays and the following Federal Holidays: New Years Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day and Christmas Day 2 ZI:- tNOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related re gulations. (Ord. No. 92-28, § 1, 12-21-92) :EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. s`- ,INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all 'required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE /• INSPECIRON TYPE DATE WMAL CODE t INSPECTION TYPE ME SAL 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 206 Final Plumbing j200 Final Re -Roof 210 Final Electrical 261 Final Block/Retaining Wall 212 Final Fire Prevention f202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site, B DA 4 Final Demolition 250 Final Building/Occupancy X 1-51c WORKERS' COMPENSATION DECLARATION:I I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain workers' compensation insurance, as required by section 3700 of the Labfir Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier:S (TVs secaan need not be c ompreted if the pew* is valued atone hundred "ars ($100) or less) Policy Number: Coosw r7 -tort_ ❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to th rkerscompensation provisions of Section 3700 of the r Co shall hwith comply with these provisions. 2 2011 Applicant's Signature Date WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full forcb and effect. s 7 Lic. # Z G Class # +a 2 t 1L�11 un ractor's Signature bate CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lenders Address: Signature Date OWNER -BUILDER DECLARATIONS: hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Sign$ture 3057-46 (3107) Date Owner ID verified by driver's license. ❑ Yes )] No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which e person is required to descend, MJI be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code), ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicants Signature Division of Industrial Safety Permit Number: Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Govemment Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air duality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If 'yes', attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all stale laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: f certify under penalty of perjury that I have read this application and state that the information given is correct I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree'not to occupy or allow occupancy of any building authorized by this permit until final inspection. Sig�u of Le er(s) Da e An or Wharized Applicant Date ...��, ti ,.� .,.+n,.-rr r� r�-t�r�'!' kir'�r�r%7di3z^.*nK'r �+i"+,:- i. �"r�f.,.r*r► �. �4,..,�.Y ,.�ryi�,,,�..w'r�3S.r""isZv,.� a'yi,-,,...•-rc;r Cl- Y OF COSTA MF '.A Development Services, Division of Building and Safety CERTIFICATE"OF OCCUPANCY woo This certificate is issued pursuant to the requirements of.the Uniform Building Code, Section 308 adopted by the City of Costa Mesa certifies thatat the time of its issuance the building structureherein below described was inspected and approved foroccupancy as follows; Building Address 3333 Bristol St. Sp, '1617 'BIdg."PermitNumber B06-00176 Use Cosmetic Retail Sales {1,4989 s fV. Group `� Type of Construction 1 _ F R � e M. Use Zone PDC OwnerofBuilding South: Coast Plaza- Tenant MAC Address 3315 Fairview Pd., Ceota�tiesa, CA 9262h <p, By.:. -�, BUILDING OFFICIAL-Khanh Q.,Nguyen,. C.B.Q. Date REQUIRED TO BE POSTED IN A CONSPICOUS PLACE (714) 754-5273 • Fax (714) 754-4856 " www.ci.costa-mesaWLDING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Suite: 1617 Vicinity: STE 1617 MAC Primary Occ: M Display/Sale Merchandise Parcel Number: 41250107 Applicant: LORIOT, DAN Address: SUITE 103 Owner: SOUTH COAST PLAZA Address $1,133.75 SMIP Res: COSTA MESA CA SMIP Com: 3315 FAIRVIEW ROAD Contractor: HURST AND SIEBERT = Address: 2377 SO EL CAMINO REAL Total: SUITE 103 SAN CLEMENTE, CA Zip: 92672 Type of Construction: Zoning: PDC Phone: 949-254-0574 Zip: Phone: Zip: 92626 Phone: 949-361-0111 License: 622681 ISSUED BY: Status: ISSUED Applied: 02/02/2006 Issued: 03/29/2006 Arch : MBH ARCHITECTS,INC Eng: Address: 1125 ATLANTIC AV Address: Phone: 510-865-8663 Phone: ALAMEDA, CA Zip: 94501 License: C12815 License: SCOPE OF PERMIT INTERIOR 1498 SF STORE TI FOR "MAC' IN SUITE 1617. WORK TO INCLUDE NONBEARING PARTITIONS, CEILING, DOORS, BATHROOMS, LIGHTING AND MECHANICAL. Plan Check: $184.24 Permit: $1,133.75 SMIP Res: $0.00 SMIP Com: $26.25 Other:. $0.00 Inspection: $0.00 Total: $1,344.24 SETBACKS MAIN STRUCTURE Front 0-0 Rear 0- 0 ACCESSORY Front 0 0 Rear 0-0 PARKING Existing: 0 Required: 0 FEE SUMMARY PLANNING & ZONING Left 0-0 Left 0-0 Proposed: 0 Calc Valuation: Claim Valuation Right 0-0 Right 0-0 $125,000.00 $125,000.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-26, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all requires! Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued, have and will maintain workers' compensation insurance, as required by section 3700 o1 the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: �Carler. = T_Rrl rjdr-t� Policy Number!; 06, 98 1 ` 2cos- _ (Ml section need not be completed If the permit is valued at one hundred dollars ($100) or less.) ❑ I certify that in the performance of the wo fpr which this permit is Issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, an,( agr at If 1 should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these pr Appticant'Slgnature: WARNING: FAILUREO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP T4 ONE HUNDRED THOUSAND DOLLARE (S100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions o1 Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license Is in full force and effect. UC.-R Class t• Comiaetots'Slgnature:"� (Date,. u aG CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is Issued. (Sec. 3097, Civil Code). Lenders Name: Lender's Address: Signature: Data: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption, Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of safe.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to Construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of properly who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License taws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, lalsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division o1 Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to lite and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _.........................._---.._.............................._........................................ _......................-..._-.... -......—._..— .... —..... _ 2 Does or will the applicant or present or future building occupant need to filo a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume o1 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ................_.................... _................... --- ...................... --- ---._.._............................... ---................................................................................................. ._....................... .......... ................. _........... -...... -_......— 3 El Yes or will th❑e applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? NoLSecfion 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire apartment of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ........ ............... ...................................... ....... _..... ......... _. 4 If an RMPP is presently required, has Section 25534 of the Calilomia Health and Safety Code been fully complied with? ❑ Yes [I No _ ................... - ...................- _...._.__. _..._.................................. ....._................. .... �...._—..—..--- 5 Does or will the applicant or present or future building occupant require far the work which Is the subject of thisa plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? S Yes M No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ........ .............. ............... _........................ --.................... -•---.--.-_-............................... ........................................................................................................... ........................--•-•--.......__.......-..........._ _-- - fi Will any part o1 the facility to be constructed under this permit be within 1000 feat from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). — - . _...----- -- --------..._................................................._...-------------. 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No _....................----....._.._....... .... _........_ —................................_ ..........................................................................................................................._------------•--..............--------- 6 (I1 yes', attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances rotating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described properly for inspection purpose agree not to occupy or allow occupancy of any building authorized by this permit until final inspection, re Ow } Date �. Z4 bG And/Or Au horized Applicant (-Date. L CODE I INSPECTIONTYPE Q&N KnAL8 CODE! INSPECTION TYPE QBEINTMA 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final BlocVRetaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Sita 204 Final Demolition 250 Final Building/Occupancy W (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca,us 77 FAIR DRIVE, COSTA MESA, CA 92626 lob Address: 3333 BRISTOL ST Suite No 1517 Vicinity: 1617 -Parcel Number: 41250107 Applicant: SANDERS,BILL - Address: 1140 RED GUM ST ANAHEIM, CA- ' MECHANICAL PERMIT Phone: 714-630-3200 Zip: 92806 Status: ISSUED Applied: 04/19/2006 Issued: 04119/2006 ISSUED BY: C-"�- owner: SOUTH COAST PLAZA " Address: ' COSTA MESA CA-,'',', Phone: . 3315 FAIRVIEW ROAD . Zip: 92626 Contractor: THERMALAIR INC Address: 1140 RED GUM ST Phone: ,714-630-3200 ANAHEIM, CA Zip:, • 92806 + License: 102216 SCOPE OF PERMIT REF B06-00176 UNIT -1617 1 VAV BOX 1 VENT FANISINGLE DUCT FEE SUMMARY Quantity Quantity ? ISSUE FEEL $23.50 Repair/ Alt Absorbtion Unit $0.00 0 Inst FAO <100 k BTU $0,00 0, ' Repair /'Alt Refrigeration Unit $0.00 0 Inst FAU >100 k BTU, $0.00 -0 _ _ __ Ventillation System $0.00 0 .Repair/ Alt CoolingtHeat . $0.00- 0- Evaporative Cooler $0.00 0 Inst / Rep. Recess Wall Htr $0.00 0 Commercial Incinerator $0.00 0 Refrig Sys X100 k BTU $0.00 0 Domestic Incinerator $0.00 0 Refrig Sys >100 k BTU $0.00 0 Compressors /Absorption Systems ,Gas Piping -$0.00 0 Up to 3 hp 1100 k BTU $0.00 0 FactFireplace, $0.00 0 ory 3 To 15 hp / 500 k BTU $0.00 0 Hood w,/Mech Exhaust $0.00 0 15 To 30 hp 11,000 k BTU $0.00 0 VAV Box $10.65 1 30 To 50 hp 11,750 k BTU $0.00 0 Vent Fan 1 Single Duct $7.25 1Over n 50 hp /;Over 1,750 BTU $0.00 0 Appliance X- 0,00, -,0 .a .T a Boilers � Fire Dampers.' \ a x$,� " 0.00 0 Up to 3 hp $0.00 0 Smoke Dampers, j ` $0.00 0 3,To 15 hp $0.00 0 Inst or Relocate Appl.Vent :) $0.00`:0 ,-` _ 15 to 30 hp `$0.00 0 Air Handlers < 10000cfm $0.00 0 - '- 30 to 50 hp $0.00 0 Air Handlers > 10000cfm $0.00 0 •. ,. Over 50,hp $0.00 0 Floor Furnace \ '. $0.00 0 _ Other Mechanical Fee Floor or Suspend Heater ` $0.00 0 Investigation Fee` ' $0.00 Pian Check Fee y Reinspection Fee TOTAL CALCULATED FEES COMMENTS 1 SPECIAL•CONDITIONS $0.00 $0.00 $41.40 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92.28, § 1, 12-21-92) 1 EXPIRATION: This permit shall automatically expire and become void it work is not commenced wlihin 180 days, or it work Is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2449-48 (6=) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty, of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the ork for which this permit Is issued. have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code for the performance of the work for which this permit is issued. workers' compeennssatlon (Ins rance caTrriar and policy number are: C r. � � 17 1 R S mbar: �B+050aSs is section need not be completed if the permit is valued at one hundred dollars ($100) or less.) ❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Califomla, and agree that It ! should become subject to the workers' compensation provisions of Section 3700 of the Labor Coda, I shall forthwith with the vi Ion pplicant nature: Tt W : FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED HOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED C ACTORS DECLARATION: I q0b atf' t I am licensed under provisions of Chapter 4 (commencing with Section 7000) of Divisand Professions Code, and my license Is in tuff Uc. 0 CI�C_2 Contra at its"_. - *�� - 06 CO STR N LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code), Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 {commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. It, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she'did not build or improve for purpose of sale.). - ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WiTH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Coda: The contractors License law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner 10 verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feel in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 W III the applicant or present or future building occupant need to lite and Certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ......................................................._ ........................---...............—.......................... _.................... .,,.....,.................................................... _ _ ».....- .... ........... _.... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ..............-...............................»»....................... _....................... __........................................................ ............................................................ ................................... _............................... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the Cahfomia Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP Is presently required, has Section 25534 01 the California Health end Safety Code been fully complied with? [ Yas ❑ No ................ . _ .........................._._.—.................................» —......................_............................................... ....................».......................................»»................................ 5 Does or will theapplicant or present or iuture building occupant require for the work which Is the subject of this a plication apermit for such construction or modiTicatlon from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes ❑ No (Section 65850.2 of the California Government Coda requires that the requested information be furnished on applications for non-residential building permits). ..... ........................ —................ ...._..._.... _.................... _._._......... _... —_._.................. _..................... __........................................... ................... ........................ ....... ......... ...._... — 6 WIII any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? (:]Yes ❑ No (It "yes', the facility must meet the requirement of Sections 25534 and 42303 o1 the California Health and Safety Code). . •• -- ....... ................ —._._..... _............... -......... -..... ...—.-.—»....................-.... -......................... .............................................................................................. ..................... ................ .................. ....... -..... ---...... 7 !f a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by Celitomia Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ..»»..._...............•---------........_......_—...---._.............—_...............—_._...................................... _...».........................»....... B (If fres", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the Information given is correct. k agree to comply with all s ate Taws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-abed props r Inspe b n purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. ,.�-�1�-OCo -- Signature Of Legal Ownar(s) Date Anavok Authorize hcant Date CORE I• INSPECTION TYPice$ CODEJ INSPECTION TYPE 2&IL INTITIA 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Fina! 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Waft 212 Final Fire Prevention 202 Final Factory Fire Place n 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final BuildinglOccupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 PLUMBING PERMIT JobAddfess:- 3333 BRISTOL ST Status: ISSUED Suite No 1617 Applied: 04/24/2006 AMT CITY .. - r Issued: 04/24/2006 Vicinity: AMT CITY ISSUE FEE Parcel Nunmber. 41250907 $0.00 0 1001, Applicant: FLYNN, DON Backflow irrigation $0,00 0 ISSUED BY: / Address: 28051 LUCERO Swimming Pool $0.00 4 Backflow Preventer $0.00 0 Phone: 949-770-6194 0 Trap Primer MISSION VIEJO, CA Zip: 92692 $0.00 0 Owner: - SOUTH COAST PLAZA 0 - $0.00 Address. - - $0.04 0 Process Piping (per 10 ft) $0.00 0 COSTA MESA CA Phone: 0 Connect (Ice,Soda,etc) '�; $0.00 0 3315 FAIRVIEW _ROAD Zip: 92626 Vacuum Brkr Bkflow(5+) $0.00 0 'Dental Units , `• r ' "$0.00 0 Septic Tank - $0.00 0 Wash Basins ' $9.80 1 Contractor: FLYNN PLUMBING COMPANY INC '.$0100 0 Address: 28051 'LUCERO 0 Drain, Floor - $9,.80 1 Sewer Connect $0,00. Phone: 949-770-6194 $0.00 0 MISSION VIEJO, CA :-Zip: 92692 $0.04 -•0 s License:. 737.154 Drain, Roof $0.00 `,; 0, i -,; • _„ Shower " $0.00. ' 0 " • Water, Heater 1 vent $0.00 0 Drinking Fountain', g $0.00 ��o�C' ' . �0� �; Sink, bar .. - lr SCOPE OF PERMIT INTERIOR 1498 SF STORE TI FOR "MAC' IN SUITE 1617. REF.: 646-00176 PLUMBING TO INCLUDE: 1 FLOOR DRAIN, 1 BAR SINK, 1 TRAP PRIMER, 1 WASH BASIN, 1 WATER CLOSET AND 1 WATER PIPING. ' FEE SUMMARY AMT CITY .. - r AMT ;QTY AMT CITY ISSUE FEE , $23.50 - .i - -Lau ndryTub/-Washer- $0.00 0 Sump Pump $0.04 0 Backflow irrigation $0,00 0 Landscape'lrrigation_ $0.04 0 Swimming Pool $0.00 4 Backflow Preventer $0.00 0 P -Trap $0.00 0 Trap Primer $9.80 1 Bathtub $0.00 0 Pressure Regulator $0.00 0 Urinal $0.00 0 Clarifier System $0.04 0 Process Piping (per 10 ft) $0.00 0 Vacuum Brkr Bkflow(1-4) $0.00 0 Connect (Ice,Soda,etc) '�; $0.00 0 Receptors $0.00 0 Vacuum Brkr Bkflow(5+) $0.00 0 'Dental Units , `• r ' "$0.00 0 Septic Tank - $0.00 0 Wash Basins ' $9.80 1 Dishwasher $0.40 0 Sewer Cap for Demo '.$0100 0 Wash Basin.Set $0.00 0 Drain, Floor - $9,.80 1 Sewer Connect $0,00. .0 Waste and Vent System $0.00 0 Drain, Rainwater $0:00 0 SewerPrivate Line $0.04 -•0 Water'Closet (Toilet) $9.80 1 Drain, Roof $0.00 `,; 0, i -,; • _„ Shower " $0.00. ' 0 " • Water, Heater 1 vent $0.00 0 Drinking Fountain', g $0.00 ��o�C' ' . �0� �; Sink, bar .. - $9.S0 1 Water Piping {Inst or Rep.} $9.80 1 Expansion lank "$0.00 ``� Sink, commercial $0.04 0 Water Re -pipe $0.00 0 Gas Earthquake Valve $0.00 0 ,-,Sink, Floor - $0.00 0 Water Service $0.00 0 Gas (1-4 outlets) $0.00 0; ,` Sink, kitchen' $0.00 0 Water Softener $0.00 0 Gas (Over 4 outlets) $0.00' r 0 • Sink; servicelmop $0,00- 0. OTHER , $0.00 Gas Repipe $0.00 0 Spa (private)ti - $0.000 VIOLATION $0.00 Gas Service $0.00 0. " Spa,(public) $0.00 0 PLAN CHECK $0.00 Interceptors (Grease, Oil) $0:00 0 REINSPECTION $0.00 0 interceptors (Sand Auto ) $0.00 4 ` .TOTAL CALCULATED FEES: $82.30 COMMENTS LSPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes and all required inspections and final approval must be obtained. Failure to obtain inspections and fins! approval will result In the expNitlon of this permit. FOR INSPECTIONS CALL: (714) 7545626 2446-46 (600) DECLARATIONS WORKERS' COMPENSATION DECLARATION: 1 hereby affirm under penalty of perjury one of the following declaiations: ❑ 1 have and will maintain a certificate o1 consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued, irmi:have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workors' compensation Insurance carrier and pollcy number are: - • ��j %� � JETA jn Pollber'_- Dn z�71� Gw� '!s section neer not be completed it the permit is valued at one hundred dollars ($100) or fess.) Lr ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Cslifo agree that It I should become subject to the workers' compensation provisions of Section 3700 of the tabor Code, I shall forthwith comply with these provision . / r .ApplicantSlgnature: � [-Date:--_ �'i ,WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYF-R TO CRIMINAL PENALTIES AND CAVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000i, IN ADDITION TO THE OOST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3705 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I ICohheereby affirm.that.l am licensed under prove or�S Chapter 9 (commencing with Section 7000) of Division 3 of.the.Busine_ss and Professions Code, and my license Is in full force and affect Uc. a- S Klass # — �,_ - ntractor'sSl� Dat` CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is Issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Data: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (See. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sale compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or Improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or improvement Is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth Into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Titte 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, Cr a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _.._................_.. ._.._.............. _.................. _.. _. _ _.....-- -_ —_.._...-----......_......._......__........._........-----.......-------- 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Daes or will the applicant Cr present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire apartment of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. -......................................................................................................................................................................................'S"'a"_.._..................e"e"..........................I'ie,...................-'-......a...............................-----..._.......................................�......... 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑Yes ❑ No 5 Does or well the applicant or present or future building occupant require for the work which Is the subject of this a plication aPermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes 19 No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ..................................................................................................................................................................................................................................................................... ........................ ._................................................................ 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ................_..................................... _...._.,..................................................................._............................................ ......................................... --_......... I _ ......................................................... ....... ........ ................ 7 If apermit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No •..-•..............._.................................................. -............................. ................................................................................................ ................ _................................................................. 6 (It yes", attach cenificate of compliance from the appropriate air pollution control officer), CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Data: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state taws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. __.SigP&ure Of Legal Owner(s) Data Z, . Or.Authorized"Applicant"— CDDE i"lX§EEGJI9N JX01 Qd: INTITIALS CQOEI INSPECTION TYPE 1?ALE�INTIMALS - 1616 Fixed System Final Fire Prevention 206 Final Mechanical ��t 1266 Pool Spa Final 208 Final Plumbing Z -cavo `06 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign r " 222 Final Site 204 Final Demolition 250, FInaI Building/Dccupancy Job Address: 3333 BRISTOL ST Status: ISSUED Suite: 1617 Applied: .05/15/2006 Vicinity: Issued: 05115/200 Parcel Nunmber: -41250107 " Zoning: PDC PDC ISSUED BY: Applicant: MANCINO, RANDY Address: 818N GRAND AV' - Phone: 626-913-6720 - COVINA, CA' ti Zip: 91724 - Owner: , SOUTH COAST PLAZA- LAZAAddress, Address, COSTA MESA CA ' A Phone: 3315 FAIRVIEW ROAD Zip: 92626 Contractor:", ALLREADY FIRE SPRINKLER -Address: 818 N.GRAND AV Phone: 626-913-6720 COVINA, CA Zip:. 91724 License: 358795 ' i "SCOPE OF PERMIT RELOCATE 17.OVERHEAD SPRINKLERS FOR "MAC" IN SPACE 1617 FEE SUMMARY Plan Check: $54.11 " Calc Valuation: $2,500.00 Permit , $83.25 I . '° e. ;y .. Claimed Valuation: $2,500.00 Other •` $0.00 Total:, .. $137.36 1 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days,, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 2446.46 (6100) JJ • WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. q_ -,have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. CMy workers' compensation Insurance carrier and policy number are: Carrier:. Z- 2 rX_rx 11-44 r-22tO GJ C_ Number: GC_ y (This section need not be completed if the permit T valued at one hundred dollars ($100) or less.) f ❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these prov' ' ns. Applicant Signature: Date: _ WARNING: FAILURE TO SECURE WORK RS' COMPENSATION COVERAGE IS UNLAWFUL AND SMALL SUWEC7 AN EMPLOYER TO CRIMINAL PENALTIES ARID CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE (5100,000), IN ADDI TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic.- 2, <-4D, Class fi Contractors Signature: Date:TIS CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there Is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alcor, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, Le. - property tax bill or dead): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: © I hereby certify that no excavation five (5) or more feet in depth into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ........................................................ •........................................................................................................................................................................................................................................................................................... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .............. .... ...--.-..........................................................................................-..........--.......................................................................................................................................................... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. .......................7is -..............................._......'-• ---cii',1"1n1,1,1'12'1115-..............................."or'"i'a".......ali'.................f-e-.....................*.e-'........................................................................................................................................................ 4 If an RMPP is presently required, has Sectio534 o.. the California Health and Safety Code been Tully cpmplied with? ❑Yes ❑ No 5 Qoes or will the applicant or present or future building occupant require for the work which is the subject of thisa plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? N Yes M No (Section 65850.2 of the California Goverment Code requires that the requested Information be furnished on applications for non-residential building permits). ......... ............................................................. ............................................................................. ............................................ .... ............................................................................................................................ ....1..111..... ... _........... ..... 6 Witl any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (it'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). .....................................:........................................................................................................................................................................I............................................................... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑Yes ❑ No ................................................................................. •-­--......................................................................................... ............................................................................................................................1111 attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the Information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Dale: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the Information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Si ature Of Legal Owner(s) r Date r Authorized Applicant Date CODE N. INSPECTION TYPE DAM igI.rrIALs COPE# INSP�,CTIONTYPE 2219 It 1616 Fixed System Final ire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention Q� 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4656 • www.ci.costa-mesafftTRICAL PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Suite No 1617 Vicinity: Parcel Nunmber: 41250107 l Applicant: * SCHMIDT, BRAD' Address: 2083 GRACE ST Phone: 951-509-2954 RIVERSIDE, CA Zip 92504 Owner: SOUTH COAST, PLAZA Address COSTA MESA CA Phone: 3315 FAIRVIEW ROAD Zip: 92626 Contractor: S AND S ELECTRIC Address: 2083 GRACE ST Phone: 951-509-2954 RIVERSIDE, CA Zip: 92504 License: 454118 Status: ISSUED Applied: 04124/2006 Issued: 04/24/2006 k , ' •r ISSUED BY: COMMENTS I SPECIAL CONDITIONS 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work Is not commenced wifhin 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: to order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes; and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2aa5-0 (arca) SCOPE OF PERMIT INTERIOR 1498 SF STORE Ti FOR "MAC' IN SUITE 1617. WORK TO INCLUDE NONBEARING PARTITIONS, CEILING, DOORS, BATHROOMS, LIGHTING AND MECHANICAL. REF.: 806-00176 ELECTRICAL TO INCLUDE: 122 LIGHT FIXTURES, 22 OUTLETS, 14 SWITCHES, 1 SIGN CIRCUIT, 1 BATH FAN < 1 HP AND 1 INSTA HOT TANKLESS WATER HEATER. FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 Temp Dist System 1 Lighting $0.00 0 Temp service test $0.00 - - - Busway 1100 ft $0.00 0 Res. a/c package $0.00 Standing Section $0.00 0 New Res (1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0 New Res (3+units) $0.00 0 Transformers up to 1 kva/kw $0.00 0 Pool l Spa $0.00 0 ................up to 10 kva/kw $0.00 0 Lighting Fixts, $96.46 122 ................up to 50 kva/kw $0.00 0 Recept Outlets $23.46 22 .................up to 100 kvalkw $0.00 0 Switches $15.40 14 ..................over 100 kvalkw $0.00 0 Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0 Res Appl $0.00 0 Low Volt Wiring System / Ckt $0.00 0 Service to 200a $0.00. -0 . Misc. Conduit $0.00 0 Service to 1000a $0.00- 0 Misc, Conductor $0.00 0 Service over 1000a : $0.00` "0 '- Circus (gen or ride) $0.00 0 Motors to 1 hp $4.75 Circus (mech ride or lights) $0.00 0 Motors to 10hp $0.00 "0., ; Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 0 - Fireworks Stand $0.00 0 Motors to 100hp $0.00 0 Other Electrical Fee $9.80 Motors over 100hp $0.00 0 Communication drops $0.00 0 Investigation Fee $0.00 Sub panel to 200a $0.00 0- Plan Check Fee $0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $24.60 1 Temp Pwr Pole $0.00 0- _ TOTAL CALCULATED FEES $197.97 Intermed Pole 50.00 0 COMMENTS I SPECIAL CONDITIONS 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work Is not commenced wifhin 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: to order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes; and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2aa5-0 (arca) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ -1 have and will maintain a certificate of consent to self-]nsure for workers' compensatlon, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. "❑ I have qndwUl maintain workers' compensation Insurance, as required by section 3700 of the tabor Code, for the performance of the work for which'this pemtJl is issued. My coo erg' compensation tns u carrierr8 dd policy number are: ,Carrie - ✓ PoIICy.Number. IA! kZ � 3"Re � .(This section neenot be completed if the permit is valued at one hundred dollars ($100) or lass.) ❑ I comity that in the performance of the work for which this permit is Issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that f I should become subject to the workers' Compensation provisions of Section 3700 of the Labor Code, I shall forthwith compty with th ions. 'Appli�anil Signature - Omate'�+? � m24W.4d ri -WARNING: FAILURE TO SECURE WO RS' COMPENSATION OOVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TOAMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000], INA DnMON TO THE COST OF OOMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am tic ns d under p visions of Chapter 9 (commencing with Section 70DO) of Division 3 of the �B�slneandofessions Code, and my license is In full for�e�and.offect..Llc..mY_ CC1a Contraaors_Signeture: ate:. CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: _ _ Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Protessions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors Lloense Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500),): ❑ I, as owner o1 the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or Improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or Improvement Is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ f, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Coda: The contractors License law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No, Expires: Verification of Ownership by (type of document, i.o. - property tax bill or dead): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feel in depth Into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Tltle 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number. HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the appffcant or present or future building occupant need to fife and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). - ...................................._.................... 11.11..................... ._.......................................................................................,,,...,,,,....................................................... ............ 111....._ 1111.... 2 Does or wily the applicant or presenter future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight o1 500 pounds, or a volume of 55 gallons, or 200 cubic feat of compressed gas at standard temperature and pressure). ... ........................... -._................._.,..........--.._.._—................. --•-•--............. ..._...................... .......... ................................................................. -_ ................. -._..... _... — 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous material$)? Q Yes ❑ No (Section 25534 of the California Health and Safety Coda provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presentiy required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this a plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes (9 No (Section 65850.2 of the California Govemmeht Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? © Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 o1 the California Health and Safety Code). •.........................................._._...........-•---••--•--..................._.-._....----.......-...............-...__._........ .._is - 1-1_11 7 If a permit from the South Coast Air QualityManagement District or other air pollution control district or agency is required for the work which the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (If 'yes", attach Certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHOR17ATION OF ENTRY: I camity under penalty of perjury that I have read this application and state that the Information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costs Mesa to enter upon the above-described property for Inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Aligns Of gal WS) Date An OrAuthodzed Applicant- -- Date CODE -#. INSPECTION TYPEQaj$ f CODE 1 INSPECTION TYPE QaIE INTITIA 1616 Fixed System Final Fire Prevention 206 Final Mechanical 7266 Pool Spa Final �- 208 Final Plumbing �6 200 Final Re-Roof 210 Final Electrical 201 Flnal BlocklRetaining Well 212 Final Fire Prevention 202 Final Factory Fire Place y 220 Final Planning Approval . 203 Final Sign 222 Final Site 204 Final Demolition _ 250. Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4$56 • www.cl.00sta-mesa.'8{!RLDING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Status: ISSUED Suite: 1617 Applied: 06/12/2006 Vicinity: 1617 Issued: 06/12/2006 Primary Occ: M Display/Sale Merchandise Type of Construction: I -FR Parcel Number: 41250107 Zoning: PDC Applicant: SMALL,JONATHAN - Address: 400 WFOOTHILL Phone: 626-335-2887 ISSUED BY: GLENDORA, CA Zip: 91.741 Owner: SOUTH COAST -PLAZA"', - Address COSTA MESA CA Phone: 3315 FAIRVIEW ROAD Zip: 92626, Contractor:. R AND R SIGNS Address: 400-W FOOTHILL - Phone: 626-3354867�`� GLENDORA; CA"-"" �% Zip: 91741�� License: 740985 V� , Arch Eng. \ Address: Address: . Phone: Phone: Zip: License: _ License: r SCOPE OF PERMIT.-_ FOR MAC SUITE 1617 REF B06-00176. ILUMINATED STORE WALL SIGN FEE SUMMARY Plan Check: $29.15 Calc Valuation: $1,2oo.o0 Permit: $44.85 \"` f r`;`'�Claim Valuation: $1,200.00 SMIP Res: $0.00 SMIP Com: $0.50 Other: $0.00 Inspection: $0.00 F Total: $74.50 PLANNING'& ZONING SETBACKS MAIN STRUCTURE; Front " 0-0 Rear 0-0. 1 Leh '0-,0 Right 0-0— -0„ACCESSORY ACCESSORY Front 0-0 - Rear " 0-0 Left 0-01 , ^; ", Right , . 0- 0 . PARKING Existing: 0, Required:,, •0 Progosed: 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under CaGfomia statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shalt automatically expire and become void if work is not commenced within 160 days, or if work Is suspended or abandoned for a period of ISO days. INSPECTIONS: In order for the worts authorized under this pemdl to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Falhn to obtain Inspections and final approval will result in the expiration of this pemdt. FOR INSPECTIONS CALL: (714) 75&5626 z"a-4a (am DECLARATtdgi.� WORKERS' COMPENSATION DECLARATION: t hereby affirm under penalty of perjury one of the following declarations: ; ❑ 1 have and will maintain a certificate of Consent to self-Insure for workers' compensation, as provided for by section 3700 of the tabor Code, for the performance of the work for which this permit Is issued. ! have and will maintain workers' compensation insurance, a5 required by section 3700 of the Labor Code, for the ante of the work for which this permit is issued, workers' compensation Incur rico carrier and policy number are: �^ a 'or: a n r [ �C �sj�^ a o1ICy Nu rr Co )ci••7 )°1 ,�PG,6 action need not be Completed If the permit is valued alone hundred dollars {$100) or fess.) {_] 1 certify that in the performance of the work for which this permit is issued, i shall not employ any person in arty manner so as to become subject to the workers' on laws of Calilomia, and a roe that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith co wi these pr Sion Ap nt attire: "to: W NG: FAILURE T CURET WORKERS' TION COVERAi3E IS UNLAWFUL AND SHALL SUBI =CT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOl1A 100,DOOj, IN ADOrr10N TO 7HE COST OF OOMPF_NSlhT10N, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereb licensed under rovisions of Chapter 9 (Commencing with Section 7000) of Div o the f3 ss and Professions Code, and my license is in full for c. a o - t7 p on nature: CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the porformance of the work for which this permit is issued. (Sec, 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: 1 hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city Or county which requires a permit to construct alter, Improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors license Law (Chapter 8 (commencing with Section 7000) of Division 3 o1 the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for safe (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. It, however, file building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who Contracts for such project with a contractor(s) license pursuant to the Contractors license Laws.). ❑ 1 am exempt under sac. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Drivers License No. Expires: verification of Ownership by (type of document, ice, - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth Into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) foot high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title B, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division Of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and carilty a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to of greater than a weight of 500 pounds, or a volume o1 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ............... .................................................................................................................... _.......................................... ................................ ................................................... .................... ...................... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes 0 No (Section 25533 of the Califomle Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _— .........................._- — --._.� _1 111_ 1111....... _...... ............................ .................................................................. _......... . ................. . .... 111 _... _ 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire 0epartmont of an RMPA by businesses which are required to register acutely hazardous materials with the Fire Department. .................. — ...._.... _ ._.............. _—..........................._..._._._........... ........... _. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully Complied with? []Yes ❑ No 5 Does Or will the applicant or present or future building occupant require for the work which Is the subject of this a plication aermit for such constriction or modification from the South Coast Air Quality Management District or from any other air pollution Control district or agency? lJ Yes a No (Section 65850.2 of the California Goverment Code requires that the requested information be furnished on applications for non-residential building permits). ........._....—._—...__----- .....Constr ..............-----------............�....—..._.._........_._�... 1111. 6 Will any part of the facility tO be ucted ter under this permit be within 1000 feet from the ouboundaries of a school? ❑ Yes ❑ No (if -yes-, the facility must meet the requirement of Settl34 ors 255and 42303 of the Califomia Health and Safety Code). _1111. ----�......._.---..._........_� _ _.-- - ................. ---- - -. - 7 it a permit from the South Coast Air Quality Managemant District ar other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures proscribed by California Health and Safety Coda Section 42303 bean made? ❑ Yes ❑ No ---- .................._...._.._ ...... _.............. _.... —_.... _............... ......................---........................—_......................... .�..... ...... ... _......................._.1111..................1111..... -_... 8 (If 'yes', attach certiffcate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is Correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all slate laws and dry ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. l agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Si nature O1 L er s Date uthorize ticani Oa BODE N. INSPECTION TYPE 2&H INTITIAL$ CODE IRSPI 00141 IYPE QdTE iflTITIAL� 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Root 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place��� 220 Final Planning Approval ' 203 Final Sign 222 Final Site T 2134 Final Demolition �7�'/ 2$0 Final Building/Occupancy ELECTRICAL PERMIT Job Address: 3333 .BRISTOL ST Status: ISSUED Suite No 1617 Applied: 06/12/2006 Vicinity: 1617 Issued: 06/12/2006 Parcel Nunmber. 41250107 Applicant: SMALL,JONATHAN Address: 400 W FOOTHILL ISSUED BY: Phone: 626-335-2887 GLENDORA, CA y ✓, Zip 91741 - Owner: SOUTH COAST PLAZA E f';1"r Address COSTA MESA CA\, .Phone: �, - �_ �'`i ,` `• ' +. 3 . - � � �. ! ••. �. � 3315 FAIRVIEW ROAD \ 1.' Contractor: RAND R'SIGNS-, Address: 400 W FOOTHILL Phone: 626-335-2887 GLENDORA, CA Zip: (!'91741 License'740985 NOTICE, The work Aulhortaed.by this permit shali comply with all applicable handicap access requirements under California statutes and related regulations, (Ord, No. 92~2x}, § 1,12.21.92) EXPIRATION; This permit ahotl automalically ettpire and bmme void if work Is not commenced within 190 days, ar it work 19 suspended or abandoned for s pertod of 100 days. INSPECTIONS; In prdo( for the work authorised under thlo permit to be considered tegal, such work must comply with all applicable codes, and all regltlmrd'napactlpna and final appmal must be obtained. Failure to obtain inspections and final approval will result In the expiration of this permit. FOR INSPECTIONS CALL: 17'14) 754,3929 2.44x-4@ (On) SCOPE OF PERMIT; FOR MAC SUITE161TREF B06-00167. ILUMINATED STORE WALL SIGN 'REF B06-00928 SIGN PERMIT ' FEE SUMMARY ; "Quantity_ � Quantity. ISSUE FEE $23.50 Temp Dist Systeme/ Lighting- ', $0.00 0 ` '. service test $0.00 &swaY1,100 rl r . , ` 0Tenp Res, a/c package $0.00 '. = _ Standing.Section.:_ - - $0.00 0 New Res (1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0 ' New Res (3+units) $0.00 0 Transformers up to 1 kva/kw $0.00 0 ; Poo] l Spa$0.00 0_ ......; rup to.10 kvalkw-- $0.00 0 Lighting Fixts $0.00 --0 --- - -.......up to 50 kvaAw.: d $0.00 0 Recept Outlets $0.00 1'-0 :.:up to 100 kvalkw $0.04 0 Switches $0.00 0 ............. .,%over,100 kvalkw $0.00 0 f Non Res App] $0.00 0 Low Voltage,Equipment $0.00 0' . - Res Appl $0.00 0 Low Volt Wiririg System 1 Ckt $0.04 0 ' Service to 200a $0.00 0 Misc. Conduit "' $0-00 ,,-0 Service to 1000a- $0.00 0 . ,. ;,Misc. Conductor $0.00 :•;0 Service over 1000a $0.00 0 Circus (gen or ride) $0.00 %/ .0 ? ` Motors to 1 hp $0.00 0 ' '"Circus (rdech ride or lights) :$0.00'i' ' 0 ' Motors to.l0hp $0.00 0 *' ! ' Christmas Tree Stand, $0.00`j 0' Motors to 50hp' ��' $0.00- s'- 0.'!�� " Fireworks Stand%=` - �.�^''�' x$0.00' 0.' � Motors to 100hp $0.00,,�� 0 ,-. „Other Electrical Fee ,sb.00 ` Motors over 100hp $0.00 _'��� 0 . - �/; Communication drops �. $0.00 �` ,' 0 _, .Investigation Fee='��'�.�' $0.00_ Sub panel to 200a,, $0.00 ; .0'`;t... ? Plan Check Fee. -.r Pole Light Pk 9 9 Sign Circuits '- $17:00 -'� 0` - � i , ,' , $24.60 / '1 '��� ��. - Reins action Fee", �' ,_,; �_ -. A _ $0.00' - _ _ '---- �j J Temp Pwr Pole fi x$0.00` J 0? , _=-_ _ TOTAL CALCULATED FEES Intermed Pole -0 . $0.00 COMMENTSTSPECIAL CONDITIONS'- r NOTICE, The work Aulhortaed.by this permit shali comply with all applicable handicap access requirements under California statutes and related regulations, (Ord, No. 92~2x}, § 1,12.21.92) EXPIRATION; This permit ahotl automalically ettpire and bmme void if work Is not commenced within 190 days, ar it work 19 suspended or abandoned for s pertod of 100 days. INSPECTIONS; In prdo( for the work authorised under thlo permit to be considered tegal, such work must comply with all applicable codes, and all regltlmrd'napactlpna and final appmal must be obtained. Failure to obtain inspections and final approval will result In the expiration of this permit. FOR INSPECTIONS CALL: 17'14) 754,3929 2.44x-4@ (On) /11 WORKERS' COMPENSATION DECLARATION: 1 hereby affirm under penalty of perjury one of the following declarations: I have and will maintain a certificate of consent to serf Insure for workers' Compensation, as provided for by section 3700 of the Labor Code, for the performance of,the work for which this permit is issued. aP d will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My ers' compensation Insurance carrier and policy number are: C. C Sia -� P_ _ i t^ 1 S ,y, � �c.ln L olicy Num aQ � 1 -71 � ^ xL'.0 C, — (This secfion ne� completed it the ermit is valued at one hundred dollars ($100) or less.) ❑ 1 certify the a performance of the work for which this permit Is issued, I shall not etnploy.awf anner so as to become subject to the workers' c la of alifomia, n agr hat if Id become subject to the workers' compen on provision f Section 3700 of the Labor Code, I shall forthwith mply with t isions. / Applica ure: Data: ARNING: FAILURE T ECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PE TIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND $100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby a ' nsed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of and Professions Code, and my license is in full C rac ure: d CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is Issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Dale: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, Cr repair any structure, prior to its Issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors license Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner at property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under see. Business and Professions Code for this reason: Signaturo: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title S, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ............................ . ................................................... ............................................. ........... .............................................................. .............................................................................. ....................................................................................... 2 Does or wi11 the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _........ . ............................ _..................-.........._.................... —... _................. ._—._.............. ---._................................ -----............ _..-^--_.................... _... ............ - ........._.............. _ __.. 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)7 ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. .... ............................................................................................................................... ........................................................................ ......'--,.................................................................. ............................ ......•..,,......................................... 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No s or will thea applicant or resent or future building occupant require for the work which is the subject of this a lication a ermit for h n r 5 Doe pp p g p q j p o such construction o modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes L I No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). B WIII any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes C No .......... (It 'res', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ............ ................................................... ..,.•......................................................... ................................._ .............................................................................._ w..........................................._.... . ............................... -................ 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (If '"a*, attach certificate of compliance from the appropriate air pollution control officer), CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I cenity under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. i agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. a Of Le al Irl Cob Date orized pplicant Date Q IflTMAL$ CODE I INSPECTION TYPE �`� 2M INIMA 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention - 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy AnDRESSOilSWLDING: 3333 BRISTOL ST UfIT: 1617 D19NE1rSNAMEIFF410 fl: C.J. SEGERSTROM & SONS FLOOD: AO -38 L - ADORES& 3315 FAIRVIEW RD COSTA MESA CA 92626 (714)546-0110 APPL. MAIIING ADDRESS: ARCHITECT OA ENGNEER: L HOWARD NUD EL L LIC, NO.: C-10580 ARCILOREN3ADDRESS: 30600 NORTHWESTERN HGWY UNIT: FORMINGTON HILLS MI 48334 CONTRACTOR'S NNE; B & B CONTRACTORS (714)627-3651 CONTRACTOR'S MAILING 13745 S EM I NO L E � f ADDRESS: CHINO CA LIC ND.: 436418 91710 UNIT: LICENSED CONTRACTORS DECLARATION: I hereby affirm under penally of perjury that I am licensed under provisions of Charger g (oommenting with Section 7000) of Division 3 of the Business end Professions Code, and my license is In full force and effect. CITY LIC. NO.: LIC, CLASS: B UC. NO. 436418 EXP : J Oats: /d `%� � 9 S Contractor: OWNER BUILDER DECLARATION: I hereby aMrm under penalty of perjury that I am exempt from the Contractors License Law for the following reason (Section 7031.5 Business and Professions Coda: Any city or county which requires a permit to construct, alter, improve, femolish, or repair any structure, prior to as issuance, also requires the applicant for such permit 10 file a signed statement that he or she . licensed pursuant to the provisions of the Contractors License Law (Chapter a (commencing with Section 7000) of DNislon 3 of the Business and Professions Cade] or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a swig penalty at nor more than We hundred dollars [55001). ❑ I, as owner of the properly or my employees with wages as their sola compensation, will do the work. and the structure is not intended or offered for sale (Section 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon. and who does such work himself or herself or through his or her oven employees, provided that such improvements are not intended or offered for sale. lf, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving he or she did nog build or improve for the purpose of sale). ❑ I, as owner of the property. am exclusively contracting with licensed contraclom to construct the pmjact (Section 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or impmes thereon and who contracts for such projects with a ooraractor(s) licensed pursuant to the Contractors License Law). ❑ I am exempt under Section; S. E P.C., for this reason: Date: Owner: Ido hereby certify Viet 1 sm aware of and understand the requirements of California Health and Safety Code Sections 25505, 25533, and 25534, and that I or any INure building oocupam will 1 will not (circle one) need to comply with said state codes and the requirements for a para forconsiruction or modlfiraticnlrom the Airu�aty Ul7anagemenl District. Residanlial conalnidion applicalionsare exempt from these provisions. Date: Applicam: WORKER'S COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: © I have and wig maintain a certificate d consent to sell -insure for workers' compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which Ihis peri is issued. - - -- I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance eamiar and policy number are: Carver: FREMONT COMP IN EXPIRES Policy Number: Ldp 9 S5 5 7 2 2 7 n 1 04/01/96 (This section need not be c+omph ad N the permit is for one hundred dollars 131001 or less) ❑ 1 certify that in the performance of the wok for which this peri is issued, i shall not employ any person in arty manner so as to becorna subject to the workers' compensation laws of CaGlomia, and agree that if I shouj# become subject to the workers' compensation provisions of Section 3700 of the Labor Code. 1 shay.forijrwilh py wriSh provisiorw. Dale: O -14 " 95" Applicant: Waming: Failure to secure, workma'rompermlion coverage 1s uMawful, and sftafl aeWect an employer to cflmlrral periafdas and clv1I fins up to one htndrad thousand dollars ($1 04000), In sddldon to the cost of comp wWtlon, damages u provfded for In Secdon 3706 of the Labor Code, lntaruf, and attorney's lees. CONSTRUCTION LENDING AGENCY: I hereby affirm under penafty of perjury that them is a construction lending agency for the performance of the work, which this parol is issued (Section 3687, Civ, C). LENDER'S NAME: LENDER'S ADDRESS: I carlify that I have read this application and state that the above information is correct. I agree to comply with all dry and county ordinances and state laws relating to building construction and hereby authorize representatives o1this city to entor upon the above-mentioned property for inspection purposes. .DAVID RUCK Name b _ Date: w` Q ...7 /— 7 Sign re of OwnerlAgentlApp4eantlContractor (515t415WP) White -Building A Wery; Green -File: Canary-Applli=l; Pink -Revenue; Goldenrod -Assessor CITY OF COSTA MESA -- BUILDING PERMIT PERM NO: B 07484 PERMIT NO: B 074846 PLAN CHECK NO: 03979-95 A GOVT: N SUPP: N CONSTRUCTION TYPE: IFR SP PERMIT TYPE: STR PURPOSE: ALT JOB DESCRIPTION : COMMERCIAL T.I./RETAIL STORE INTERIOR SQ FT: 40,000 CLAIM VALUE: 40,000.00 CALC-VALUE: 40,000.00 GROUP OCC: B-2 / COMMENTS: THE "MAC" STORE/ SPACE #1617 �E * * * * >rt * * 9E �E f�E iF �E +E;rt •� !E'f �1E iE iE �E •1F * iE iF iE �E fit � � � iE f�E iE * �1E'f *'� * iE � iE �E �E'IE aE * #E if * !E * iE �E * •lE'E frE iE * •YE �E iE iE •1E iE iE iE iE iE iE iE dE •1E •1E •IF iE Z 0 N I N G R E Q U I R E M E N T S S E T B A C K S ------------ MAIN BUILDING ---------- --------- ACCESSORY BUILDING--------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RIGHT: FT IN PARKING REQ: PROV: PARCEL: 41250107 ZNE: CIS REF NO: PLANNING NOTES> TENANT IMPROVMENTS FOR A RETAIL SPACE IN SOUTH COAST,ePLAZA. > (M.A.C.) iE iE'E iE iE •IE •IE'E •1E 9E f>F * f� iE * * *!E iE iE iE dE iElE iE iE iE iE iE iE d4 iE * iE iE iE � ftE * 9E iE iE1E �E 9E •1E'E •?E � lEiE 1E {E �E dE iE iE � #E � iE •IE •iE * iE iE iE iE fit �E.�E �E,~E •IE * �E �E �E �E D E V E L O P M E N T S E R V I C E S R E Q U I R E M E N'T S ZONING APPROVED BY r�- DATE: S! BUILDING APPROVED BY DATE: 3 APPLICATION ISSUED BY: DATE: /s'�h(s, iE �E iE * iE iE iE �E # �'4.1E * iE iE'IE 9E iE iE iE iE iE �EiE * iE aE iF iE iE iE iE iE * iE �i E �E �1E LEGALIZATION:N F E E S U M M R Y STRUCTURAL SEGMENT:Y BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT 349.50 SMIP/NON-RES PLAN 56.80 8.40 ISSUE FEE BUILDING -DTV-> PERMIT ISSUE_ PLAN -CHECK TOTAL PAID DUE TOTALS ---- > 357.90 0.00 56.80 414.70 414.70- ,00 REVENUE DIVISION TOTALS--> COLLECTED: 357.90 OVER/SHORT: .00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN -CHECK 0 349.50 8.40 �1E �fE dE f6 * iE * �E � �lE �IE !E 1E iE'lE f4 IE 9E *'f �IE iE �fE dE !E � * �E'f * � �IE 1E * �lE'fr frE ftE �E � •YE iE if iE iE'!E �E• �E'1E * �E �E iE •1E iE * iE iF'IE'!E iE iE'lE iE iE iE iE iE �(' r1E * iE �lE iE 9E * !E IE iE I N D I V I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST SFC 40000 ALTER BY VALUE COMMERCIAL NOZONE 1.00 40,000.00 END OF FEES 01 001930'3-3L3i93379 TOT T OATS: lur7cf� r Till -S 12:42 CONSTRUCTION AND PLANNING POE) &SPA r APPROVALS Permit # Date Inspector APPROVALS Permit # Date Inspector 1. Tei porary Electrical Service or Pole 4 r2. 52. Pool &Equipment Location'' • l Soil Pipe-Undrgrnd, i 53. Steel Reinforcement 3..E_iectrical Q nduiY:Q imlity-Undrgr d. 54. Forms 1 4?- Elcarica€:C6bCMit-Ur.Tdrgrnd. ! 55. Electrical Bonding l Y'S,-`-S4tee1 8eiriiforce er�t 56. Rough Plumbing & Pressure Test i.� Electrical UFRG�nd. 57. APPROVAL TO COVER•GUNITE ;,,Footings 58. Electrical Cond it~tJndrgrnd. <r `14' Foundation.t; �] �, , 59- Gas Pipe, © Undfgr.nd., Test - 97Water Pipe-gp'M'nd. 60. Backwash Line rap, © E7ndrgrnd. d.0. Structural door System 61. APPROVAL TO r DECK T�1. Property Se,%er Line`& HouseQohbection 62. Backwash & Receptor -Final ; 12. Se;;, er Cap ' ^' v, 4. 63. Heater & Vent-Rinal 13. Rdol-Drains o,, 64. Plumbing System - Finaix, r J4. Rough Plumb•iVc - to 65, Electrical -Final . Rough Electricai-Coeduit L^ 66. Solar System -Final_ Rough Electric Airing{67. Fencing & AcceL55 approval 's7. Rough Weng Sign 68. APPROVED FG-"LASTERING - 1�13. Rough ElectricaP.T Ear Ceiling 69. POOL/SPA 5Y5TEJtriS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT, REQUIREMENT _ APPRDVALi�w 'Pei mit # 20. Rbudf; Fai;tor'y, Fireplace rr t u: ': = X ' r L'. ., lir f--• w s 23. cxsin trugture`-- '.. -� z S 1; r'i• 70. Undergro"Uh-d Hydro lz� Fri 22. Duct's; V fltlla•ting:- i' + rd ` = = } =' 71. Produc'f,Pzping I3 -as 40il a 23. Qas kpe- ou i & Y6t tzt rr, 7nd Flusf:D1 x f- ,2. Undergrt•� w 24. Rbof=Framing * # > ti> �, 73:�iJndergrrrd.StordaTank'IDGas 0611 25. Ron he }hing ., » �` �; cl7 * 7, j @verhead%Hydro*� 26. T-Bar.Ceiling {StrLrcxtural) & Wndccoax= !71 ` 75�,My Chemical - r t ,r 27. Frame and Flg'h g } X S - t r rSj - ? rr',-L_ 76. % ry Sta,dpjpe E '_j ., : t 2$. Lath ng &SidtFtg . t :d � r. ` 77� FIXED SY TEti3It91 INAL� T " J r*�- 29. lnsu6-.1 -. C, az r .• >8:. lati EX i x 7FIRE PREV. FINAL Lx r? r r J30. Drywall igailirtg I ^ ?i_IEALTF�J'DEP. REQiJIRMENT -'31, Piaster BGvnrt Coatf,"' i j 79. FINAL IL4 ECTrON r r,r , in tz -32. Electrical Po W12'r Mstert&nal i r1 J �4 n80T FOOD CERTIF9 TE i *S LED ` 33. Ona lectric n 4 r Ngigs `alb x 7'34. Final -Hca ing &Air onditionina n. -r I •: fix 17173 C" .Y i-rr � ti r :, r -r i - fi •� 35. T,36. FTaacf.or Canopy Y. i + c'� ,. A + y E X37. Final'Facibry Fireplace`., x.38. F_irtaI7?lu{+ing. ..,1, i � • -, _} -- t 339. wate7Serfvice Final w'r el} C'M *'15 I H L M 40. Gas Servi�,a-F-m-al t i-1 C ,:r, T _, _. n. x j I ' Z41. Solar DornestictFinal+ S r' i3a �42. ckflow Preventer cs A-4 r. "' ' r t[ i • i 43. Backflow Irri �tion =, n # r .r a, x 6 J C 94. Landscapejirripation System tri f-,) tv, Fri Z,. 7t r ru N `3cs 45. and Attenciation 3 ­-itz •- Y z F' 1- 46 ` i r tv .L 4`6. Wdicap`RegulatioriS: ., ;�,, ! r N - ,. - 47. FUNAL STRUCTURE & BUIL;DING�f so So 48. F-I'N,I 'L' PLAN'► INC - 49. Elects -it Release to Edison a ^] Ca 5Q. Gas R,1�Iease to Southern California Co -_Gas 5], CERTIFICATE OF UCCUPANV_ x >4 t F No Date ! ._._ AtIDRgVILDIW* 3333 BRISTOL ST t1Wtl4A'SN,WEiFlt7101YN: C.J. SEGERSTROM 6 SONS t ADDRESS: 3315 FAIRVIEW RD COSTA MESA UNT. 1617 FLOOD: AO -38 CA 92626 (714)546--0110 APPL, NAIUM ADDRESS: ARCHITECT Oft ENGINEER: L HOWARD NUDELL uc.NO-: C-10580 ARCILORENQ'SADDRESS: 30600 NORTHWESTERN HGWY UNIT: FORMINGTON HILLS MI 48334 cONTRAcTOR'SNAftE: THERMAL INDUSTRIES (714)634-8888 CCNTRACTOR's MAIUND 1515 S UNK I S T ADDRESS: ANAHEIM CA uc. No.: 519395 92707 UNIT: D LICENSED CONTRACTORS DECLARATION: I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. CITY LIC. NO.: �j LIC. CLASS: C 2 0 uc. NO.: 95 IrDate: 12 V f Coniratl OWNER BUILDER DECLARATION: I hereby affirm under penalty of perjury that I am exempt from the Contractors License Law for the following reason (Section 7031.5 Business and Professions Coda: Any city or county which requires a permit to oonstrucl, after, improve, iemolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file s signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7(300) of Division 3 of the Business and Professions Code] or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars [55001). I, as owner of the property or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Section 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds at improves thereon, and who does such work himseff or herself or through he or her own employees, provided that such improvements are not intended or offered for sale. ff, however, the building or improvement is sold within one year of completion, the owner -builder will hays the burden of proving he or she did not build or improve for the purpose of sole). I, as owner of the property, am exclusively contracting with licensed contractors to construct the proiw (Section 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of properly who builds or improves thereon and who contracts for such projects with a confractor(s) licensed pursuant to the Coniradars License Law). 0 1 am exempt under Section: B. & P.C., for this reason: Date: Owner: I do hereby caddy that I am aware of understand and understathe requirements of California health and Safety Code Section 255o5, 25533, and 25534, end that I or any future building occupant will 1 will not (circle ane) need to comply with said stale codes and the requirements for apermitforconstnutionormodifiralronfromtheAi anagememDistrict.Residentialconstrud'nonapp6coiomamexemptfromthese provisions. Date: Applicant: WORKER'S COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one ofthe following dedarstionw I have and will maintain a cenifirste of cornsenl to seff•insurs for workers' compensation, as provided far by Section 3700 of the Labor Code, for the performance of the work for which this parmlt is issued. - Ti I have and will maintain worksm' mmpensedion insurance, as required by Section 37W of the Labor Code, for the performance of the j� work for which this permit is issued. My workers' compensation insurance carrier and policy number are: Carrier: CAL_C{OMP ��.(EXPIRES (� Policy Number: {+� (This section need not be completed t rhe permit is for one hu re�d� jr j or fess. 0 I certify that in the performance of the work for which this permit is issued, I shall nal employ any person in any manner so as to become subject to the workars compensation laws of California, and agree that 4 1 should etorne subject to the workers' compen on provisions of SSSectt" 3700 of the Labor Code, I shall f comp provisions, Date: Applicant: T � T Wsmdng: Fall um to secure workers' carnpenastron coverage is unfawM. and abaft subject an wywioyer to ofrrfnar panarges and c10 fines up to one hundred thousand dollars (S10AW0), In adrlfnon to &a coal or coarpensation; damages as prnvlded for in Section 9706 of the Labor Code, interest and atforney's less. CONSTRUCTION LENDING AGENCY: I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work for which the permit is issued (Section 3097, Civ. C). LENDER'S NAME: LENDER'S ADDRESS: t certify that I have read this application and state that the above information is correct. f agree to comply with all city and county ordinances and state laws relating to building construction and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. ROBERT MORALES Print Name � Date: Signature of OwnerlAgenVApplicant/Contracior (5151.46.WP) White -Building R Safety: Green -File; Canary -Applicant; Pink -Revenue: Goldenrod -Assessor CITY OF COSTA MESA — BUILDING PERMIT' PERMIT NO: M 075130 PLAN CHECK NO: N, CONSTRUCTION TYPE: 1FR SP PERMIT TYPE: MEC JOB DESCRIPTION : COMMERCIAL T.I./RETAIL STORE INTERIOR CLAIM VALUE: CALC--VALUE : PERM NO: M 075130 GOVT: N SUPP: N PURPOSE: ALT SQ FT: GROUP OCC: B-2 / COMMENTS: THE "MAC" STORE TI RE:#B74846 Z O N I N G R E Q U I R E M E N T S S E T B A C K S ------------ MAIN BUILDING ------------ --------- ACCESSORY BUILDING--------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RIGHT: FT IN LEFT: FT IN RGHT: FT IN PARKING REQ: PROV: PARCEL: 41250107 ZNE: REF NO: -_PLANNING NOTES> f > i �3E jF � * � ♦E 'IE IE ?E iE'}E!E � lE �f ?tE fE � * � ill * * iF * * � jE ill dE dE dE �E ill iE'IE �E ?E'}E jf: * �E ill ill dE �E ill iE ill ill ill dE')F IE ill ill 3E � dE ill *'1E'1E ill iF iE'E'IE iE'IE ill ill * * ill 9E iF ill ill D E V E L O P M E N T S E R V I C E S R E Q U I R E M E N T S r ' 'ZONING APPROVED BY DATE: BUILDING APPROVED BY : r DATE: !! 'APPLICATION ISSUED BY: DATE: l r* � ?✓E IE �E ?$ #f iE'4 i(• fE ?'E � �E �F * �E ill 1E if• ill dE ill ill ill -YE * ill ill ?rt df * ill if LEGALIZATION:N F E E S U M M A R Y STRUCTURAL SEGMENT:N BLDG PMT PLUMBING ELECTRIC. MECHANIC FIRE SMIP/RES GRADING PERMIT I 6,50 25% SMTP/NON—RES PLAN " ISSUE FEE i -.,,15.00 BUILDING—DIV—> PERMIT ISSUE PLAN -CHECK TOTAL PAID DUE TOTALS-- -> 6.50 `15.00 0,00 21.50 21.50 ,00 i r REVENUE DIVISION TOTALS--> COLLECTED: 21,50 OVER/SHORT: ,00 hII,tk11 t"T VL( L titW '� FIRE SMIP /TOT GRADING PLAN—CHECK Iw iF ,� i4iF iF iF # i4 dfr 3F iF iF �l; iF �E ill ill �E �E ill ill 9E *ill 4E � !F ill � ill -FE ill ill ill iE'dE ill 3E 3E 4E ill ill ill ill ill AE �E ill ill � ?E ♦rt * AF dF ill ill �E ill iE♦IE ill ?# !E �f dE !E �F ill �E #E'!F ill •IE !E iF'lE irk ill I N D' I V I D U A L; Ft -E E; B R E A K D O W N TYPE QTY G E S C R I P T I O� Nib �I � UNIT COST TOTAL COST 6,50 END OFk,FEES 'CONSTRUCTION AND PLANNING ' APPROVALS Permit # Date Inspector POOH SPA APPROVALS Permit # Date Inspector �. 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement 3. Electrical Conduit •Utility Undrgrnd. 54. Forms 4. "E1wrical Gonciujt-Undrgrnd. 55, Electrical Bonding 5. Steel Reinforglement: 56. Rough Plumbing & Pressure Test 6• ElectricalUFEFt.Grnd. 57. APPROVAL TO COVER-GUNITE 7. Footings+_ 58. Electrical Conduit-Undrgrnd. B. Foundatiorl 59. Gas Pipe, ❑ Undrgrnd., Test 9. Waier Pipe-Undrgrnd. 60. Backwash Lines, P -Trap, ❑ Undrgrnd. 10. Str-uctural Floor System 4 61. APPROVAL TO DECK 11. Property Sewer Line,& House Connection 62. Backwash & Receptor -Final 12, Sewer Cap _ 63, Heater & Vent -Final if 13. Roof Drains p 64. Plumbing System . Final 14. Rough Plumbing 1, 65. Electrical -Final 15. Rough Electrical -Conduit 66. Solar System -Final 16, Rough Electric Wiring 67. Fencing & Access Approval t7. Rough Wiring Sign 68. APPROVED FO.R PLASTERING 18, Rough Elec.trical•T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS ' _ Permit # 20. Rough Factory Fireplace 21. Ducts: in Structure - s 70. Underground Hydro 22. Duces, Ventilating;' •• _' 71. Product Piping ❑Gas ©Oil 23. Gas Pipe -Rough & Test - _ 72- Underground Flush 24. Roof' -Framing 73: Undergrnd. Storage Tank ❑ Gas ❑ Oil 25, Roof Sheathing 74, Overhead Hydro 26. T:Sarlteiling fStructural) & Motidcoat - 75, Dry Chemical 27. Frame and Flashing _ 76. Dry Standpipe 28. Lathing Si Siding - '„ 77. FIXED SYSTEM FINAL .. 29. Insulation 7$: FIRE PREV. FINAL 30. Drywall Nailing .HEALTH DEPT. REQUIREMENT 31, Plaster Brown Coal 79. FINAL INSPECTION 32, Electrical Power Meter=Final 80, FOOD CERTIFICATE ISSUED 33. FinalElectricNotes: �"�t-?G-'SS �7 L�'D�•-�� IL _ - 34, Final Heating & Air Conditioning .: x-34 �1'•. 35. Final Gas, Pipe:Test .. 36. Hood or Canopy 37. Final.Faciory Fireplace 38. Finaf Plumbing 39. Water Service -Final { 40, Gas Service -Final -' = 41. Solar Domestic -Final'' - 42. Backflow Preventer 43. Backflow Irrigation , 44. Landscape Irrigation System r 45. Sound Attenuation 46. Handicap Regulations syn _ 47. FINAL STRUCTURE & BUILDING 48. FINAL PLANNING , 49. Electric Release to Edison 50.' Gas Release to Southt!rn California -Gas Go 51. CERTIFICATE OF OCCUPANCY NoDate E s ADDRESS of �IftL` 3333 BRISTOL ST UNIL 1617 ON'fIER'SNAf&EIFJg/ONfk C. J. SEGERSTROM & SONS FLOOD: AO -38 kDOR" 3315 FAIRVIEW RD p, 7� COSTA MESA tiPpL .DEss (714)546-0110 AR"n"'OREmEER' L HOWARD NUDELL LC.ND.: C-10580 AWKOREN111ADDREss: 30600 NORTHWESTERN HGWY FORMINGTON HILLS MI 48334 OolrIRACTOETsItAIfE: SMALLCOMB WIRING INCORPOR (714)556-8591 carrNAcrorr9llAlLlNc 136 E GARRY ADDREss' SANTA ANA CA m"O.: 145961 92707 UNIT. U LICENSED CONTRACTORS DECLARATION: I hereby gain under penalty of perjury that I am licensed under provisions of Chapter 9 (commence g with Section 7000) of Owmion 3 d die Business end Prafassfara Code. and my license is in fud fora and effed. CITY uc. No.: 0110 0 5 UC, CLASS: C 10 LIC. NO.: 14596 EXP : 08/96 Data 11 — Sr `I5 Contractor: f ! _. OWNER BUILDER DECLARATION: I hereby affirm under penalty of perjury that I am exempt from the Contractors Lioense Law for die following reason (Section 7031.5 Business and Professions Code: Any city or county which requires a permit to constrict, after, improve. demolish, or repair any structure, prior Was issuance, also requires the applicant for such penia to file a signed statement drat he or she is licensed pursuant to the provisions of the Contractors License law [Chapter 9 (commencing with Section 7000) of Division 3 of the Business end Prdessions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant lar a permit subjects the applicant to a civil penalty of not more than five hundred dollars (SSW)). © I. as owner of the property or my employees with wages as their sob compensation, will do the work, and the structure is not intended or offered for sorb (Section 7044, Business and Professions Coda: The Contractors License Law does not appy to an owner of property who builds or improves thereon. end who does such work himself or herself or through he or her own employees. provided that such improv ,mems are not intended or offered for sale. it, however, the building or improvement is sold within one year of completion. die owner -builder will have the burden Of proving he or she did not build or improve for the purpose of sale). 1, as owner of the property, am exclusively contracting with licensed contractors W construct the project {Section 7044, Business and Professions Code: The Contradors License Law does not apply W an owner of property who builds or improves thereon and who contracts for such projects with a oomractor(s) licensed pursuant to the Contractors License Law). I am exempt under Seclian: B. iL P.C., for this reason; Date: Owner: 1 I do hereby certify that I am aware of and understand the requirements of California Fk afth and Safety Code Sections 25505, 25533, and 25534, and that I or any future building occupant will ! wdt not (circle one) need to empty with said awe oodes and the requirements for a permit farconstrvctixn m modification from the Air a�y enagement District. Residential construction applications areexempt from these provisions. Dale: APPritam: WORKER'S COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following dedaraliDm I have and will maintain a carl6rate of consent to sallainsure fa mmvrkers' compermsetion. as provided for by Se tion 37Do of the Labor Code, for the pedormance of the work for which this permit is issued. - I have and will maintain workers' compensation wirsum ice. n required by Sedfon 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance artier and policy number are: Carrier: Ca racrraT.Tv EXPIRES Policy Number: lai e y 9 0 Do I L10 1 10/01/96 (MT section freed not be cnsnplatsd d Cha pert& a for aw hundred dollars (SiOoj or less.) 0 1 certify that in the perfarrrnanee of the work for which this Perna is issued. I shill not employ arty person in any manner so as to become subject to the workers' compensation Laws d CaRomia, and agree that if I should become subject to the workers' compensation provisions d of 3700 the Labor Code. ! slyell fafhwith comfy)\wit t proasrons. - Date. ! t `S -9r APdicam: (u/ l(�1,.fl ( . Warring: Failure to secure workers' cornparufifon coverage is unbrit luf, and shall subjoct an wWvyw to criniffrcl penafNas and civil flnes tip to Dna hundred thousand daflan f$IOGLOWA In add WR to dta easf of Co pensadon6 darraps as provrdad tar in Socdon 37016 of the Labor Cade, Inferask and e8ornaf%s fou. CONSTRUCTION LENDING AGENCY; I hereby affirm under penalty of perjury that there is a construction lending agency for the W.ormance d the work for which the permit is issued (Section 3097. civ. C). LENDER'S NAME: LENDER'S ADDRESS: I certify that I he" read this application end state that the Above information is coned. I agree to campy with all city and county ordinenoes and stale laws rebting to building construction and hereby authorge representatives Of this sty to enter upon the above-mentioned property for inspection purposes. K VIN SCHELIN Print Name G� Date:— gnature of GwmdAgent/Awkz;a lConlrador (5151-45.WP) White -Building d Salary; Greon�File; Canary-Appkcenl; Pink -Revenue; Goldenrod -Assessor CITY OF COSTA MESA - BUILDING PERMIT PERMIT NO: E 075095 PLAN CHECK NO: N CONSTRUCTION TYPE: 1FR SP PERMIT TYPE: ELE JOB DESCRIPTION : COMMERCIAL T.I./RETAIL STORE INTERIOR CLAIM VALUE: CALC-VALUE: PERM NO: E 0 75095 GOVT: N SUPP: N PURPOSE: ALT SQ FT: GROUP OCC: B-2 / COMMENTS: THE "MAC" STORE TI, RE:#B74846 Z O N I N G R E Q U I R E M E N T S S E T B A C K S ------------ MAIN BUILDING ---------- --------- ACCESSORY BUILDING---------- FRNT: FT IN REAR: FT IN FNNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN PARKING REQ: PROV: PARCEL: 41250107 ZNE: REF NO: PLANNING NOTES> 9E 9F * dE �E i� �'� �'� aE'� * ?tF')f '� *'lit' �'if ? E iI' IE'1E 3f"1f '1E �E'1E'1[• iE iE �(' �F iF jf• aF �F �f• jE iE'lE dE IE �E �ME �E �F �E jE IE dE dE � ►E �E )(•'1E rlE 1F iE iE df• �E jC• dE dE if �E �)E �F -IE' IE 1E �(• iE iE'1F �1F D E V E L O P M E N T S E.R V I C E S R E Q U I R E M E N T S ZONING APPROVED BY DATE: END OF -"FEES 01 G�1a4J1�—L131�1g7$ TQT :1.95 BUILDING APPROVED BY : f DATE: W a APPLICATION ISSUED BY: DATE: '1E'lE iE �E � ;+E -I(• �E �E iE 1F �F •)E �E iF iE �E iE iE iE ♦f iE iE ♦F iF !E �f !E * iE iE')f• � dE LEGALIZATION:N F E E r S U M M A R Y STRUCTURAL SEGMENT:N BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT 66.45„ 50 SMIP/NON—AES PLAN ISSUE FEE 1,5.0,0- : BUILDING—DIV—> PERMIT ISSUE PLAN=CHECK TOTAL PAID DUE TOTALS ---- > 66.95 15.00 �7 0:00' 81,95 81.95.00 REVENUE DIVISION TOTALS--> COLLECTED: 81.95 OVER/SHORT: .00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK 81.95 * % * iE � �E �E mfr lf lE 9f ')E iE iE iE �F * ? F �F �E �f• iF 1E �(- �E �E IE �(• �E iE iF iF dE iE iE !E �E iE:iE iE •IE iE iE 3E �E 1E �E iE dE jE �E iF dE iF'E 9E iE iE 1E iE iE iE iE iE iE iF IF �(• if IE iE iE �E dE �E• �E iE iE iE I N D I V I D U A L� F 'E E B R E A K D O W N TYPE QTY D E S C R I P T I O.'N ; UNIT COST TOTAL COST ELE 20 FIXTURES, LIGHTING. 1 ST '20 EA. .75 15.00 ELE 46 FIXTURES, LIGHTING ADDITIONAL EA. .45 20.70 ELE 17 RECEPT/OUTLET•1 ST 20 EA. .75 12.75 ELE 10 RECEPT/SWITCH 1 ST 20 EA. .75 7.50 ELE 1 SUB—PANEL 11.00 11.00 END OF -"FEES 01 G�1a4J1�—L131�1g7$ TQT :1.95 F CONSTRUCTION AND PLANNING APPROVALS Permit # Date inspector POOH SPA APPROVALS Permit # Date inspector 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd. 53• Steel Reinforcement 3. Electrical Conduit Utility•Undrgrnd. 54. Forms 4. Electrical Conduit•Undrgrnd. 55. Electrical Banding 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6' Electrical UFER Grnd. 57. APPROVAL TO COVER•GUNITE .7:.Footings 58. Electrical ConduitA)ndrgrnd. 8. Foundation, 59. Gas Pipe, 0 Undrgrnd., Test 9. Water Pipe-Undrgrnd. 60. Backwash Lines, P•Trap, 0 Undrgrnd. 10. Structural Floor System 61. APPROVAL TO DECK ` t1. Property Sewer. Line & House Connection 62. Backwash & Receptor -Final 12. Sewer Cap 63. Heater & Vent -Final 413. Roof Drains V 64. Plumbing System - Final ' 14. Rough Plumbing 65. Electrical -Final _ 15. Rough Electrical -Conduit 76. Rough Electric WiringZ. 17. Rough Wiring Sigh 1 6' 9b Solar System -Final 7, Fencing & Access Approval g 68. APPROVED FQR PLASTERING r ' 18. Rough Electrical•T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DE=PT. REQUIREMENT APPROVALS Permit # 20. Rough Factory Fireplace 21. Ducts, in Structure _ f J 70. Underground Hydro 22, Ducts, Ventilating - 71, Product Piping D Gas ©Oil 23. Gas Pipe -Rough & Test r 72. Underground Flush X 24. Roof Framing - 73. Undergrnd, Storage Tanks©Gas 0 Oil 25, Roof Sheathing 74. Overhead Hydro 26. %•Bar Ceiling (Structural) & Monocoat 75. Dry Chemical _ 27. Frame and Flashing 76. Dry Standpipe - 28. Lathing & Siding 77. FIXED SYSTEM FINAL 29. Insulation 78. FIRE PREY. FINAL 30. Drywall Nailing _ tHEALTH-DEPT. REQUIREMENT, 31. Plaster Brown Coat i .-79. FINAL INSPECTION ' 32. Electrical rower Meter -Final 33. Final Electric -34. Final Heating & Air� Conditioning6 35.7Final Gas Pipe -Test �z 36. flood or Canopy ` ' / 80. p^OD CERTIFICATE ISSUED fig' - - - 37. F7nal Factory Fireplace J - 38. Final Plumbing v - 39. Water Service -Final , 40. Gas Service -Final 41. Solar Domestic -Final 42. Backflow Preventer - 43. Backflow Irrigation - 44. Landscape }rrigation System 45. Sound Attenuation 46. Handicap Regulations 47. FINAL STRUCTURE .& BUILDING _ 48. FINAL PLANNING 49. Electric Release to Edison 50. Gas Release to Southern California Gas CD 51. CERTIFICATE OF OCCUPANCY No. _... Date / BUILDING: 3333 BRISTOL ST UNIT: 1617 oP WAMEwnm: C.J. SEGERSTROM & SONS FLOOD: AO -38 ADDREss: 3 315 FAIRVIEW RD COSTA MESA ZA 92626 (714)546-0110 APPL. MAILING ADDRESS: ARctirmo OR ENGINEER: L HOWARD N UD E L L uc. ND.: C-10580 MR. OREN(I.'SADORE% 30600 NORTHWESTERN HGWY UNIT: FORMINGTON HILLS MI 48334 COMRACTOR'S NAME. J E D S PLUMBING (714)283-1586 CONTRACmxSMAIUM 387 SMOKERIDGE TERRACE ADDRESS: ANAHEIM 92807 CA UC."O., 547467 UNIT: LICENSED CONTRACTORS DECLARATION: I hereby affirm, under penalty of perjury Me I sm licensed under provisions of Chapter 0 (commencing with Section 70DO) of Division 3 of the Business and Professions Code, and my license is in full torte and effect. cifLER C.NO.:064588 uc.cuss: C 36 uC.NO.: 547467 EXP: 03/96 y/ -.%cit Contractor. r BUILDER DECLARATION: I hereby h>lTirtn under penalty of perjury that 1 � ramp from the Comrectos License Law lathe following reason (Section 7431.5 Business and Professions Cade: Arry city or Cort which requ'uas a panne to oonstrud, alter, improve, demolish, or repair any structure, prior tots issuance, also requires the applicant for such permit to file a signed statement that he or she is ticemsed pursuant to the provisions of the Contractors Lioense Law (Chapter 9 jomvnendrg with $edbn'7o00) of Division 3 d the Business and Professions Code] or that he or she is exempt theretran and the basis for the alleged enempiori. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a cid penalty of not more than five hundred dollars ($500))• ❑I, as owner d the a em with as their sale eons t•1 PropemY rrN Ptoyaes wages perisation, will do the work, and the structure is not intended or offered lar sale (Section 7D44. Business and Professions Code: The Contractors License Law does riot Apply to an owner of property who builds or improves thereon, and who does such work himself or hemell or through his or her own employees, Provided that such improvements are not intended or offered for sale. 9. however. the building or emprownent is sold within one year of completion. the owner -builder will have the burden of prov(ng he or she did not build or improve for the purpose of sale). ❑ I, as owner of the props". am exclusively contracting with fiaensed contractors to construct the project (Sidion 70x4, Business and Professions Code: The Contractors License Law does rid apply to an owner of property who builds or improves thereon and who contracts for such projects with a contractors) licensed pursuant to the Co tradors License Law). ❑ I am exempt under Section: B. 6 P.C., for this reason; Date: Owner: I do hereby Certify that I am aware d and understand the requirements d 50 California Health and Safety Code Sections 255, 25533. and 25534, and that I or any future building occupant will I will not (circle one) need to can" with said slate codes end the requirements lent a permit for omsuuctionor modification from the Ar au[y ansgemem District. Residential constriction appimtions ars exempt from these provisions. Date: Appficam: WORKER'S COMPENSATION DECLARATION: I hereby affirm under penalty d perjury one of the following declarations; I have and will maintain a canifirate of consent to salldnsure for workers' compensation, as provided tot by Section 3700of the Labor Code, for the performance d the wok for which this Permit is issued. I have and will maintain workers' compensation insurance, m required by Section 3700 d the Labor Code, for the performance d the work for which this perms is issued. MY workers' 9 fMirrsyphU friar end policy number are: E X P I R E S Carrier. ry Number: —1 9: t N iV U 01/01/96 (This section need not be complstad d the psm k is for one hundred doNers [V oq] or Isss ) ❑ I amity that In the ped0rm w" d the work fa which this pennq h issued, i *hail nit employ any person in any manner so m Io ami subject to the workers' compensation laws of California, and agree that H 1 should become subject to the workers' Kt ompensation provisions d Section 3700 d the Labor Code, I sheat so "ply with those provisions. Date' AJ�1°c._1/4 Appticam: WaminQ: FaAure to secure workers' comparmatfon caverns Is unlawful, and shall f an ernployu to erlrrifnel penti l" and clvll firms rp to oma hundred thousand dollars (SIOQOWA In addhion ro rhe c o1 Ceml enesdan, damepp as prodded for In Sectfon 3706 of fns labor Coda, Interact and attomay's leu. CONSTRUCTION LENDING AGENCY: I hereby affirm under penalty d perjury that then it a corhatruction lending agency for the performance d the work for which this permit is issued (Section 3097, CM, C), LENDER'S NAME: LENDER'S ADDRESS: I sanity that I have read this application and mate that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to buiW rg corwAxtion and hereby aulhorUs representatives ofthis cityto ager upon the ebove•mertioned properly for inspection purposes, DAVID GRIMM Prim Name .. - nr• • o - Dale: 0 9 (5151-44.wP) while-9ulkiing 6 sdat)r. Pink -Revenue; Goldenrod -Assessor rr CITY OF COSTA MESA — BUILDING PERMIT PERM NO: P 07491 PERMIT NO: P 074912 PLAN CHECK NO: N GOVT: N SUPP: N CONSTRUCTION TYPE: 1FR SP PERMIT TYPE: PLU JOB DESCRIPTION : COMMERCIAL T.I./RETAIL STORE INTERIOR CLAIM VALUE: CALC—VALUE: PURPOSE: ALT SQ FT: GROUP OCC: B-2 / COMMENTS: THE "MAC" STORE / SPACE #1617 Z O N I N G R E Q U I R E M E N T S S E T B A C K S ------------ MAIN BUILDING ---------- --------- ACCESSORY BUILDING--------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN PARKING REQ: PROV: PARCEL: 41250107 ZNE: REF NO: PLANNING NOTES> �E � iE iE• # � �1E !E iE IE iE �1E iE � ♦'E �E iE * jE !E iE �lE IE !E � #E � �E �E iI- * iF �E iE'E iE iE'lE iE iE iE iE � * dE iE iE dE iE 3E iE iE i(- iE iE iE iE iE iE iE iE � * * * �1E dE �E �[• dE * 1E �E �E �E iE iE iE iE D E V E L O P M E N T S E R V I C E S R E Q U I R E M E N T S ZONING APPROVED BY DATE: BUILDING APPROVED BY : DATE: APPLICATION ISSUED BY: - DATE: �D dF iE iE * iE � * iE iE iF iF iE �E 1E iE �E �E iE �E iE iE iF iE• � iE * IE �E 9E iE iE IE iE �� LEGALIZATION:N F E E S U M M A R Y STRUCTURAL S GMEN :N BLDG PMT PLUMBING ELECTR`1C 011 MECHANIC FIRE SMIP/RES GRADING PERMIT 21.00 252 SMIP/NON—RES PLAN 11 ISSUE FEE 20.00 BUILDING—DIV—> PERMIT ISSUE PLAN:'—:CHECK TOTAL PAID DUE TOTALS ---- > 21,00 20,00 0.00 41.00 41,00 .00 REVENUE DIVISION TOTALS--> COLLECTED: 41.00 OVER/SHORT: 00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMTP/TOT GRADING PLAN—CHECK 41.00 V'1 rl r 'J(-'lE � dE �E � iE• iE iE iE df iE'JE'JE IE iE * 9E * !E if !E'lE'JE �E 1f '1E'� ?f iF iE'IE !Fitt � !f 1E � ♦F � i@ 9E !(iE'!(-'!(-?tk'f iG')E iE'E iE irk �(- ♦f jE �'lE iE iE if iE iE iE iE it iE iE• iE iF iF it �(• iF iE i(• ♦rt �E I N D I V I D U A L `.F 'E E B R E A K D O W N r TYPE QTY D E S C R I P T I O Na UNIT COST TOTAL COST PLU 1 WASH BASIN PLU 1 WATER CLOSET (TOILET,), PLU 1 WATER SERVICE r"f END�OFFEES 7.00 7.00 7.00 7.00 7.00 7.00 01 00197203-0019a293 TCIT 41.00 DATE: TlrE: 13:07 .ONSTRUCTION AND PLANNING POOH 6r SPA APPROVALS Permit # Date Inspector APPROVALS Permit # Date Inspector 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location 2, Soil Pipe-Undrgrnd. 53. Steel Reinforcement .3. strlectrical Coriduit Utility-Undrgrnd. 54. Forms '4,'lectrical--CQndu�t-U''drgrnd. 55. Electrical Bonding " 5.--Steel Reinforcement • 56. Rough Plumbing & Pressure Test R 6. Electrical _GF,ER Grnd. 57. APPROVAL TO COVER-GUNITE _Footings=4' ' ' ' Foatin s` X 58. Electrical Conduit:Undrgrnd. 8. Foundation moi-+ a 59. Gas Pipe, Q Undrgrnd., Test 9, Water Pipefit?1rglrid. J 60, Backwash Linm,:P_Trap, Q U drgrnd. 10. Structural Floor System 61. APPROVAL TSU DECK -11. Prbperty Sewer Li.t &House°Connection (.- 62. Backwash & Receptor-Final 12. Sewer Cap 63. Heater & Vent-Final 13. Rgof Drains 64. Plumbing System - Final ` 14. Rough Plumbing. to 65. Electrical-Final :1'5. Rough Eiectrical4-Cortduit 66. Solar System-Final 7,6. Rough Etactric Wirir►g 67. Fencing & Access-Approval t 17. Rough Wiring Sign 68. APPROVED FWPLASTERING 18. Rough Electridij Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19, Rough Heating & Air Conditioning F) -REQUIREMENT Y T - + _ - APP�Ogjl"- Permit 20. rRoui3n FaLto� Fixe lace r- ; ,< , 21.4I3ucts, in`StWctuxe' t: 70.:tndergr� i ADDRESS OF BUILDING: 3333 BR I S TOL ST' ;/ UNIT: 1617 Dams mm: C.J. SEGERSTROMS ADDSEss: 3315 FAIRVIEW RD COSTA MESA, CA 92626 APPL. MAILING ADDRESS: ARCHITECT ORENGNEER: J HOWARD NUDELL ARCH Lr—NO- C10580 ARCH. OR END:S ADDRESS: 30600 NORTHWESTERN HWY UNIT: FARMINGTON HILLS MI 48334 1` CONTRACTarrsHAME: GST CONSTRUCTION (714)257-0162 �CONTRACTOR'SMAILINO 923 GRAND CYN RD ADDRESS: B R E A CA tic. No: 548625 92621 UNIT: LICENSED CONTRACTORS DECLARATION: I hereby alf'em under penalty operjand I under provisions d Chapter 9 (commencing with Section 7000) or Division 3 d the Business asdooa . y ' is n fug force and erred. CrrY L1C. O.: 0 T 44 7�- UC. CLASS: B No-: 4 86 5 EXP: 04/96 Dale: Contract OWNER BUILDER DECLARATION: I hereby affrm under pesky d Lhat 1 emnempr from tractors License Lew for the following reason (Section 7031.5 Business and Professions Godo: Any ei[y whictm requires a d to construct, after, improve, demolish, or repair any structure, prior to ds issuance. also requires the applicant for such permit to We a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law [Chapler 9 (commencing with Sedion 7000) of Division 3 of the Business end Profasaions Code] a that he or she is axampt therefrom and the basis for the alleged exemption, Any violation of Sedion 7031.5 by any applicant for a permit subjects the applicant to a civil penally of not more than live hundred dollars 13sw ). ❑ 1. as owner of the property or my employees with wages as their sole compensation, will do the work, and the structure is net intended or altered for sale (Section 7044, Business and Profession Code: The Contractors License Law does not apply to an owner of property who builds or improves (hereon. and who does such work himself of herself or through he or her own employees, provided that such improvements are not intended or dlered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden d proving he or she did not build or improve for the purpose of safe). ❑ 1. as owner of the property. am exclusively contracting with licensed conuantors to construct the projed (Section 70". Business and Professions Code: The Comractons License Law does not apply to an owner of property who builds or improves thereon and who contracts for such projects with a contractor(s) licensed pursuant to the Contractors License Law). ❑ I am exempt under $action; B. 8 P.C., for this reason; Date: Owner, I do hereby comity that I am aware of and understand the requirements of Callanin Health and Safety Code Sections 25so5, 25533, and 25534, and that I or arty future building ocnnpent will f will net (drele one) need to comply with said nate sods and the requirements for e permit for construction or modification homtheAikue'taragernam District, Resldemial comoruciian applications we exempt from these Provisions. Date: Applicant: WORKER'S COMPENSATION DECLARATION: I hereby alfmrm under po affy of perjury ona d the following decimations: ❑ I have and veil maintain a camifrcete of oormsent to saMdnsure for waken' compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this porme is Issued. I have and veil maintain workert' oompenswien Insurancs, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurerea terrier and poky number are: Carriers: STATE FUND EXPIRES Policy Number. I 1 8 1 1) 4 4 =4 --� 03/01/96 (This aadian need not be compietad l arta perms is /of one hundred olden (51001 or Nes. ❑ I comity that in the performance of the work for which Is issued, 1 not person in any manner e0 as to become ubject n the workers' computsalion laws tlud 1 1 become subjedd to the workers' co�,mf�] n alio p lair s c action 9700 d the labor ffX'ftwwbhi with Date: Ll/ Apo Warning: Failure to secure worlrms' compensation coverage 1 1 !, and a f subleef a layer o criminal penalau end elvf! Rnu up ro oma hundrW thousand ddfan (ffOQ000k in aetlf to the eros o/ ro !loft. W as provMad for In Section 3705 of the Labor Coals, Interest, and affomey's tau. CONSTRUCTION LENDING AGENCY: I hereby affirm under penally of perjury that there is a construction lending agency for the performance d the work for which ibis pammk is asusd (Section 3097, Civ. C). LENDER'S NAME: LENDER'S ADDRESS: I o:ertNy that Ithis appfmcation and state that the above information is wrred. I agree to comply with all city and county ordinances and state la -half o building construction and hereby authorize representatives of this city to enter upon the abaw•memioned property err inspection DOU S- HA n Name Date: (5151.48,WP) Whit"uildag 5 Safely; Green -FIs: Canary -Applicant; Pink -Revenue; Goldenrod -Assessor CITY OF COSTA MESA — BUILDING PERMIT PERM NO: H 074429 PERMIT NO: B 074429 PLAN CHECK NO: N GOVT: N SUPP: N CONSTRUCTION TYPE: PERMIT TYPE: STR PURPOSE: ALT JOB DESCRIPTION : DEMOLITION IN PREPARATION FOR FUTURE TI SQ FT: 5,000 CLAIM VALUE: 5,000,00 CALC—VALUE: 5,000.00 GROUP OCC: B-2 / COMMENTS: DEMOLITION FOR FUTURE "M.A.C. COSMETICS" STORE TI Z O N I N G R E Q U I R E M E N T S S E T B A C K S ------------ MAIN BUILDING ---------- --------- ACCESSORY BUILDING--------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN PARKING REQ: PROV: PARCEL: 00000000 ZNE: REF NO: PLANNING NOTES> _ > 9F YF 3F iE aF �E iE dE iE #� iF �E � )E � dE 3f dE dF �E lE dE �E 3E * �E �E 3E ?'E �E iE �E �E iE �E i': iE iE * 3F ifr iF �E iE 3E iE iE dE iF �E # iE iE !E iF � iE iF iE �E iE iE �(- iF iE }E iE iE.iE iE � ill iE• �F �iF �iF 3E D E V E L O P M E N T S E R V I C E S R E Q U I R E M E N T S ZONING APPROVED BY DATE: BUILDING APPROVED BY : DATE: ,.. APPLICATION ISSUED BY: DATE: LEGALIZATION:N F E E S U M M A R Y STRUCTURAL SEGMENT:Y BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT 72.00 PLAN SMIP1NO —RES .05 ISSUE FEE BUILDING --DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE TOTALS ---- > 73.05 0.00 0.00 73.05 73.05 .00 REVENUE DIVISION TOTALS--> COLLECTED: 73.05 OVER/SHORT: .00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK 72.00 1.05 if' iE if iE iE iF iE iE iE iF iE iE iE iE iE iE �E * iE �E iE iE iE lE dE jE �E dE iE ii iE d(- �E iE iE iF iE iE iF'tE iE iE � * � iF 1(- �E dF � iE fE iE � * i(• �E -)E �E -)E itE iF iE * �F iF >>E aE aE }E iF 3E �E � � � dE'1E iE I N D I V I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST SFC 5000 DEMOLISH BY VALUE COMMERCIAL NOZONE 1,00 5,000,00 END OF FEES 01 T1)T 73.05 DATE: 10/04/45 TIVE: 20:46 y �R ` CONSTRUCTEON AND PLANNING ' APPROVALS Permit # Date Inspector POOL " SPA APPROVALS Permit # Date Inspector .1. Temporary Electrical Service or Pole 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd, 53, Steel Reinforcement 3. Electrical Conduit Utility Undrgrnd. 54. Forms 4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6. Electrical LIFER Grnd. 57. APPROVAL TO COVER-GUNITE 7. Footings 58. Electrical Conduit-Undrgrnd. 8. Foundation 59. Gas Pipe, 0 Undrgrnd., Test 9. Water Pipe-Undrgrnd. 1 60. Backwash Lines, P -Trap, © Undrgrnd. 10. Structural Floor System 61. APPROVAL TO DECK 11, Property Sewer Line & House Connection 62. Backwash & Receptor -Final 12. Sewer Cap 63. Heater & Vent -Final 13. Roof Drains 64. Plumbing System - Final 14. Rough Plumbing 65. Electrical -Final 15. Rough Electrical -Conduit 66. Solar System -Final 16. Rough Electric Wiring 67. Fencing & Access Approval 17. Rough Wiring Sign 68. APPROVED FOR PLASTERING 16. Rough Electrical -T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit # 20. Rough Factory Fireplace 21. Ducts, in Structure 70. Underground Hydro 22. Ducts, Ventilating 71, Product Piping © Gas ❑ Oil 23. Gas Pipe -Rough & Test 72. Underground Flush 24. Roof Framing 73, Undergrnd. Storage Tank ❑ Gas © Oil 25, Roof Sheathing 74. Overhead Hydra 26. T -Bar Ceiling (Structural) & Monocoat 75. Dry Chemical 27. Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding 77. FIXED SYSTEM FINAL 29. Insulation 78. FIRE PREV. FINAL 30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31, Plaster Brown Coat 79, FINAL INSPECTION 32. Electrical Power Meter -Final 80, FOOD CERTIFICATE ISSUED 33. Final Electric Notes, 34. Final Heating & Air Conditioning 35. Final Gas Pipe -Test 36. Hood or Canopy 37. Final Factory Fireplace 38. Final Plumbing 39. Water Service -Final 40, Gas Service -Final 41, Solar Domestic -Final 42. Backflow Preventer 43, Backflow Irrigation 44, Landscape Irrigation System 45, Sound Attenuation 46. Handicap Regulations 47. FINAL STRUCTURE & BUILDING 48. FINAL PLANNING 49. Electric Release to Edison - 50. Gas Release to Southern California Gas Go 51. CERTIFICATE OF OCCUPANCY No Date ADDRESS OF RUILDINO: 3333 BRISTOL ST UNIT: 1617 oWNERSNAME IFKWM: C.J. S£GERSTROM & SONS FLOOD: AO -38 ADDRESS: 3315 FAIRVIEW RD COSTA MESA 7-A 92626 (714)546-0110 APDL. IIAIUNG ADDRESS: ARCHITECT OR ENGINEER: L HOWARD NUD E L L UC, NO.: C-10580 ARCH. OR ENG.'SADDREss: 30600 NORTHWESTERN HGWY UNIT: FORMINGTON HILLS MI 48334 CONTRACTOR'SNAm: TRI COUNTY FIRE (714)589-4207 colmAcroR's mum 23052 AL I C I A PKWY ADDRESS: MISSION VIEJO�2692 CA uc,,p,, 659326 333 UNIT: LICENSED CONTRACTORS DECLARATION: I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and affect. 9c c. No.: 0 5 8 7 5 4 LIG. GLASS: C 16 UC.NO.: 659 3 EXP: 03/96 ata Zw' 1 S Contractor: NER BUILDER DECLARATION: I hereby affirm under penalty of perjury that I am exempt from the Contractors License Law for the fallowing reason (Section 7031.5 Business and Professions Code: Any cdy or county which requires a permit to construct, after, improve, demolish, or repair any structure, prior to its issuance. also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law [Chapler 9 (commenting with Section 7000) of Division 3 of the Business and Professions Code] or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation Of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of not more than five hundred dollars [5500)). Q I. as owner of the property or my amployees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Section 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended aoffered for sale. H, however, the building or impravem nt is sold within one year of completion, the owner -builder will have the burden of proving he or she did not build or improve for the purpose of sale). 0 I, as owner of the property, am exclusivey contracting with licensed contractors to construct the projed {Section 7044, Business and Professions Code; The Contractors License Lew does not appy to an owner of property who builds or improves thereon and who contracts for such projects with a contractors) licensed pursuant to the Contractors License Law). © I am exempt under Section: S. R P.C.. far this reason: {late: Ovmer. I do hereby certify that I am aware of and understand the requirements of California Health and Safety Code Sections 25505, 25533, and 25534, and that I or any future building occupant will i will not (circle one) need to campy with said state codes and the requirements for a Permit lot constnlctionormodifKabonfrom the A'r'Mly tagemenlDistrict. Residential comlrudionappiratiamareexemptfmmthese provisions. Date: Applicant: WORKER'S COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the logowing declarations: I have and will maintain a certificate of consent to selfminsure for workers' compensation, as provided for by Section 3700 of the Labor Code, for the padonnance of the work for which this permit is issued, I have and vriIt maintain workers' compensation insurance, as required by Section 370D of the Labor Code, for the performance of the work For which this parrie is issued. My warkere' fMt ins}l( `Vis' and 'icy number are: EXPIRES Carrier: r U �U Policy Number: t 6 5 29-9-5) 01/01/96 (This section need nor be completed if the pem it is for one hundred dollars [Stool or ksa.j I candy that in the Performance of the work for which this permit is issued, I shall not employ any prion in any manner so as to becamna subject to the workers' compensation lam of California, and agree that it I should became subject to the workers' Compensation provisions of Section 3700 of the Labor Cade. I shalt lonhwith comply with th provisions. Dar .1 Applicant: �--= -- arnlnq: Failure to *@euro workers' compensation co"L cgs Ia unlawful, and shelf subject an amployar to cdadnal penaldes and civil Ifnes up to one hundred thousand dollars (S100,oatlj In addidar to the cost of compensatlsrn, damapas as provided for In Section 3106 of the Labor Code, Interest, and attomsy i test. CONSTRUCTION LENDING AGENCY: I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work for which this permlt is issued (Section 3097, Civ. CI. LENDER'S NAME: LENDER'S ADDRESS: I certify that I have read this application and stale that the above information is correct. I agree to comply with all dry and county ordinances and state laws relating to building construction and hereby authorize representatives of this cityto enter upon the above-mentioned property for inspection Purposes. TOM PONTOLILLO Data: 12-- ! — I T (5151d6.WP) Whist -Building d Safety; Green -File; Canary -Applicant Pink -Revenue; Goldenrod -Assessor CITY OF COSTA MESA — BUILDING PERMIT PERM NO: F 07544 PERMIT NO: F 075448 PLAN CHECK NO: 04589-95 L GOVT: N SUPP: N CONSTRUCTION TYPE: 1FR SP PERMIT TYPE: FIR JOB DESCRIPTION : COMMERCIAL T.I./RETAIL STORE INTERIOR CLAIM VALUE: 2,700.00 CALL—VALUE: PURPOSE: ALT SQ FT; GROUP OCC: B--2 / COMMENTS: THE "MAC" STORE TI, SPRINKLER SYSTEM ALT, RE:#B74846 Z O N I N G R E Q U I R E M E N T S S E T B A C K S ------------- MAIN BUILDING ------- ------ ACCESSORY BUILDING --------_------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN PARKING RES: PROV: PARCEL: 41250107 ZNE: REF NO: PLANNING N TES> 9E �E 3E -)E iE )E �E 3E � dE 1E 3E'1f` 3E -)E �E �E �E iE iE iE iE � iF iE iE iE iE iE iE iE iE iE iE jE 9E �E � iE 1E iE 3I^ aF 3F * iE iF iE * � � � iF �E dF * iE iF 1E �E iE iF iE iE �F iF 3E iE iF -lf- it• aE dE iE iE• iE ih iE ill: D E V E L O P M E N T S E R V I C E S R E Q U I R E M E N T S ZONING APPROVED BY DATE: BUILDING APPROVED BY DATE: APPLICATION ISSUED BY: L. DATE: r� lEiEiE#iE9E#3E�EiEiEiE�EiEiEiFIE9E**�� f it �iF*iEaEi6�if�dE 7C�'�E LEGALIZATION:N F E£ U M M A R Y STRUCTURAL SE MENT:N BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMTP/RES GRADING PERMIT '54.00 65% SMIP/NON—RES PLAN 35.10 ISSUE FEE BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE TOTALS-----> 54.00 0.00 35.10 89.10 89.10 .00 REVENUE DIVISION TOTALS--> COLLECTED: 54.00 OVER/SHORT: .00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN --CHECK 54,00 iE dE iE jE a4 dE � -)� # 4E � iE iE �E iE if iE iE iE iE iE � iE iE iE �F jF ->f iE dE � 9E iE 9E ->f �E iE 3E ie jE iE * aE 9E iE 9E �E aE iE # � aE � � � �E fE �E 1E � lE � -IE iE iE iE jE 9E jE iE jE;f * aE iE jE jE iE iE I N D I V I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST FIR 54 FIRE EQUIP FEE (FROM BLDG VAL TABLE) END OF FEES 1.00 54.00 01 C+t24 �21_U"I7 b2� T0T ;4,010 DATE: 12l+-ir55 iT7F' 4u:5 r CONSTROCTION AND PLANNING I APPROVALS Permit # Date Inspector P.00,G &SPA APPROVALS Permit # Date Inspector 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement ' 3. Electrical Conduit Utility-UndrgP.nd. 54. Forms 4. Electrical Conduit-Undrgrnd, 55. Electrical Bonding 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6. Electrical LIFER Grnd. 57. APPROVAL TO COVER-GUNITE 7. Footings 58. Electrical Conduit-Undrgrnd. 8, Foundation 59. Gas Pipe, 0 Undrgrnd., Test 9. Water Pipe-Undrgrnd. 60. Backwash Lines, P -Trap, 0 Undrgrnd, 10. Structural Floor System 61. APPROVAL TO HECK 11, Property Sewer Line & House Connection 62. Backwash & Receptor -Final E 12, Sewer Cap •- 63, Heater & Vent -Final 13. Roof Drains ' 64. Plumbing System -Final 14. Rough Plumbing 65, Electrical -Final 15. Rough Electrical -Conduit 66. Solar System -Final 16, Rough Electric Wiring 67. Fencing & Access Approval 17. Rough Wiring Sign 68. APPROVED FOR PLASTERING 18, Rough Electrical -T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit # 20. Rough Factory Fireplace 21, Ducts, in. Structure 70. Underground Hydro 22. Ducts, Ventilating 71, Product Piping 0 Gas 00il 23, Gas Pipe -Rough & Test 72. Underground Flush 24. Roof Framing 73. Undergrnd, Storage Tank 0 Gas 0 Oil 25. Roof Sheathing 74. Overhead Hydro 26. T -Bar Ceiling (Structural) & Monocoat 75, Dry Chemical 27. Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding 77. FIXED SYSTEM FINAL 29, Insulation 78, FIRE PREV. FINAL 30. Drywall failing HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat 79. FINAL INSPECTION 32, Electrical Power Meter -Final 80. FOOD CERTIFICATE ISSUED 33. Final Electric Notes: 34. Final Heating & Air Conditioning _ 35. Final Gas Pipe -Test ` 36. Hood or Canopy ^ 37. Final Factory Fireplace 38. Final Plumbing 39, Water Service -Final 40. Gas Service -Final 41. Solar Domestic -Final 42. Backflow Preventer 43. Backflow Irrigation 44. Landscape Irrigation System 45. Sound Attenuation 46. Handicap Regulations 47, FINAL STRUCTURE & BUILDING _ 48. FINAL PLANNING 49. Electric Release to Edison 50. Gas Release to Southern California Gas Co ,y 51. CERTIFICATE OF OCCUPANCY No Date „ __ CITY OF COSTA MESA BUILDING DIVISION f77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 www.ci.costa-mesa.ca.us FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BX09-00102 PERMIT TYPE B MISC STATUS: ISSUED APN: 412501070? DATE ISSUED: 05/06/2009 Zoning: PDC, ISSUED BY: co JOB ADDRESS: 3333 1805 BRISTOL ST CW_ 1 Suite/Unit: 1805 Vicinity: ri.' Primary Occ;_ ' ; Const Type :?? Std. FT: 0 -valuation: _ ' $2,500.00.' SCOPE OF WORK: WALL SIGN FOR "CORNER BAKERY". REF: CLOSED^PERMIT NUMBER: B05-1956:'' _OWNER: SOUTH COAST PLAZA ew, Address:: 3315 FAIRVIEWRO " Unit City/State: COSTA MESA';,CA,'�;� lj;. ; Zip Code: 92626 . Phone: ..i . 2820 E GRETR LN APPLICANT: WONKCHINDA; ROCHARIN . "< ' ;Atftlress: ` Unit: „,• City/State: ANAHEIM; CA ::? ti '` Zip Code:.: 928061;,, Phone: 714-683-1120 CONTRACTOR: PS�SERVICES;INC „--__: Licerise.No.,. .614$76 Address: 2820 E GRETA LN r - Unit: City/State: ANAHEIM, CA Zip Code: 92806 _ Phone 714-683-1120 Cell: ARCHITECT: -� - License No. ; Phone ENGINEER: a . ' License No. Phone FEE SUMMARY + Building Plan Check: $0.00 Buiiding Permit: ;, _ $83.25 Electrical Permit: _ $44.90-:- SMIP Residential ,y $0.00 SMIP Commercial'$0.00'' Bldg Std Admin Fund '_ $1.00 TOTAL FEES -$129.15 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. 9022 , tN2€00N TM� 1618 Fixed System Final Fire Prevention 1266 Pool Spa Final 200 Final Re -Roel 201 Final BlocIdRetaining Wali 202 Final Factory Fire Place 203 Final Sign 204 Final Demolition DATE IN1TnALS r S'mN�II� 206 Final Mechanical . 208 Final Plumbing 210 Final Electrical 212 Final f=ire Prevention 220 Final Planning Approval 222 Final Site RA P�n INTmALS 250 Final i3uildinglOccupancy P�n INTmALS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ." ❑ I have and will maintain a certificate of consent to self -Insure far workers' compensation, as provided for by. section ,3700 of the Labor Code, for the performance of the work for which this permit is issued. ' ❑ I have and will maintain workers' compensation insurance; as required'by . section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: (Tho sectan need not be compfetedY1he permd is valued al one hundred dollars (S100) or less.) Policy Number: ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisions. Applicant's Signature Dale WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7090) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic. # Class # Contractor's Signature Date CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the ewrk for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): [1 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or. her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I. as owner of the property, am EXCLUSIVELY CONTRACT]NG'WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractors) license pursuant to the Contractors License Laws.)... ❑ I am exempt under sec. Business and Professions Code for this reason: S49nalure Date 3057.46 (31071 Owner ID verified by driver ....,sense. ❑ Yes []No .Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OFIINDUSTRIAL SAFETY PERMIT CERTIFICATION: ' ❑ I hereby certify that no excavation five (5) or more feet in depth into which a pe n is required to descend, will be made in connection with work authorized by t 1 d that no building structure, scaffolding, falsework, or demolition or di f, a more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, f ministrative Code). ❑ ownTI , I I not ploy anyone to do work which would require a per ' ndustrial Safety, as noted above, unless such person has a permit to work from the division. Applicant's Signature Division of Industrial Safety Permit Number: Dale HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Govemment Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If 'yes', attach certificate of compliance from the appropriate air'pollution control officer). CERTIFICATE'OF COMPLIANCE: I certify that under penalty -of perjury.the information given above is correct. I agree to comply with all.state laws and city ordinances regarding Hazardous Materials and Emissions. &gnalure Date' CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and -state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature of Legal Owner(s) Andlor Authonzed ApphCant Date Date (714) 754-5273 • Fax (714) 754.4856 • www.ci.costa-mesa.B. #LDING PERMIT .lob Address: 3333 BRISTOL ST Plan Check: Suite: 1805 Calc Valuation: $2,000.00 Permit: Vicinity: SPACE 1805, CORNER BAKERY Claim Valuation: $2,000.00 SMIP Res: Primary Occ: Type of Construction: SMIP Com: Parcel Number: 41250107 Zoning: PDC Applicant: AQUISTAPACE, TIMOTHY Inspection: Address: 316 EAST DYER RD Total: $114.76 STE B -Phone: 714-513-1870 SANTA ANA, CA Zip: 92707 Owner: SOUTH COAST PLAZA MAIN STRUCTURE Address Rear , 0- 0 Left 0-0 Right 0-0 ACCESSORY Front 0-0 COSTA MESA CA Phone: PARKING Existing: 0 3315 FAIRVIEW ROAD Zip: 92626 Contractor: P S SERVICES Address: 316 EAST DYER RD STE B Phone: 714-513-1870 SANTA ANA, CA Zip: 92707 License: 614676 Arch : Eng: Address: Address: Phone: Zip: License: 1 WALL SIGN FOR "CORNER BAKERY", SPACE 1805. SCOPE OF PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Status: ISSUED Applied: 10/31/2005 Issued: 10/31/2005 ISSUED BY: _IndJ t%Y'RyjD Phone: License: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 006-06 (6w) FEE SUMMARY Plan Check: $45.01 Calc Valuation: $2,000.00 Permit: $69.25 Claim Valuation: $2,000.00 SMIP Res: $0.00 SMIP Com: $0.50 Other: $0.00 Inspection: $0.00 Total: $114.76 PLANNING & ZONING SETBACKS MAIN STRUCTURE Front 0- 0 Rear , 0- 0 Left 0-0 Right 0-0 ACCESSORY Front 0-0 Rear 0-0 Left 0- 0 Right 0-0 PARKING Existing: 0 Required: 0 Proposed: 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 006-06 (6w) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will malntain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. L1y,,i•hmra and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. >✓My workers' oompensatlon Insurance carrier and policy number are: Carrfer.` i `7TGt-F-P_ 4Q ki 3- — _ - Po icy Nu" M17L1106 ' � 3- (This•sectlon need not be completed if the permit is valued at one hundred dollars ($100) or less.) ❑ 1 certify that In the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California. and agree that If I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provi ns. ���/ Applicanl Sign lure: s , % . _ Data] - -� U WARMNO.'FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUaJECT AN EMPLOYER TO CRIMINAL PENALTIES AN6 CIVIL ANES UP TO ONE HUNDRED THOUSAND DOLLARS (S100.000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I.hereby sf6irm;Jihat-1 am licensed under provisions of Chapter 8 (commencing with Section 7000) of Division 3 arth Business an Professions Code, and my license Is in foil �Mrca.and- eMict. Lic. # - �t-Z�-ZG -_ -_- Class �� �` C atractor s-Sigrtatore:'ate: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there Is a construction lending agency for the performance of the work for which this permit is issued, (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031,5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to Its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or Improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). • ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Data: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby Certify that no excavation Five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be mere than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Tifle 8, Calitomla Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 WIII the applicant or present or future building occupant need to file and cenity a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _......................................................................................................................................................................................................................................................................................................................................................................... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of SS gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ........................................................................................................................................................................................................................................................................................................................................................................................ 3 Qoes or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Sectlon 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ...............................................y'r'............................................ 2.5..................---.................. i' a,,.................. rid, ...... Department. ......................... ..a ...................................................................................... 4 It an RMPP is presently required, has Section 25534 of the Califomia Health and Safety Code bean fully oompliad with? ❑Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plicstion a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control' district or agency? 1U Yes 15 No (Section 65850.2 of the California Government Code requires that the requested information be iumished on applications for non-residential building permits). ............................................................................................................................................................................................................ .............................................. ................................. I............ 6 WI[I any part of the facility to be constructed under this permit be within 1000 feet from the outar boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). .................... ................................. __................................ -....................... --.................... ---................................................................ ..... ....... ......................... ....--.......... ............... ..................... 7 It a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which Is the subject of this application, have all of the disclosures prescribed by Califomia Health and Safety Code Section 42303 been made? ❑ Yes ❑ No _...._............................................................................_............................_....................._........................._._..........................................................._..........................._........................... _ .................... 8 (If des", attach certificate of Compliance from the appropriate air po0ution control officer). CERTIFICATE OF COMPLIANCE: I oertity that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for Inspection purposes. 1 agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature Of Legal Owner(s) _ > / Di tp6 S A QrAuthorized Applicant ` r_� � '(late cooE f. INSPECTION TYPE QAM INTITIA CPDE INSPECTIONTYPINTITR 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wali 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.cB10ILDING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Status: ISSUED Suite: 1805 Applied: 07/25/2005 Vicinity: SPACE 1805 Issued: 10/11/2005 Primary Occ: A-3 Assem X300/no stagelrest Type of Construction: 1 -FR Parcel Number: 41250107 Zoning: PDC Applicant: CHRIS AKI Address: 2515WEST WOODLAND DEIVE ;Phone: .:714828-1191 ISSUED BY: ANAHEIM, CA Zip 92801 „ „•_ .- Owner: SOUTH COAST PLAZA`. "' Address COSTA MESA CA Phone 3315 FAIRVIEW ROAD Zip: 192626 Contractor. MAGNUM ENTERPRISES Address: 2515 W WOODLAND DR u ' Phone: 714-828-1191 ANAHEIM CA Zip: 92801. - License: 436517 Arch : GOOD, LAWRENCE _ Eng: =<, ,Address:, 2808 FAIRMOUNT Address:. SUITE 300• Phone:: 214-303.1500 Phone`. -- � DALLAS;:TX". .. Zip:. '75201: License:-C2D995 License: k•' SCOPE OF PERMIT' ""I X3,676 S.F. INTERIOR ,TENAN7 IMPROVEMENT FOR "CORNER BAKERY" SUITE 1805 ,t • FEE SUMMARY Iv Plan Check $434.49 rCalc Valuation .$400,000.00 Permit: $2673 75 z T Clam' Valuation: $400,000.00 A C60 SMIP Res: i >• SMIP Com'. $84.00 Other '<, $0:00 Inspection r. '$0:00, O Total: ' ".$3,192 24 t .�. N PLANNING & ZONING SETBACKS MAIN STRUCTURE Front ':0 0 Rear,_ 0- 0 ` ALeft 0-0 Right 0-0 ACCESSORY Front 0-0 Rear:., 0=:0 :Left,' 0 0 Right'` 0-0 PARKING Existin : - 0 Required: 0 -"' Proposed: 7.0' : 4 t t� "% � • .� Jam"' - . NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permlt shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will resul - e expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 244646 (6100) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations:' ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for bisection 3700 of the Labor Code, for fhe performance of the work for which this permit is issued. (�dlVe and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. workers' compensation Insurance carrier and policy number are: rs section Head not be completed if the perrnft is valued at one hundred dollars ($ t 00) or fess.) ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisions. APp� nt.ignature: � JJI '�Yl . f .�/� _ I7aie:-� 1D_ /// �f -J WARNING: FAILURE TOE WORKERS' EN ION COVERAGE IS UNLAWFUL AND SHALL SUEUECT AN EMPLOYER TO CRIMINAL PE TIES AN CIVIL FINES UP TO ONE HUNDRED THOUSAND DOU ARE ($100,000), IN ADDITION TO THE CAST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR OODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm.that,l.am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Plpfesslons Code, and my license is in full to a ar a#ect Lic. q ( > L CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Cade), Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, after, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption, Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of properly who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ' ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivePs license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, talsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title B, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ........................................................................................................................................................................................................................................................................................................................................................................ 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? [3 Yes ❑ NO (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ...................................................................................................................................................................................................................................................................................................................................................................... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ....................................................................................................................................................................................................... ............................... 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No I—— .............................. ..... ................................................. ............ ................................................. .•-----................................................ ....................................................................................................---................................................... 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this a plication a armit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? L] Yes a No (Section 65550.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ......................................................................................................................................................................................................................................1 • 1111................ ........................ ............................................................... 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? [] Yes ❑ No (1f "yes", the facility must meet the requirement o1 Sections 25534 and 42303 of the California Health and Safety Code). .....................................................................................................................................................•........................_................................................ _............. ............................................................. ......................... - ............. 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency Is required for the work which is the Subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ................................................................................................... •.........................................._..............------....................................................................................................................................................................................... 8 (If "yes", attach certificate of compliance from tha appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described properly for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature Of gal Owner(s) Date `Atidf uthorized'AWcant d, CODE R. INSPECTION TYPE - 2M - IfM CODE :INSPECTIONTYPE , LIME - IWITIAL$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical .201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 'Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition ` 250 Final Building/Occupancy Li k f I (714) 754-5273,- Fax (714) 754-4856 • www_ci.costa-mesa.ca.us .lob Address: 3333 BRISTOL ST Suite: 1805 Vicinity: UNIT 1805 77 -FAIR DRIVE, COSTA MESA, CA 92626 Status: ISSUED Applied: 10/18/2005 Issued: 11/09/2005 Parcel Nunmber: 41250107 Zoning: PDC PDC $97,25 Applicant: APODACA, DENNIS _ t - ISSUED BY: Address: 130SHIGHLANDAVENUE, Phone: 714-767-9240: 7 FULLERTON, CA ( Zip: 92832 \ Owner: Address "- i Phone: Contractor., ORTIZ FIRE PROTECTION` Address: 130 SOUTH HIGHLAND Phone:' 714-680-5174 FULLERTON, CA Zip: 92832 License: 467165 .-'-SCOPE OF PERMIT RELOCATE 35 SPRINKLER HEADS FOR 3,676 S.F. INTERIOR TENANT IMPROVEMENT FOR "CORNER .BAKERY" SUITE 1805 REF#: B05-01233 Plan Check: $63.21 Permit: $97,25 Other: $0.00 Total: $160.46 7 ; FEE•SUMMARY. ; Calc Valuation: $4,000.00 Claimed Valuation: 54,000.00 NOTICE: The work authorized by -this permit shall comply with all applicable handicap access requirements under California statutes.and related regulations. (Ord. No. 92-28, § 1, 12-21-92) ;EXPIRATION: 'This permlt+shall automatically expire and'become void if.work isnot commenced.within 180 days, or if work Is suspended or abandoned for a period of 18o days. INSPECTIONS: In order.for'the•.work authorized under -lhis:permit ,to -be considered legal,: such,,work•must,comply •with:all applicable codes, and all -required Inspectlonwand,final:approual- must 'be obtained: Failure to obtain inspections and final approval .will result in the expiratlon of this permit_ :FOR INSPECTIONS, CALL: (714) 7545626 244648 (9!00) DECLARAVONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ' ❑ I have and will maintaina certificate of consent to seil-insure for. workers' oompensa8on, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. —1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. worksrs' compensation Insurance carrier and policy number are: Oarrtdr--,;, Z U vA .•S Cd Pell Imbert~ ne is ed not be completed it the permit is valued at one hundred dollars ($100) or less.) ❑ 1 cartity that in the performance of the work for whicti this permit Is issued, I shall not employ any person ih any manner so as to bocome subject to the workers' compensation lilorriia, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply witanprovisl s. plrcant furs: +{paie_j WARNING: FAILU ECURE WORKERS' COArPENSATION COKF_RAGE IS 11NLAW FIJL AND SHALL SUBJECT AN FJutPLpYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000}, IN ADDITION TO THE DOST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3705 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed nder provisions of Chapter 9 (commencing with Section 7000) of Division 3 the Busine and Professions Code, and my license Is in full f�br �ceffe . uc. a Cla�— t L GorrtraetvStgnature:� (Dafe;� CONSTRUCTION LENDING AGENCY: - ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lenders Name: Lender's Address: Signature: _ _ Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or County which requires a, permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a Civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or Offered for sale. If, however, the building or improvement is sold within one year of Completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). - El I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractors) license pursuant to the Contractors License Laws.). ❑ I em exempt under sec. _ Business and Professions Code tar this reason: Signature: — Date: Owner ID verified by driver's iicartse. ❑ Yes ❑ No Drivers License No, Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAI ETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feel high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, TI11e 8, California Administrative Code). ❑ As owner -builder, I will nal employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: _ Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be tiled with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _ ......................_........ __........... —...................................................... _. .......- 2 boas or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the Califgmia Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic foot of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department, 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No ................................—...... ...... ..._ _ ........................_...................... _._.............. ..................................................................... -................................ ............... .....................-.................... ..... ......... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification from the South Coast Air quality Management District or from any other air pollution control district or agency? [p] Yes f No (Section 65850.2 of the California Goverment Code requires that the requested information be furnished on applications for non-residential building permits). ---—._........_._._ _ _ ----............_......................._..................................................._....... ........----.----------........—................—_.._......._..-- 6 will any part of the facility 14 be constructed under this permit be within 1000 teat from the outer boundaries of a school? L1 Yes ❑ No (If 'gee, the facility must meal the requirement of Sections 25534 and 42303 of the California Health and Safety Code). .... ........................................................ .... ................... .................... —.................................. ............. ............................................................................................. ......_.................................._..-..................... --- .............. _..... _-- - 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject at this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No fires", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signaturo Of Legal Owner(s) _Date F nd/Or Aulhorized-AppIted-M, CODE #. JNSPECTIO TYPE p NTMAL,q CODE INSPECTION TYPE QST INTITIA 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Root 210 Final Electrical 201 Final Block/Retalning Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy r (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesafttTRICAL PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Suite No 1805 Vicinity: CORNER BAKERY, SPACE 1805 Parcel Nunmber: 41250107 Applicant: ELIZABETH ARNOLD Address: ADT SECURITY ANAHEIM CA Phone:"949-394.9876 r ISSUED BY: Status: ISSUED Applied: 10/1912005 Issued: 11/14/2005 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all appillc codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiVon of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446-45 (6100) 4161 E LA PALMA AVENUE-- - .Zip 92807 Owner: SOUTH COAST, PLAZA _ 1 Address -Phone:Y COSTA MESA CA 3315 FAIRVIEW ROADS �r Zip: 92626 Contractor:'.' ADT SECURITY SYSTEM Address: 5400 W,.ROSECRANS AV V is Phone: ,310-725-2936 ` ' - HAW THORNE, CA i Zip: '90250 "Lir ense,707408. e `, •`ti �j' !', r •� r ;r` �- i .�I �„ , {t moo-- ' _ SCOPE OF PERMIT LOW VOLTAGE -PERMIT FOR SECURITY ALARM SYSTEM FOR "CORNER BAKERY"; SPACE 1805.'REF#: 605-01233°< WORK TO INCLUDE: -1 LOW VOLTAGE EQUIPMENT - -FEE SUMMARY, Quantity _~. ; Quantity . 'ISSUE FEE , $23.50 r^: Temp Dist System ! Lighting $0.00 0 . Tempsenrice test ', $0.00 • r 4�._. .:_ `"" Busway 1,100 ft `'r"':.. $0.00 0 ' ` Res. a/c package $0.00 -_ --� - ._ s `� ,_-".Standing Section ; -'-' : _ $0.00 0 New Res (1-2 units) $0.00 "� 0 -« ~Mist Electrical: Equipment - $0.00 0 New Res (3+units)' $0.00 0 Transformers up.to 1 kvalkw $0.00 0 Pool I Spa $0.00 0 up to 10 kvalkw$0.00 0, Lighting Fixts _ $0.00 0 ............:...up to 50 kvalkw $0.00 0.• Recept Outlets $0.00 0 .................up to 100 kvalkw $0.00 0 Switches 50.00 0 � ?r.:..::...........over 100 kvalkw $0.00 .,-:0)/ Non Res App! $0.00 0 ;'_,F" ?:''.• Low Voltage Equipment $18.20 .%`� 1 j Res Appl $0.00 0 Low Volo Wiring System 1 Ckt $0.00 0 ;\ Service to200a` $0.00 0 f' -r Service to 1000a ' $0:00 "; �.- O s` �,0 Misc. Conduit $0.00,if 0. Misc. Conductor ` s I;L* "$O.60 0 ' '> �; . .", Service over 1000a, _ . / % $0.00, ,. Circus (gen.or ride) ` i- -$0.00 0 Motors to 1hp T^ $0.00 `\4`0 �a '.f $0.00 Q ; Circus (meth ride"or lights) r; $0.00( 0, `Christmas Tree Stand' -4 � $O.OD f�0, Motors to 10hp ` . ,; Motors to 50hp $0.00 0 - ` _ ;,,Fireworks Stand - = $0.00; Motors to 100hp $0.00 �� 0 A -, _ • Other -Electrical Fee' Motors over 100h Communication drops $0:00 lti_ `f 0, �'''='' �l6vestigation Feet= x$0:00 � .i Sub ane! to 200a p `^• $0:00.,0/�� _. ••P lan Check Fee'" $20.85 •i ,.-' Pole Light Pkg $0.00 = 0 -''_ Reinspection Fee��,"�` -'$0.00 Sign Circuits $0.00 - �0 _Reinspection: Temp Pwr Pole $0.00 ` .. 0= -�, TOTAL CALCULATED'FEES. $62.55 Intermed Pole $0.00 0` COMMENTS ! SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all appillc codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiVon of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446-45 (6100) L DECLARAVONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty Of perjury one of the following declarations: s.• ❑ I have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. h a v e and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. My wo ers' compensation insurance Carrie and policy number are: Ca riot: yD Policy ubm'97 WC- k l 00 _— FThI section need not be completed it the permit is valued at one hundred dollars ($1170) or less.) ❑ I certify that in the performance of the work for which this permit is is§ued, I shall not employ any person in any manner so as to become subject to the woikers'. compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3 of t e Labor Code, I shalt forthwith comply with these provisions. -Applicant Slgriattir@: � , f A A WARNING: FAILURETD`SECURE K MpENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMP EIYERTO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED ie�THQUBAAtD DOI.LARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SEMON 3705 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under pro . ion of Chapter 9 (commencing with Section 7000) of Division 3 of tho,Business and Profo i Code, and my license Is in full 7, orca and-effect7l ic: H . r� ti R z` -Contractor s'Signatia�e "` Date:--•—. . CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code), Lander's Name: _ Lender's Address: Signatura: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sate (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). - ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a coniractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. _ Business and Professions Code for this reason: Signature: _- Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (S) or more foot in depth Into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, l will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: _-- _ _ Date: Division of industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSION$ CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health end Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time duritlg a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ........•........................................................................I................---- •-•-............ .............. ................................................................................. ................. ....................................................................... 2 Qoes or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ................................................................................................................................................................................-----. -----............................................................................---•-••....................................................----.................................... 3 Does or will theapPplicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? E3 Yes 13No (Section 25534 of the Califomia Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses Which are required to register acutely hazardous materials with the Fire Department. ............. ..................................................................................................................................................................................................................................................................................•------......................................... 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes ❑ No ..............................................................................................................•-••--------...............................................--.---........................................................................---..-..---....................................................-.----......--..I......................... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication agermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Ll Yes LJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ...................................................................................................................................................................................................................................................................................................................................................... fi Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the Catifornia Health and Safety Code). ........................................................---............. ---•........................................................................................................ ....-..-..............................-................................. ......................................................................................................... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? Cl Yes ❑ No ............... �..................................................... .....,........................................................ ............................................. .....................................-.......................... ......................................................... -........................................................ 8 (!f fres" ...., attach Certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. ig ature Wd/;.Oar.Authorized Applicant4~~••«v;a,,.•.. 4 t �lPate` CODS: ". tNSEfECTIOH TYPE DAM : CODE INSPEOON TYPt: .-. • •SCE INTITIAL 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing � V 200 Final Re Roof 210 Final Electrical 1 .Z 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning 'Approval <. 0 .. 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 MECHANICAL PERMIT ,lob Address: 3333 BRISTOL ST Suite No 1805 Vicinity: Status: ISSUED Applied: 10/05/2005 Issued: 10/11/2005 Parcel Number: 41250107i .-..:..; :::.., -: •;::; •- ..:' ISSUED BY: Applicant: CHRIS AKI A Y x, ` Address: 2515 WEST WOODLAND:: RIVE Phone:, , 714-828-1191 ANAHEIM CA_ Zip 92801 { Owner: SOUTHCOAST PLAZA Address COSTA MESA CA Phone: �d " 3315 FAIRVIEW.ROAD Zip: 92626 - Contractor. MAGNUM..ENTERPRISES r ` Address: s" X. 2515,W WOODLAND DR Phone 714-828-1191 ANAHEIM, CA Zip: A92801 License:436517 } � ;a SCOPE OF PERMIT 3,676 S.F. INTERIOR TENANT IMPROVEMENT FOR "CORNER BAKERY". SUITE 18053:REF,; , B05-01233 MECHANICAL TO INCLUDE: 1 REPAIRIALT COOLING/HEAT, 1 REFRIG SYS ,< 100K BTU, 1 'A GAS PIPING, 2'H OODS.WIMECH:EXHAUST,.4.,VAV BOXES, 3,VENT FANS, AND 1 AIR HANDLER. Y.r .. FEE SUMMARY 5 Quantity x r` Quantity , ISSUE .FEE;. ,;,• ,c` : r,.. .$23.50 Repair/ Alt Absorbtion Unit:": H.. $0.00 0 Inst FAU <100 k BTU' $0.00.. 0 " Repair/Alt Refrigeration Unit a'` $0.00. ,,0 Inst FAU y100 k BTU :, t. $OAO:::�O: Wentillation System,:: $10.65 1 Repair/Alt Cooling/Heat $13.70 1„” "" Evaporative Cooler" a,$0.00':'•.D Inst 1 Rep. Recess Wall Htr . $0.00 0 Commercial Incinerator $0.00 0 Refrig Sys <100 k.BTU: $14.80 1 Domestic Incinerator $0.00 0 s" Refrig Sys >1 DO k BTU ' $0.00 0 Compressors !Absorption Systems, Gas Piping $6.15 1 Up to 3'hp 1 100 k BTU .$0.00 0 Factory Fireplace v. $0.00 0 3 To 15 hp 1500 k BTU $0.00 0 Hood w/Meth Exhaust $21.30 2 15 To 30 hp 11,000 k BTU $0.00 0 VAV Box:,.'.: $42,60 4 30 To:50 hp 11,750 k BTU :. $0:00 0 Vent Fan7,Sirigle Duct $21:75 3 Over'50 hp! Over 1,750 BTU . $0.00 0 Appliance # '$6.00 y0 Boilers Fire Dampers :j Upao 3 hp $0.00 0 Smoke Dampers,, $0.00: -D, i ., ,.; 3 To 15 hp . $0.00 0 Inst or Relocate Appl Vent ..:$0.00 0. a5.to 30 tip $0.00 0 v Air Handlers < 1040t)cfm $10.65 i'' • . •• 30"to 50 hp ;.:z ; % $0.00 0 Air Handlers > 10000cfrn $0.00 0 -Over 56'6p ' $0.00 0 Floor Furnace?: $0`00 0;,,: • `•� Other Mechanical Fee Floor or Suspend Heater e,. ; $0.00, . 0 Investigation Fee;, $0.00 Plan Check Fee : ,.``:. $0.00 Reinspection Fee;' $0.00 TOTAL'. CALCULATED FEES $166.10 COMMENTS°I SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes aFd related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work Is not commenced within 180 days, or if work is suspe de/abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446-46 (drool DECLARATIONS WORKERS' COMPENSATION DECLARATION: hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of Consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the r I =for which this permit is issued. 19 and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. My workers' compensation Insurance carrier and policy number are: Iff?W✓ieG/�1i9 CSr�.ec J: � CDe ..<•✓C P�,�"`.f�p�/CGS/ 7,ti/D / s section need not be completed if the permit Ls valued at one hundred dollars ($ 100) or lass.) ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provislon WARNING: FAILURE T SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL P TIE D CML FINES UP TO ONE HUNDRED THOUSAND DOLLAAE (3 ),IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: that I am I€tensed nder provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business andErofessions Code, and my license Is in full I ce and effect. Lic. # AC512 Class„- �nRtr"ac)a�s:Stlyfwce:ze CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, altar, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any Violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors license Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. if, however, the building or Improvement Is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ' ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ t am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth Into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-sic (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I WIII the applicant or present or future building occupant need to file and cenlfy a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa s=ire Department by every business which hes at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume o1 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ............................................................................................................................................................................................................................................................................ .... 2 Does or will the applicant or present or future building occupant need to fits a regisirat€on form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costs Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feel of compressed gas at standard temperature and pressure). .................................. ................................................. ........................................................................................... ........................................................................ .............. ............................... .... .................................. ......... ...................... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ........l'y' r'e"....................................................4, o"...............-l'if'o, r'--......................rid,............................................................................................- ---............................................................................................ 4 If an RMPP is presently required, has Sect€on 25534 of the California Health and Safety Coda been fully complied with? ❑Yes ❑ Nc 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this a pl€cation armit for such construction or modification Pge from the South Coast Air Quality Management District or from any other air pollution control district or agency? lJ Yes ❑ No (Section 65650.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits), :...................................................................................... ........................ ............................................................................... 6 WIII any part o1 the facility 10 ba constructed under this permit he within 1000 feet from the outer boundaries of a school? El Yes ❑ No (11 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ..................................................... ..11-,---•.,............................. ....................................... _....................... _.................. ..,,...........I'll ....................-......... .... .................................. -.-.... _............................... __................................ _................ 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ................................................................._........................................ __..................... --..................................---............................... _.._...................... _........................... 6 (If yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the Information given is correct. I agree to comply with all state laws and city ordinances retailing to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for Inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature I Legal ) Date cAutho icant --.-.- CODE t. INSPEC11ONTYPE — Od1T. INTMALS CODE# INSPECTIDNTYPf Alli 1616 Fixed System Final Fire Prevention 206 Final Mechanical - '0 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 ' Final Demolition 250 Final Building/Occupancy 40 CITY OF COSTA MESA BUILDING Df VISION -11T C)EVEt.OPMENT SFRVICES PERMIT va FIRE SUPRESSlON PERMIT (714) 754-5273 • Fax (714} 754-4856 • y,.ww•ct.co5ia mesa.ca•us NUMBER 77 FAtR pRiVE, Ct35TA MESA CA 92626 Status_ ISSUED Applied: 1110412005 Jab Atidsess; 3333 BRISTOLST - _ _ , Issued: 12105/2005 Suite: 1805 Vicinity; i805 Zoning= PDC PDC Parcel Nunmbei, 41250107 ISSUED BY: applicant: VICKI CHRISTOPHERSON •;�` .-;,,;.>_: Address: -'Phone'. 909.706-2090 Zip' owner: SOUTH COAST PLAZA �< .. R s ft Address Phone COSTA MESA CA Zip:' 9282E 3315.FAlRVIEVV ROAD _ SON CONSTRUCTION contractor: CHRISTOPH;=R Address: P 0 BOX 23 03,, phone: 909 591-0438 Zip; -191708 CHINO, CA license: 437874 SCOPE OF PERMIT CORNER BAKERY" SMITE 1805 REF 805 01233 3,67 INTERIpI TENANT IMPROVEMENT FOR NOOK SUPRCSSION SYSTEM,79T FEE SUMMARY Calc Val►saEio $1,04o.0D C4aimed Valuation" $i,oDa D0 Cheek: $25.19 ;€ Plan Permlt $3B• IF Other.. Total: $63.94 shall comply with all applicable handicap access requirements under CaffOmia statutes and related I NOTICE: The work authorized by this permst suspended or abandoned 1,12-21-92) regulations. (ord• No. 92-28, § and all rk is unit shall automatically expire and become void if work is not commenced rNtthin 180 days, ar It WO alI applicable codas, for a pAiod of This Pe permit. for a period of 180 days• oval will result in the exfliration 01 this Ise i ed. Failure to obtain inspectlons and final aPPr n order For the work autlGorized unda�this permit to be considered legal, such work musk cornPY INSpEC7I0NS. i ravel must be obta required In$�tlona and final app FOR INSpECTIONts CALL. (714)764'6626 DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the wK for which this permit is Issued. Al have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the perfarmanve of the work for which this permit is issued. My w e ens �s�urran crier and policy number are: Carri6r �sL "• r Lfl/! I V _ Policy Numh r:_ i �(Thls'sectian)7e d not be co plaUla,and 'Ns valued at one hundred dollars ($iDU} or less.) ❑ I certify that In the performafor which tit' permit is iss d, I shall not employ any person in any manner so as to become subject to the workers' compensation Iaws f Califoth t If I htiuld trecome subj ct to the workers' compensation provisions of Section 3700 o the Labor Code, I shall forthwith comply with these p vi n �_o fApplicant.Sigttature:' ' Date: WARNING: FAILURE TO SECURE WORKERS'COMP T1 COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER -TO CRIM1 PENAL ES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO E CAST F COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I d r r hereby affirm that I am licensed v' i s of 0hapter 9 (comme Ing with Section 7000) of Division 3 of the Business and Pra sl ns Code, and my license is in full force.andeftedYtic. p i Class MS Coniractors.Signature: 7 (-Date. s �p l CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does net apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or Improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, ialsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ............................................................................................................................................................................................................_.....................................................•----....................................... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? []Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .......... ... ............ ............................................--.................................................................................................................................................................................................................................------•-..... ­ ................... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. -,i'r"e..................'---111I'O"n............................................'n-1 ...............................f-e-.............................................................w,ii............... Ye,'........................................................................................ 4 If an RMPP .. presently required, has Section 25534 o.. the California Health and Safety Code been fully complied with? ❑Yes ❑ No 5 Does or will the applicant or present or future building occupant require far the work which is the subject of this a plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes (� No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). "an ...............................cII'l-----.................ri's- r-u-'..........----------............e'r,.......*b-a........................ I'a"'ot-....................... ie"'..........rid, ..rle'..................h, c,................. -- a ................... ................. ............................... 6 Will any part of the facility to be constructed under this permit be within 1000 feet From the outer boundaries of a school? ❑Yes ❑ No (It `yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ...1111............------•.....................................................................................•--................................................................................................. ..................... .............................. 1.11..1...... .......... 1111....................... ... 7 if a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ........................-----------------......................................................................................................-•--•------------......................................................................................---------------..................................... 8 (If "yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Data: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the Information given is correct. I agree to comply ith all state laws and cityordi+; ces relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described props for inspection purposes. agree not occupy or allow occupancy of any building authorized by this permit until final inspection. '1 1 Sig tura f L I Owner(s) I- n rAVthoriied'Applicant4 CODE A INSPECTION TYPE i7AIj'INMIALS CODE if INSPEOAON JYPE QA%E INTITA 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical a 201 Final Block/Retaining Wall 212 Final Fire Prevention r �' 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy 0 & (714) 754-5273 • Fax (714) 754-4856 • www.cl.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT .lob Address: 3333 BRISTOL ST Suite No 1805 Vicinity: Parcel Nunmber: 41250107 Applicant: CHRIS AKI Address: 2515 WEST WOODLAND DRIVE Phone: 7.14-828-1191 SCOPE OF PERMIT ANAHEIM, CA ,' Zip, 92801 3,676 S.F. INTERIOR TENANT IMPROVEMENT FOR "CORNER BAKERY" SUITE 1805. REF.: Owner: SOUTH COAST PLAZA Address ..COSTA MESA CA Phone: 3315 FAIRVIEW ROAD Zip: 92626 Coniracto,v MAGNUM ENTERPRISES Address: 2515 W WOODLAND DR Status: ISSUED Applied: 1010512005 Issued: 10/11/2005 ISSUED BY: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days, or If work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable code •end all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration s permit. FOR INSPECTIONS CALL: (714) 7545626 244548 (6=) ANAHEIM, CA Phone: 714-828-1191 Zip: . 92801 License: 436517 SCOPE OF PERMIT 3,676 S.F. INTERIOR TENANT IMPROVEMENT FOR "CORNER BAKERY" SUITE 1805. REF.: B05-01233 ELECTRICAL TO INCLUDE: 91 LIGHT FIXTURES, 50 OUTLETS, 21 SWITCHES, 1 NON RES APPLIANCE, 1 SERVICE TO 1000 AMPS„ 1 MOTOR TO 10 HP, 4 COMMUNICATION DROPS AND 4 SUB PANELS TO 206 AMPS. FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 Temp Dist System /Lighting $0.00 0 '-Temp service test.,'. - MOO Busway 1100 K $0.00 0 Res. a/c package $0.00 Standing Section $0.00 0 New Res (1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0 New Res (3+units) $0.00 0 Transformers up to 1 kvalkw $0.00 0 Pool -I Spa $0.00 0 .........-......up to 10 kvalkw $0.00 0 Lighting Fixts $73.83 91 .................up to 50 kvalkw $0.00 0 Recept Outlets .$43.90 50 .................up to 100 kvafkw $0.00 0 Switches $22,73 21 ..................over 100 kvalkw $0.00 0 Non Res Appl $4.75 1 Low Voltage Equipment $0.00 0 Res Appl $0.00 0 Low Volt Wiring System 1 Ckt $0.00 0 Service to 200a $0.00 .0 Misc. Conduit $0.00 0 Service to 1000a $0.00 0 Misc, Conductor $0.00 0 Service over 1000a $0.00 0 Circus (gen or ride) $0.00 0 Motors to 1 hp $0.00 0 , Circus (mech ride or lights), $0.00 0 Motors to 10hp $12.30 1 Christmas Tree Stand $0.00 0 ` Motors to 50hp $0.00 0 Fireworks Stand $0.00 0 Motors to 100hp $0.00 0 Other Electrical Fee $0.00 Motors over 100hp $0.00 ` 0 a Communication drops $4.40 4 Investigation Fee $DAO Sub panel to 200a $122.00 4 Pian Check Fee $0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $0.00 0 . Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $307.41 Intermed Pole $0.00 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days, or If work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable code •end all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration s permit. FOR INSPECTIONS CALL: (714) 7545626 244548 (6=) a a DECLARAVOINS WORKERS' COMPENSATION DECLARATION: hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 6aeme and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. ,hMy workers' comyenation Insurance carrier and policy number are: Cart0l PoHCy_Numti �G/I %4 /0// Pis section need not be completed i1 the permit is valued at one hundred dollars {$100} or less.) ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that If I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these pro _Sig ure: Applicant�W AIE 3 r T SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLO44'h6CRIMINAL PENAL16ES AN CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under p ovisions of Chapter 9 (commencing with Section 7000) of Division 3kD ess and Professions Code, and my licansa is in full forewartdand Lic. # CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code), Lender's Name: Lender's Address: Signature: Data: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions o1 the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more then five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply 10 an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. 11, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ' ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Coda: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, Califomia Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .................................................................................................................. _...................................................................... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .....•-••--•.............................................................................................................................................................................................................................................................................................................................................................................. 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Coda provides that the Costa Mesa Fire Department may require the preparation, cartification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ...........................n'd' ......-------- .....................'n f'...................4ie'...............................a ....................................................................................... 4 If an RMPP is presently required, has Section 25534 o.. the California Health end Saieiy Code been fully complied with? ❑Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication agermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ILJ Yes LJ No (Section 65850.2 of the California Govemment Code requires that the requested information be furnished on applications for non-residential building permits). ----- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 111.1.................. .................................... 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yee, the facility must meat the requirement of Sections 25534 and 42303 of the California Health and Safety Code). . ....�----- ...................................................................................................................------...................................................................................................................................................-..........................1111.......................... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safely Code Section 42303 been made? ❑ Yes ❑ No ................. .......... ............_.................................................................................................................................................................. ............................................................. ............................... I ................................ 1111..1111.. ............ ............. 8 (If fres", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature f Le al ner(s) Date S� f_ fe2f-' �- Rplulfq t[L,��.•-�•.,__ I,Data�:.� CODE 0. INSPECTION TY£E 2AT_E i(M9L$ CODE( INSPECTIONTYPE I?A1E IRML$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 4a 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 ' Final Demolition 250 Final Building/Occupancy - (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa"ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 PLUMBING PERMIT Job Address: 3333 BRISTOL. ST Suite No 1805 Vicinity: Status: ISSUED Applied: 10105/2005 Issued: 10/11/2005 Parcel Nunmber: 41250107 Applicant: CHRIS AK1w ,., ` �€.,.� ISSUED BY: j. .,. Address: 2515 WOODLAND DRIVES >:- Phane:.'"7:1A-828-1191 ANAHEIM, CA Zip: 92801 Owner: SOUTH -COAST PLAZA: Address . COSTA MESA CPC Phone: 3315 FAIRVIEW ROAD'" ` Zip: 92626 ,Contractor: , MAGNUM ENTERPRISES -'k Address: 2515 W WOODLAND OR ,,- .4. Phone: ',714-828-1191 F, ANAHEIM, CA.. ,, Zip: ,,'92801 License:, -43.••6517: ; SCOPE OF PERMIT 3,676 S:F. INTERIOR TENANT IMPROVEMENT FOR "CORNER BAKERY" SUITE 1$05 REF:: , PLUMBING TO INCLUDE: 1 BACKFLOW PREVENTER, 2 CONNECTIONS, 1 DISHWASHER, 9 FLOOR 3.- 4DRAINS, 1:EXPANSION TANK, 1'GAS (1-A OUTLETS) 1'GAS (OVER 4 OUTLETS)4 P -TRAPS 1 •-:> SEWER CONNECTION; 2 COMMERCEAL SINKS, 9 FLOOR SINKS,'1 SERVIC EIMOR SINK, 2 TRAP _ PRIMERS;'1 URINAL, 3 WASH BASIN SETS, 1 WASTE"AND VENT SYSTEM, 1 WATER, CLOSET, 1 WATER HEATER,,1 WATER PIPING,AND 1 WATER SOFTENER. FEE SUMMARY, .: AMT OMY AMT -. QTM AMT QTY ISSUE,FEE $23.50` Laundry Tub 1 Washer $0.00 0 F Sump Pump - $0.00 0 Backflow irrigation ),"so -00'..' , 1 Landscape Irrigation $0.00 0 '; Swimmirig:Pool , � $0.00 q ° 0 BackflowPreventer .$9.80.-0. P -Trap $39.26 4 Trap Primer :• $19.60 2 Bathtub -,$0,00::::: 0' Pressure Regulator, $0.00 0 Urinal; ::' ::;;:'' : $9.80-' 1 Clarifier System " $0.00 0, Process Piping (per 10 ft) $0.00 0 Vacuum Brkr Bkflovr(1-4) $0.00 0 Connect (Iee,Soda,etc) $19.60 2, Receptors .;$0.00 0 Vacuum Brkr Bkflow(5+)„ $0:00 0 Dental Units „SF..::: $0.00 01 Septic Tank $0.00 0 Wash Basin $0.00 0 Dishwasher $9.80„ 1, Sewer Cap for Demo .$0.00 C0 . Wash Basin Set .$29.40 3 Drain, Floor $88.20`i9" Sewer Connect $24.65 1Waste ' and Vent System .$9.80 1 Drain, Rainwater' $0.00 0 Sewer Private Line ` $0.00, 0 Water Closet (Toilet) $9.80 1 Drain, Roof"`. . $0.00 :. 0', Shower,$O OD; 0 Watar Heater /,vent . $12.30 1 Drinking Fountain - $0.00 0 Sink, bar, , x •$0 00 0:3 • : Water Piping'(Inst or Rep") $9.80 1 Expansion Tank $9;80j "61 d ` Sink; commercial x S19 60 .:2 Water Re pipe $0.00 0 Gas Earthquake Valve . '" •$0.00.. 0 Sink;-Floor$88,20 9 '" .Water Service $0.00 0 Gas (1-4 outlets) . $6.15 1 t,. ` :.J>'sr : Sink, kitchen " `.. .. $0.00 0, ,. "Water Softener $9.80 1 Gas (Over 4 out)ets) $1:10.; i - ` : "' ` ' Sink .servicelmcp $9.8Q, , •::1 OTHER: $0.00 Gas Repipe $0.00 0 Spa'(private) .$0.00„ 0 `. VIOLATION $0.00 Gas Service $0.00 0 ,. Spa (public) ; $0.00 - 0 ;=PLAN CHECK $0.00 Interceptors (Grease, Oil) $0.00 0 REINSPECTION $0.00 0 Interceptors (Sand Auto ) $0.00 0 --- e:-, } TOTAL CALCULATED FEES: $459.70 l n11 UPK1Tc r CPGf'IA1 C nAlr%1TlnA14` NOTICE: The work authorlied by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply wlth all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this FOR INSPECTIONS CALL: (714) 754-5528 DECLARATIONS A WORKERS' COMPENSATION DECLARATION: I hereby affimi under penalty of perjury one of the following declarations: ❑ I have and will maintain's certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 0!�hga_ve and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued.' My workers' compensation Insurance carrier and polloy number are: rr asmr:-=::-.• �.2�.>✓i.� t 5d;,/0e,.5, "J i �i"avt on need not be completed if the permit is valued atone hundred dollars {$10.0} or less. j ❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that If I hould beco a subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisions. Ap Ii�pant Signet WARNIN : FAILURE T SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLO TYER O CRIMINAL PEN TIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF 114E LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of•the•8 siness and P ofessions Code, and my license is in full fo{c�ndct. Lic. # 'Gess # tCcRfractor p� CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of Salo.). • ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Data: Owner ID verified by drivers license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, Le. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec, 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the Catifomia Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ......................................................... .... ..........................................................................................................................................................................._......... . 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .................. .....1---•.. .................. ..................................................................................... .... .................................................... ................. ,................ ,.,.............................. ,.................,,.................................. ....................... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire 4 Department. f...... . .............. ••..... ......................-----------...................................................................................................... ............................................................................................. an.RMPP..s presently required, has Section 25534 of the California Health and Safety Code been fully complied with? [:1 Yes ❑ No -- -................................................................-•-•-------..................................................................... ......-............... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication aQermil for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes 19 No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). :........................... ........... .......................................................................................................-•-•--....................................................................................................................................................... .............................................................. 6 Will any part of the facility lobe constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Coda). F.--............................................ - ... - - .......... .......................................................... .................................. ............................................. ------....----...........----...---......................................................................................................... 7 I! a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by Califomia Health and Safety Code Section 42303 been made? ❑ Yes ❑ No .....- ......-•---•-••-----------------........................................................................................................-- .............------...........-----....................-------••---------........--...- ...................................---------...... 8 (If 'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY. I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. ignature Of L lal Own.94sk Date f—And/ ut orifi Y nt _ t ,ODE N, INSPECTION TYPE 2&U Ifs - CODE INSPECTION F'LPE Q INTMALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 final Re -Roof 210 Final Electrical Y92 / 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 2134 Final, Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.cl.costa-mesa.864LDING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Suite: 1805 Vicinity: SPACE 1805, CORNER BAKERY Primary Occ: M Display/Sale Merchandise Type of Construction: I -FR Parcel Number: 41250107 Zoning: PDC Applicant: JEFF CARIKER Inspection: Address: 2300 SO RESERVOIR $736.01 STE 111 Phone: 909.465.1500 POMONA, CA Zip: 91766 .n Owner: SOUTH COAST PLAZA ' Address COSTA MESA CA Phone: 3315 FAIRVIEW ROAD Zip: 92626 Contractor: KNIGHT DEMOLITION SERVICES INC ISSUED BY: Status: ISSUED Applied: 09/14/2005 Issued: 09/14/2005 Address:'` 2300 SO RESERVOIR'< STE 111 Phone: 909.465.1500 POMONA,CA Zip: 91766 License: 790242 Arch :. Eng: Address: Address: Phone: Phone: Zip, License: License: SCOPE OF PERMIT 'NON-STRUCTURAL INTERIOR DEMO FOR 3,676 S.F. INTERIOR TENANT IMPROVEMENT FOR ."CORNER` BAKERY" SUITE.1805 REF* B05-01233 " FEE SUMMARY Plan Check: $287:46Calc Valuation: ='$30,000.00" Permit: $442.25 Claim Valuation: $30,000.00 SMIP Res:' $0.00 ,r SMIP Com: $6.30 w Other:. <', $0.00 Inspection: $0.00 Total:' $736.01 SETBACKS MAIN STRUCTURE Front 0-0 ACCESSORY ° . Front 0-0 PARKING Existing: - 0 ` PLANNING & ZONING Rear 0- 0 Left 0- 0 Right 0-0 Rear 0-0 Left 0-0 Right 070 Required:' 0 Proposed: 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12.21-92) EXPIRATION: This permit shall automatically expire and become void it work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2"6-48 (6ro0) DECLARAVONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the �work•iar which this permit is issued. ❑ ` I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. �—;•;My workers' compensation insurance carrier and policy number are: Policy.Number.--9 q (This section need not be completed it the permit is valued at one hundred dollars ($100) cr iess.) ❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Callfomia, and agree that ii 1 should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these pro ns. �/ -Applicant',Sig�Pate:. ate:. = g?� 7 ­0 S_ --- WARNING: FAILURE TO SECVE W ERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SEC ON 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full ,for fo car and effect: Lic`'M' D Class# ti C"s j_ ontracto7(s.Slgna@ e7-_'--J D CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, altar, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption, Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for safe (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, Califomla Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of tndustrial Safety, as noted above, unless such person has a permit to do such work from the division. Signalure: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the Califomia Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ........................................................................................................................................................................................................................................................................................................................................................................... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the Califomia Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ........................................................................................................................................................................................................................................................................................................................... ..... ............ 3 Does or will theaappplicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? [I Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ............................................................................................................................................................................................................................................................................................................................................................... 4 It an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No ................ .. ..................................................................................................................................................................................................................................................................................................................................................... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a pllcation a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes No (Section 65850.2 of the Califomia Government Code requires that the requested information be fumished on applications for non-residential building permits). ...................................................................d -"IR"................... b"e".......................... f'e"' t"I'-.................. u"t' .......................e o- f a - c"h' -•--..................-.......-................................................................................ 6 Will any part of the facility to be constructed under this permit be within 10D0 feat from the outer boundaries of a schoof7 ❑Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the Califomia Health and Safety Code). ................................................................................................................................................................................................................................................................................................................................ 7 It a permit from the South Coast Air quality Management District or other air pollution control district or agency Is required for the work which is the subject of this application, have all of the disclosures prescribed by Califomla Health and Safety Code Section 42303 been made? ❑ Yes ❑ No -............................................................................................................................................................................---.............-----...........................-.................................................................................... 8 (If "yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signet 1 La Owners) Dat 1; A Or Autho zed A pl ccant,� r nate CODE i. INSPECTION TYPE OATS INTMAL CODE t INSPECTION TYPE !?ATI: 1 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa. ELus ECTRICAL PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Suite No 1407 Vicinity: ELECTRICAL ROOM Parcel Nunmber 41250107 Applicant: KUBACKI, JACK Address: 3422 W MAC ARTHUR ST UNIT B Phone: 714-751-6133 SANTA ANA, CA Zip 92704 Owner: SOUTH COAST PLAZA $0.00 0 Address $0.00 Busway 1100 H $0.00 COSTA"MESA CA _ Phone: $0.00 3315 FAIRVIEW ROAD Zip: 92626 Contractor: J A K ELECTRIC 0 Misc Electrical Equipment Address: 3422 W MAC ARTHUR ST New Res (3+units) $0.00 0 _ UNIT B Phone: 714-751-6133 Pool! Spa SANTA ANA, CA Zip: 92704 $0.00 0 ' License: 405289 ISSUE Status: ISSUED Applied: 09/1112006 Issued: 09/11/2006 NOTICE: The work authorized by this permit shall comply with all applicable handlcap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 2"846 (6m) SCOPE OF PERMIT ELECTRICAL PERMIT FOR REPAIR TO AN ELECTRICAL SERVICE PANEL FOR "MAXMARA", SPACE 1407. ELECTRICAL SERVICE LOCATED IN THE ELECTRICAL ROOM NEAR THE NEW RENOVATED ENTERANCE AND CONCIERGE. FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 Temp Dist System I Lighting $0.00 0 Temp service test $0.00 Busway 1100 H $0.00 0 Res. a/c package $0.00 Standing Section, $0.00 0 . New Res (1-2 units) $0.00 0 Misc Electrical Equipment $18.20 1 New Res (3+units) $0.00 0 _ _ . Transformers up to 1 kva/kw $0.00 0 Pool! Spa $0.00 0 ................up to 10 kvalkw $0.00 0 ' Lighting Fixts $0.00 0 ', up to 50 kvalkw $0.00 0 Recept Outlets $0.00 0 .................up to 100 kvalkw $0.00 0 Switches $0.00 0 ..................over 100 kvalkw $0.00 0 Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0 Res Appl $0.00 0 Low Volt Wiring System 1 Ckt $0.00 0 Service to 200a $0.00 0 Misc. Conduit $0.00 -0 Service to 1000a $0.00 0 Misc. Conductor $0.00 0 Service over 1000a $0.00 0 Circus ( gen or ride) $0.00 0 Motors to 1 hp $0.00 0 Circus (mech ride or lights) $0.00 0 Motors to 10hp $0.00 0 Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 0 Fireworks Stand $0.00 0 Motors to 100hp $0.00 0 Other Electrical Fee $0.00 Motors over 100hp $0.00 0 Communication drops $0.00 0 Investigation Fee $0.00 Sub panel to 200a $0.00 0 Plan Check Fee $0.00 Pole Light Pkg $0.00 ' 0 Reinspection Fee $0.00 Sign Circuits $0.00 0 Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $41.70 Intermed Pale $0.00 0 COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handlcap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 2"846 (6m) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self-Insure for workers'. compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is issuaq. ❑-r1 have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permlt is Issued. My, workeri' compensallon Insurance carrier and policy number are: �rrtor , -% Policy Number: is section need not be completed if the permit is valued at one hundred dollars ($100) or less.) I cartify that In the performance of the work for which this permit Is Issued, I shall not employ any person In any manner so as to become subject to the workers' compile satsnly,with ton law F f California and agree that if I should become subject to the workers' compensation provisions of 3700 of the Labor Code, I shall forthwith cot1 x� fApplk �t Signature: Data: 10 %YARNLNG: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS LP AWFL& AND SHALL SUBIECT AN EMPLOYER TOCMl ENALM TiES AND CL FINES UP TO ONE HUNDRED THOUSAND DOLLARE (S=000j IN ADDMON TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE f CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Coda, and my license is In full Tome and affact..Llc. k 542,2 Class a C COntractors:Slgnal6re: Date: `"—Ft Io,G 4- CONSTRUCTION CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is issued. (Sec. 3097, Civil Code). Lender's Name: _ _ _ Lenders Address: Signature: _ Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professlons Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provtslons of the Contractors License Lew (Chapter B (commencing with Section 7000) of Dlvisfon 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my bmployees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not Intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ' ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts far such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: —__ Dale: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or mare feet in depth into which a person is required to descend, will be made In connection with work authorized by this permit, and that no !wilding structure, scaffolding, falsawork, or demolltJon or dismantling thereof, will be more than thirty-six (38) feat high. (Chap. 3.2, Grp 2, Art 2, Sac. 341, Title 8, Califomia Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Data: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Hgallh and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one timg during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure)._ __............. ....—........................... ......_ ......... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 D �r will t❑e applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? 10 (Section 25534 of the California Health and Safely Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑Yes No 5 Does or will the applicant or presegt or future buUding occupant require for the work which is the subject of this pRpilcaiion a.aerrrrit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes U No (Section 65850.2 of the California Government Code requires that to requested information be furnished on applications for non-residential building permits). .......-..........�..... ... ......_................................................... w_1........ _.._......................................... ..............--...........—._.... ..................................,,,,................... 6 Will any part of to facility to be constructed under this permit tie within 1000 feet from the outer boundaries of a school? ] Yes d No (If 'fres", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ............................_ ....._................. — ........ _ ---.._....................-- - ----- _—_.—.....�............... ............... -- 7 If a permit from the South Coast Air duality Management District or other air pollution control district or agency is required for to work which is the subject of this application, have all of the disclosures prescribed by Callfamis Health and Safety Coda Section 42303 boon made? ❑ Yes ❑ No 8 (If 'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury to information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certity under penalty of perjury that I have read this application and state that the Information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of to City of Costa Mesa to enter upon to above-d")dbed property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Ignature Of Legal Owners) _ _ Date _—And/or Authorized Applicant Date CODE 1. �5?ECIMTYPE pi, INTMALS CODE INSPEOONT" IN$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1288 Poo! Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retalning Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Oomolition 250 Final Building/Occupancy .'"OJECf;'hORESS: 3333 BRISTOL ST UNIT: 2887 OWNER'S NAME: C J SEGERSTROM 6 SONS ADDRESS: 3 31 S FAIRVIEW RD COSTA MESA CA 92626 (714)546-0110 ARCHIENGINEER: REG.NO.: ADDRESS: UNIT: PERMITTEE: DOC ELECTRIC INC. (714)543-1776 ADDRESS: 1669 E WILSkIRE 605 SANTA ANA CA 92705 LICENSED CONTRACTOR DECLARATION: I hereby atfirm that I am licensed under provisions of Chapter 9 (commencing with Section 70001 of Division 3 of the Business and Professions Code, and my license is in lull force and effect, CITY LIC.: 044456 STATE LIC. :509628 C -10 Dale: 12 7 C Z Signature: - — WOR%ERS' COMPENSATION DECLARATION: I hereb it I have a certificate of consent to sed insure or a certificate of Workers' Compensation Insurance or certifie 8-5/01/93 . copy thereof on 3800. Lab. POLICY NO,: 69935 - 9� EXP. DATE: 5/ 0 1/ 9 3 COMPANY: STATE FUND ® Certified copy is hereby furnished. ❑ Certified copy is filed the city ' ing Division. Date: / Z' 7 ^2�— Applicant: '-EXEMPTION FROM WORKERS' COMPENSATION DECLARATI • s section need riot be completed if the permit is lot one hundred (SI 00) or less►. I certify that in the performance of the work for which th permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California. Date: Signature: NOTICE: 1f, after making this declaration, you should become subject to the Workers' Compensation provisions of the Labor Cade. you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Section 3097, Dv, C). LENDER: ADDRESS: OWNER BUILDER DECLARATION: I hereby affirm that I am exempt Irom the Contractors' State License Law for the following reason (Section 70.31.5 Business and Professional Code: Any city of county which requires a permit to construct, alter, improve, demolish, or repair any structure. prior to its issuance. also requires the applicant for such permit to file a signed statement that he/she is licensed pursuant to the provisions of the Contractors' State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business arid Professions Code) or that he/she is exempt therefrom and the basis for the alleged exemption. Any violation at Section 7031.5 by any applicant tot a permit subjects the applicant to a civil penalty of not more than live hundred dollars ($500). I. as owner of the property or my employees with wages as their sole compensation, will do the work, and the ❑ structure is not intended or offered for sate Ghon 7044, Business and Prolessionat Code: The Contractors' State License Law does not apply to an owner of a property who builds or improves thereon, and who does such work himself/herself or through his or her own employees, provided that such improvements are not intended or offered for sale. It, however the building or improvement is sold within one year of completion, the owner will have the burden of proving he/she did not build or improve for the purpose of sale). I. as owner of the property. am exclusive] y contracting with licensed contractors to construct the project (Section 7044, Business Eland Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon and who contracts for such projects with a contractar(s) license pursuant to the Contractors' State License Law). I am aware that proof of their Worker's Compensation insurance should be provided to me. ❑ 1 am exempt under Section: B. d P. C. for this reason: Date: Owner: I do hereby certify that I am aware of and understand the requirements of California.Heallh and Safety Code Sections 25505, 25533, and 25534 and that I or any future building occupant will/will not (circle one) need to comply with said state codes and the requirements for a permit for construction or modification from the Air Duality Management District. Residential construction applications are exempt from these provisions. Date: Applicant: I hereby certify that I have read this application and stale that the above information is correct. I agree to comply with all city and county ordmances and state laws relating to building construction and ;hereb7yaulho'represenlays of this city to enter upon the above-mentioned property for inspection purposes - Date: % Z — Signature: Driver's License or Social Security #. .r641-46 White—Buildino: Green—Code Enforcement: Canary—ADolicant: Pink—Revenue: Goldenrod—Assessor CITY OF COSTA MESA - BUILDING PERMIT PERMIT NO: E 060231 PLAN CHECK NO: N CONSTRUCTION TYPE: PERMIT TYPE: ELE JOB DESCRIPTION : INSTALL EXPRESSO BAR COUNTER CLAIM VALUE: CALC-VALUE: PERM NO: E 060231 GOVT: N SUPP: N PURPOSE: OTH SQ FT.- PURPOSE: T: GROUP OCC: B-2 / COMMENTS: "ANTONELLO'S ESPRESSO BAR" / REPLACES "AMATO'S CAFE" *lFlFlFlFIFlFlrlFltlFlFlFlFlFlFIEIElFItlFlFlElFlFlFIFIFlfltlFlElFlfiEiE����������**iFiFiFlFltlFlilElflFlFiFlEiFiF*�����***�*����* Z O N I N G S E T B A C K S R E Q U I R E M E N T S ------------ MAIN BUILDING ---------- --------- ACCESSORY BUILDING--------- FRNT: FT IN REAR; FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN PARKING REQ: PROV: PARCEL: 41250102 ZNE: REF NO: PLANNING NOTES> > lElElElE�lElElElFlFlFlFiFiFiFIFlFlt:lElElElFIF�lF�lFlFiFiFlFlFiFlFlFlFlF�*itlFlFlF>�lFlFlFlFlFlFlF*lF��lF�lFlFlFiEiFlElFlElFlFlFlFlf**lFlt�lFlF*lF D E V E L O P M E N T S E R V I C E S R E Q U I R E M E N T S i ZONING APPROVED BY r. A DATE: BUILDING APPROVED BY APPLICATION ISSUED B lF iF iF lF lE iF l! lF lE * if lF lF lF lF lE lF lF lF lF lF iF iF if jf if if if lF lF lF lF lF lF lF lF lF iE l! it LEGALIZATION:N PERMIT PLAN BLDG PMT 17tot DATE.- DATE: ATE:DATE: �i�iF lF lF lE iF iF lF lF lE lE lE iF lF lF iF lF lE lF lE lE lF lE iF iF lF lF lF iF lF lF It lF * lF lE STRUCTURAL SEGMENT:N FIRE SMIP/RES GRADING SMIP/NON-RES ISSUE FEE 15.00 BUILDING -DIV-> PERMIT ISSUE PLAN -CHECK TOTAL PAID DUE TOTALS ---- > 17,25 15,00 0.00 32.25 32.25 - ,00 REVENUE DIVISION TOTALS--> COLLECTED- 32.25 OVER/SHORT: BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SHIP/TOT GRADING PLAN -CHECK 32,25 lE lE lE lF lF lF lF lFiE iFlE iFlFiFlFlF lF lF lF lFiF iF lF lF lF lF lF lE lF lF lF lF iF iF iF iF iF lF iF iFltiF iF iF iFlF lF lFlF It lF lFlF iF lF lF iF iF lF lF iF lF lF lF lF lF lF iF iF iFiFiF lF lF iF /Flt lF iF I N D I V I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST ELE 9 ELE 8 FIXTURES LIGHTING 1 ST 20 RECEPT/OOTLET 1 ST 20 EA, 75 EA, :75 6; 75 00 ELE 2 RECEPT/SWITCH 1 ST 20 EA. .75 1.50 ELE 1 SIGN/ADDTN'L BR CIRC WITHIN SAME EA, 3.00 3,00 END OF FEES j CONSTRUCTION AND PLANNING X POOL PA APPROVALS Permit Date Inspector APPROVALS Permit Date Inspector is Temporary Electrical Serve or Pone., 52. Pool & Equipment Location 2. Soil Pipe-Undr rnd. - d 53. Steel Reinforcement r �. .�nn ,13 �ac�Firal Gonddi,Aility �Undrgrnj1+`` 54. Forms w 4. Eidsrrieal Conctuir,.L idr9mcl, a..::) 55. Electrical Bonding tor�17XW 4inforceaW4 " 56. Rough Plumbing & Pressure Test 5 :� ctr3tal UFE�•Grnd. c 57. APPROVAL TO COVER-GUNITE Q ootims n,; 58. Electrical Conduit-Undrgrnd. y oundation 59. Gas Pipe, ❑ Undrgrnd., Test V g, Water Pipe-Ung grnd, 60. Backwash Lines, P•Trap, ❑ Undrgrnd. 1;0Structural Floor System 61. APPROVAL TO DECK 1.1'. Property Sewer Lirtm& Horse Conrmction 62, Backwash & Receptor-Final 12, Sewer Cap 63. Heater & Vent-Final j 13. Roof Drains +� w 64, Plumbing System • Final 14. Rough Plumbing - 65. Electrical-Final 15. hough Electrical-Conduit 66. Solar System-Final 16. Rough Electric--Wiring 67. Fencing & Access Approval x,17, Rough Wiring Sig_9 68. APPROVED FOR PLASTERING 1-18. Rough Electrid;C Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROpVA� -, oCPe it #_1 ,� - 20?Rou h F3ct6l±y Faeplace I M!r] <^i Y C n S �. -* : S' r tr. �' S p• x x r x F, .' rr, r=1 j . r 21 f Dins, ir,►tStr�ctu . .. ,5 w -+t :70. de�gro6ttH'dro # 22. Dins, 1?aintiSatiri =71. ProdlJd -i[�g Q3 s C3+`Oil x 2 3:�'r, a;Tipj59 h V.lest ,�, `.;c 172. Under'roVd FEus�j x g 24?Aoo1 Frring x .-'� •�-° x > C. 7 73J UndergrnT.Storgr� ank.p Gas ❑ Gii" 25. Rogf SGddathing z'V11* r: '` z y, '74; Overhead �101_001E' 26:eT-€lar Ceiling (StFZatural) &!90enecoat x U r,r 750 Dry Chemical � 27 rame and Flash 3, X 76. Dry Stan x-28. Lathing.• Sidingi;� Zx * r '� 777 FIXED 4Y,'fE -- r. ->29. InsuIatlon -Kr ' 7QFIRE PREV. FIIIIA->L_ � :Y O, Drywall_ Nailing r - HE-A LTH-DEPTx R-EO :41REWTEN X31. Plaster o p. Co" 3 P-ECTI4W. 5 Y .79�-FINALlliI E-32.Electriog'j Pourer NieterfFinali r 180.1:FOOD CERTIFLCAT+E ISSUED .33,:9:i6@ EleetriC .r m I d 2 "` YNc� es �T• c� �� :r x C�34i Final Hegting-& Ai&Conditioritng; �` .r . u * rt •t' •� t^ S C7 '.J • � 1 Y ► .-•1 u Gas Pi�e•Test'' x ~ rive, 0 _,35..TFinat :r36.rHodd ohCanopy�i I �^"' a. `, ^ -{37 7-FiniR Fa_etory FiiAI ai , 5 L! V :r f.. - _�z C__ C) r! 9[ I6 IJ •Firkaj `_38. Pi`WMbing �_ .. w y •u [m9. Water Service- Fiaa 1-11 IM M.', ^ .�#0. Gas Service-Fina +e r �.i' �? r . F ' Q er ` t t ? i41. Solar Domestic-EIIal% r•• x =s <CA �- _42.`-8ackf ovv Preventei 43. Backflow Irr�yatidrE »'� = •L 4. Landscape {rrigafiop Systemti r,n x , ., :" x xtl, 745.^Sound Atteduation' T .' - " - -' = '� 546.landicap Regulations ; ,, ••` _ x 47�F1 SAL STRUCTURE & BADING ILK ri -j S 48_':FIN_AL PLANNING r CJ x ,r r! +rl c_49_*Elegtric Release to�Edison X + y X50. Gas Release to Sou77 ern California Gas Coy r n _511. CERTiMATE 0 *OCCUPANCY r t� � rr X 1_>';0 No. Date .40JEC'-AI? RESS: 3333 BRISTOL ST OWNER'S NAME: C J SEGERSTROM 6 SONS ADDRESS: 3 5 B FAIRVIEW RD COSTA MESA CA 92626 ARCHIENGlNEER: (714)546-0110 ADDRESS: REG.ND.: UNIT: 2887 UNIT: PERMITTEE: C JT SEGERSTROM (714)546-0110 ADDRESS: M5 FAIRVIEW RD COSTA MESA CA 92627 LICENSED CONTRACTOR DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 {commencing with Section 7000► of Division 3 al the Business and Professions Code, and my license is in full force and effect. CITY LIC.: STATE LIC.: CLASS: Date: — Signature: WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to selb4n5ure or a certificate of Workers' Compensation Insurance. or a Certdied copy thereof (Section 3800, Lab, C). POLICY NO.: EXP. DATE: COMPANY: ❑ Certified copy is hereby lumished, ❑ Certified copy is liled with the city Building Division. Date: AppeCant: EXEMPTION FROM WORKERS' COMPENSATION DECLARATION; (This section medAl W Complet t is for one 1$100) or less). I certily that in the performance of the work for which this permit is is all not e y a so n arty so as to become subject to [he Wdrke 'Cpm ensa[ion Laws of California. .47 Date: 4 r Signature, TICE: It, atter making this declaration. you should become subject to the Workers' Compertea ion vistarm of the Labor Code. you must Iothm[h comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued {Section 3097. Civ. C). LENDER: ADDRESS: OWNER BUILDER DECLARATIDN: I hereby affirm that I am exempt Irom the Contractors' State license Law for the following reason (Section 7031.5 Business and Professional Code: Any city of county which requires a permit to construct. alter, improve, demolish, or repair any structure, prior to its issuance. also requires the applicant for such permit to file a signed statement that helshe is licensed pursuant to the provisions o1 the Contractors' State License Law (Chapter 9 {commencing with Section 7000) of Division 3 of the Business and Professions Code) or that helshe is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of not more than five hundred dollars (SSW). 1. as owner Of the property or my employees with wages as their sate compensation. will do the work, and the ❑ structure is not intended or offered for sale (Section 7044, Business and Professional Code: The Contractors' State License Law does not apply to an owner of a property who builds or improves thereon, and who does such work himselflherself or through his or her own Omployees, provided that such improvements are not intended or offered for sale. If. however the building or improvement is Sold within one year of completion, the owner will have the burden of proving helshe did not build or improve for the purpose of sale). 1, as owner of the property. am exclusively contracting with licensed contractors to construct the project SSection 7044, Business ® and Profession Cade: The Contractors' State License Law does not apply to an owner at Properly who bwlds or improve on and who Contracts for such projects with a contractorls) license pursuant to the Contractors' Stal License La - am awa that proof of their Worker's Compensation insurance should be provided to me. ❑ I am exempt under Section: B. 3 P, C. for iris reason: Dale: ��' Z Owner: 1 do hereby certify that I am aware of and understand the requirements of Calitornia,Health and Salety Code Sections 2 505, 25533, and 25534 and that I or any luture building occupant will/will not (circle one) need to comply with said state codes and the requirements for a permit lot construction qr moddicalion Irom the Air Ouahly Management District. ResideMiat construction applications are exempt from these provisions. Date: — Applicant: I hereby cerldy that I have read this application and state that the above intor i s edrreet. I agree [ Compty with a6 a county ordinances and sate law; relating so building construction and hereby author' r nlalive5 of tenter the ntionea progeny for inspection purposes. —Date:Signature: Driver's License or Social Security a 1641.46 Whnn--Building: Green—.Cade Enforcement: Canary—Applicant: Pink—Revenue; Goldenrod—Assessor CITY OF COSTA MESA - BUILDING PERMIT PERMIT NO: E 060263 PLAN CHECK NO: N CONSTRUCTION TYPE: PERMIT TYPE: ELE JOB DESCRIPTION : INSTALL EXPRESSO BAR COUNTER CLAIM VALUE: CALC-VALUE: PERM NO: E 06026 GOVT: N SUPP: N PURPOSE; OTH SQ FT: GROUP OCC: B-2 / COMMENTS: RE: B60179 Z O N I N G S E T B A C K S R E Q U I R E M E N T S ------------ MAIN BUILDING ---------- -------- ACCESSORY BUILDING - FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN PARKING REQ• PROV: PARCEL: 41250102 ZNE: REF NO: PLANNING N TES> > if���Atdt��t*flit+)E,)E,1F��t�*�*'1F�E3t�tiF�t�titit**!f*1tit�,7t�tit*trtititlf*itiE9t*�F�irt*trtitlt9t9E3Eitlt�iE*��**,1E,at,7t��t*ttltdtitlt D E V E L O P M E N T S E R V I C E S R E Q U I R E M E N T S ZONING APPROVED BY DATE: BUILDING APPROVED BY of A 09 DATE: APPLICATION ISSUED BY: DATE: /-2 it �! it it?If �F1t 1It � �! iE 11ElF * it'll ♦� 1tlE * * � �E,tt * 9t it �t it * it * it 9t �t�F�FlflE****i!'1E9E�E�EjEif**�t1F�E�F9E9E�F**1E�1�t,7Fi7f>IFAI�f�FlEiFiFi[•*iE*�F*!i`�!,7FiEr1(It*�F�F1I�E*��E9E9E�lAE*iE,tE***�jE9FiEAE'IE�E� LEGALIZATION:N F E E S U M M A R Y STRUCTURAL SEGMENT;N BLDG PMT PLUMBING ELE1TRICC MECHANIC FIRE SMTP/RES GRADING PERMIT 1 0 tot SMTP/NON-RES PLAN ISSUE FEE 15.00 BUILDING -DIV-> PERMIT ISSUE PLAN -CHECK TOTAL PAID DUE TOTALS ---- > 11,00 15.00 0.00 26.00 26,00 .00 REVENUE DIVISION TOTALS—> COLLECTED: 26,00 OVER/SHORT: .00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN -CHECK 26.00 I N D I V I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST ELE 1 SUB -PANEL END OF FEES 11.00 11.00 ', CONSTRUCTION AND PLANNING POO L PQ. LDateAPPROVALS Permit # Date Inspector APPROVALS Permit # 'inspector 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location 2. Soil Pipe- Undrgrrnd. 53, Steel Reinforcement 3 �rel`ral Co ndidilrlity•Undrgrnd. 54. Forms .:4. E16assiaal Conduit•UCidrgrnd. 55. Electrical Bonding rT., A - �`Sttii inforce?ni.- 56. Rough Plumbing & Pressure Test - ,_$'�ctrtral UF9'R' 57. APPROVAL TO COVER-GUNITE r_ n* r D.�Foatir�s -, 58. Electrical Conduit-Uncirgrrid. 1 N tEoandation � r- 59. Gas Pipe, 0 Undrgrnd., Test s. _ 9? Water Pipe-Undrgrnd. 60. Backwash Lines, P -Trap, ❑ Undrgrnd. 1D` Structural Floor System 61. APPROVAL TO DECK 1Y} Property Sewer Lines& House Connection 62, Backwash & Receptor -Final 12. Sewer Cap y 63. Heater & Vent -Final + 13. Roof Drains 64. Plumbing System • Fina! f 14. Rough Plumbing 65. Electrical -Final 15. Rough ElectricLConduit '" 66. Solar System -Final 16. Rough Electric;tiring 67. Fencing & Access Approval x'47, Rough Wiring Sin 68. APPROVED FOS PLASTERING}' L'18. Rough Electricjj-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL,, 19, Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT PPRlv&d 20.E OC h FIttor F -late x'X: �' - x V Tr ' 21.h`Uuets, i�rl$tr�zcturp .... _y < . may. r .7.gror-+ . O, UmderW`id:Hy-dra 22. DucM, ntil8ting-= :5S Y _ 5Qx ' 1. Product i bg Gr+os +! ibt x -^7 23.(�as 'ipp iou�h 6`fest T x M 's Ox x -72. Under9 otind Flus`�T-, e 24.ARoa Framing- :Y �- 5- •: * > C; Y S73' StorV.EZ7ank F�`7 Gas © Oil _ ,jndergrncT' oo 25. Roof, Sheathing'74„Overhead Hydro 26..=T-Bat Ceiling (SIZE ural) &:Monocoat 75•-y emr Chi al -n ,� - - x 27.,Irame and Flash- 76: Dry Standpipe r•� ,- i `_' 8. Lath4& Siding K rr -:,,C . x S * ¢ 77 � F1XED S.tgEA11,,NAL;ic '29. lnsulatiZ�i . s Ll 78 . . a. 4}'30. Drywall Nailing 4 x - HEALTI EPT.=FhEQl�1REMEIVT w r -1, , r C-31. Plaster �owP.Coatx ! -n, � ? -FINAL lNjgtCTI' _ T79.' x'32. ,ElectricAPotter MetefFinal V v .r6G..rFOOD CERTIFICAT-9 ISSUED� 33.:�in` E*tric, �rNoTes;. Netting; AircConditionrr�g r x 35. Final Gas Pip Test" w x C T Z1 a, U0 `Ts `'' s V ^D .r _ .R C7 1'. 3 L x36.'HoO o" -Canopy �7.inat Faetary Firepce�:r * •r * - '�' _ _ �. .... =.38. Final Plumbing x -. Y �_• IN x - - - C'.39. Wares' Service -Final ; t� x -1:=1 -1 X �40. Gas Service -Final t rr * 0_ - _Solar Solar Domestic•Finai ti '' K Cs x `_ c -- = a: x� '42.�ackflow Preventerx 'a -'' _ _ 43. Backflow Irr;gation'= ._ XS S X14. Landscape IFfrgation Systemr1r-) trz x: ,;I C, x nj y `yn '745.1110sound Atteaatiorr, '-a ='''a w ;Flandicap R 11ati rs y Y r .' x •� 1 ,c ;* 47.,TFINAL STRUCTURE & BUILDING f - 48.7FIN-4LPLANNINGF z-_49.-,-Eleotric Release to fsdison Y t .f X K V. 0. Gas -Release to Sout&rn California Gas Co x -- r -• ,_51. CERTIFICATE OF,OCCUPANCY No. Date PROJECT AbDRESS: 3333 BRISTOL ST OWNER'S NAME: C J. - SEGERSTROM & SONS ADDRESS: 3 � 1 S FAIRVIEW RD COSTA MESA CA 92626 (714)546-0110 ARCHIENGINEER: ADDRESS: UNIT: 2 8 8 7 Y35 - Will 3 m 1ly�- REG.NO. UNIT: PERMITTEE: C. J. SEGERSTROM (714)546-0110 ADDRESS: 3315 FAIRVIEW RD COSTA MESA CA 92627 LICENSED CONTRACTOR DECLARATION: I hereby affirm that I am licensed under provisions at Chapter 9 {commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. CITY LIC.: STATE LIC.: CLASS: Date: Signature: WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure or a certificate at Workers' Compensation Insurance. or a certdied copy thereof (Section 3800, Lab. C). POLICY NO.: EXP. DATE: COMPANY: Certified copy is hereby furnished. © Certified copy is filed with the city Building Division. Date: Applicant: EXEMPTION FROM WORKERS' COMPENSATION DECLARATION: (ibis section need not po<rtpteted i1 me per is for ane hu ($1 or less). I certify that in the performance of the work for which this permit is issue . h not empll n i any m so o become subject to the Workers' Compens on Laws of California. C`J� Date, Signature: e NOTICE: II, after making this declaration, you should became subject to the Workers' Compensation provisin s of the Labor Code. you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Section 3097, Civ. C). LENDER: ADDRESS: OWNER BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractors' State License Law for the tonowing reason (Section 7031.5 Business and Professional Code: Any city of coumy which requires a permit to construct, alter, improve, demolish, or repair any structure. prior to its issuance, also requires the applicant for such permil to file a signed Statement that helsho is licensed pursuant to the provisions a1 the Contractors' State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he/she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 70.31.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (5500). L as owner of the property or my employees with wages as their Solo compensation, will do the work, and the ❑ structure is not intended or offered for sale (Section 7044, Business and Professional Code: The Contractors' Stale License Law does not apply to an owner of a property who builds or improves thereon, and who does such work himself/herself or Ihrough his or her awn employees, provided that such improvements are not intended or offered lot sale. If, however the building or improvement is said within one year of completion, the owner will have the burden of proving he/she did not build or improve for the purpose of sale). I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sectio u ss ® and PrDlessbrts Code: The Contractors' State Lici= Law does not apply to an owner of property who builds o mproves there and who contracts for such projects with a contraclor(s) license pursuant to the Contractors' State Licens Law). I am awa that proof of their Worker's Compensation insurance should be provided to me. ❑ I am exempt under Section: B. d P. C. for this reason: n Date: e�i Ji — / V Owner: I do hereby certify that I am aware of and understand the requirements of Caktarnia,Health and Safety Code Sections 25505, 25533, and 25534 and that I or any future building occupant will not (circle one) need to comply with said state codes and the requirements for a permit for construction or meddication from the An Duality Management District. Residential construction applications are exempt from these provisions. Date: Applicant: I hereby certify that I have read this application and state that the above ordinances and State laws relaung to budding construWan and hereby aulh properly for inspection urease Date: Signature: Driver's License or Social Security #: is correcti-comply with 9K and 1641.46 White—Eluildinq: Green—Code Enlorcement: Canary—Aoolicanr: Pink—Revenue: Goldenrod—Assessnr CITY OF COSTA MESA - BUILDING PERMIT PERM NO: E 06025 PERMIT NO: E 060262 PLAN CHECK NO: N GOVT; N SUPP: N CONSTRUCTION TYPE; PERMIT TYPE; ELE PURPOSE: OTH JOB DESCRIPTION : METER SECTION IN SECURITY CORRIDOR SQ FT: CLAIM VALUE: CALC-VALUE; GROUP OCC; B-2 / COMMENTS: LOCATED BEHIND THE "DISNEY" STORE. Z O N I N GS ERTEBQAUCIKRSE M E N T S ------------ MAIN BUILDING ---------r- --------- ACCESSORY BUILDING--------- FRNT: FT IN REAR; FT IN - FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT; FT IN AGHT: FT IN PARKING REQ: PROV: PARCEL: 41250102 ZNE; REF NO: PLANNING NOTES> > iEiE9t*TEiE*1E9E*�jF�iiiEiE�E�E���*�iEitIEIti[******if**iF*�it�*if itit�*lE*�**�t•it�lFlE*!t !f***�ti6��**if***1E�iE�9E D E V E L O P M E N T S E'R V I C E S R E Q U I R E M E N T S ZONING APPROVED BY DATE: BUILDING APPROVED BY DATE: APPLICATION ISSUED B�z DATE: S- lE 1EiEiEiElEiE9E�EiE�E�ElElfiFiE�E�ElE!! '1F tt?IEYitit�Eit!!*Xt ** 1l�F9FiF9F�F1E1F�19!!!�E*�iF1E�llF9F�Fa1F**iEil�klf�t�F�FlE�1F�F�tiE�FlFifiE�FiF1fr if�t�liE�l9liE�Eit•if�ikl6�Flt�FiEiFiF�F*�EIEIElE'1E�E��F�i6it� LEGALIZATION:N F E E S U M M A R Y STRUCTURAL SEGMENT:N BLDG PMT.' PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT 18,50 PLAN }1 501 SMIP/NON-RES ISSUE FEE 15.00 ~� BUILDING -DIV-> PERMIT. ISSUE PLAN -CHECK TOTAL PAID TOTALS ---- > 18.150 15.00 0.00 33,50 33.50 .00 REVENUE DIVISION TOTALS--> COLLECTED: 33.50 OVER/SHORT: ,00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN -CHECK 33.50 iElElfll• � XE * iElF 1E !F ![•!E �[•!I!t!E!E!! 9Elf �E �E 1t * * � * * !t!t !t 9f'1f 9t Ak 9E TE iE T! iFlE iE 1F * �! TF � * *iE 1! iE if � �! �F 1FiF � � * if !t if iF�liF * it it * *!f TF if 1! 1t .I N D IN I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST ELE 1 SERVICES BELOW 600ENDSOFELOW 201 AMP 18.50 18.50 CONSTRUCTION AND PLANNING POO, ..+ SP� APPROVALS Permit # Date Inspector APPROVALS Permit # Date Inspector 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location 2.� Soil Pipe-Undrprnd� 53. Steel Reinforcement a."rJ_Aci�hical Conddit- Oility-Undrgrnd. 54. Forms a . Conduit-Ondrgrnd. 55. Electrical Bonding tEtaetrical `eieiniorcea 56. Rough Plumbing & Pressure Test '3 r- �**ctoQal UFER GF -Ad. 57. APPROVAL TO COVER-GUNITE ;Z,00tiri�s '' 58. Electrical Conduit-Undrgrnd. .0ZE;Eoundation �j 59. Gas Pipe, 0 Undrgrnd., Test 9. Water Pipe-Undr6rnd, 60. Backwash Lines, P•Trap, 0 Undrgrnd. 10, Structural Floor System 61. APPROVAL TO DECK 1•X Property Sewer Ling`& House Connection 62. Backwash & Receptor•Final ti 12. Sewer Cap 63. Heater & Vent -Final 13. Roof Drains 64. Plumbing System.- Final r 14. Rough_PlumbiLrg 65. Electrical -Final 15. Rough Electrical -Conduit 66. Solar System -Final 16. Baugh flectricdiViring 67. Fencing & Access Approval 7. Rough Wiring Ssgn 68, APPROVED FOR PL'f1STERING - '18. Rough ElectrigJ-T Bar Ceiling 69. POOL/SPA SYSTEMS1FI.NAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT tr ts• - cc i- J, �. rAPPRDVA .5,WCPerTAit # ? 20.`rRo@h 2ctorV Fireplace t M7. 0 Lr T- :it 21:':puCtsI in- tri A_ � •• .�S , r av, i -,x X70. ndergpoltiicLHybiro a T 22 Ducts, ntiiatirig+ t �S d * x •71. Produc r pTo CSs IS]il tr 23!,�a Pip�lo h 8i est M �-• � �� � tT1S q � tTJ ('* } Q O � �� :72, Under ro d Flus n E' g � %:. E 24t*Ro� Framing 6Y + i •i"' '4F-' -* > -7' i 73xUndergrnT.. Storg - ank �] Gas• 0011 1-4 �# .. 25. Roaf Sh ithin9 �ZK `� j x Overhead 26-54ar Ceiling (Structural) &$honocoat r ] Y 75*%Dry Chemical - " 27!, rame apd FlashI" x ;' -o 1K 76: DiySint; ae OX * 5 T] .. SSA .max x :� ,• 7 `.-�8. Lathing:& Siding!- -r, ""Z%5x 77 FIXED $Y E aiNAL' Fro I've--� C -4 n r InsulatiChY 78QFIRE PREV. FIMI,�L :. 30. Drywall'�Nailing x�' � f ,c t- HEALTHrDEPT'�REQUIR"VIENT r-31. Plaster �rowra CQat� * �` 799FINAL IARLCTI(,'fV'.- . ,. s �� * - 7Y -32.-_Electricaa Poorer M�;; :sterrFinal� _� ti� r60,•".FOOD CERTIFrC ISSUED r. 33 in El(ctri, 5x i a *; a ;� u ; �34a FinjR Hefting;& Airt;Conditioni` g_ r = -' k �".v X `35 .j, jirfai G's Pipe-T6t' r 'j x t; 'K ove or til ; X tr .=36. Hoa o&anopy i t a f. 5 w S_ f` .r ti t f` _37.Q:in9l Factory Firelpla1~e ' S.r r ` `t x .y -r Final Plumbing t +, i .. , •-4 a. � � � + _� ac o 4-39. Watelr Service -Final= jr J1 .; 0. Gas Servtce-Final - �41. Solar Domestic -Final i, •- r C� * �' ". 42 `Backflow Preventers + Y ' " �' ; r r ) 43. Backflow Irrbatioa 4. ;44. Landscape Ir-iiqati@nSysterpm rt ;, r r :e 5round Attenuation' -.x:. '� t� } r- -+ .. x N. 6.''Handicap•R'uiatic[ps r •.Y K S _ r 47 ,,_,F4'AL STRUCTURE & BLADING ti - a' x 48:"�INAL PLANNING' i '� r, * F i ; ;u -49_�Eleotric Release to>Edison �c r 0.,Ga -Release to Sou(hern Calft; orla Gas Co •_ j;f c. t. CERTIFICATE OFACCUPANCY , _ No. Date PROJECT ADDRESS: 3333 BRISTOL ST UNIT: 2 8 8 7 OWNER'S NAME: C J SEGEASTROM ADDRESS: 3 315 FA I RV I EW RD C.H. ARCHIENGINEER: REG.NO.: ADDRESS: UNIT: PERMITTEE: HILLCREST PLUMBING (714)354-0449 ADDRESS: 2900 ADAMS B-5 RIVERSIDE CA 92504 LICENSED CONTRACTOR DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7%) of Division 3 of the Business and Professions Code, and my license is in full lo:ce and effect. CITY LIC.: STATE STATE LIC.:609 310 CLASS: C 6 Date: /Z- 6 Signature: —,zker -- WORKER$' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent [ I -insure or a certificate of Workers' Compensation fns ra rc�y 9{ C�JSJ c py thereof (Section 3800. Lab. 1 POLICY RO.:W8PLL�Il�W EXP. DATE: 7/01/93 COMPANY: GREAT AMERICAN J Certified copy is hereby furnished. IN Certified copy is fiilled_%Wh the city Building Division. Date: Applicant: EXEMPTION FROM WORKERS' COMPENSATION DECLARATION: (This section need not be completed it the perfs for one hundred (S100) or less). I certify that in the performance of the work for which this permit is issued, I shall not employ any person ih any manner so as to become subject to the Workers' Compensation Laws of California. Date: Signature: NOTICE: If, after making this declaration, you should become subject to the Workers' Compensation provisions of the Labor Code. you must forthwith comply with such provisions or this permit shall be deemed revoked. 4' CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the'perlormance of the work for which this permit is issued (Section 3097, Civ. C). LENDER: ADDRESS: OWNER BUELGER DECLARATION: I hereby affirm that i am exempt from the Contractors' State License Law for the foltowing reason (Section 7031.5 Business and Professional Code: Any city of county which requires a permit to construct. alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he/she is licensed pursuant to the provisions of the Contractors' State License Law (Chapter 9 (commencing with Section 7000) of Division 3 at the Business and Professions Code) or that he/she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (S500►. i, as owner of the property or my employees with wages as their sote compensation, will do the work, and the ❑ structure is not intended or offered for sale (Section 7044, Business and Professional Code: The Contractors' State License Law does not apply to an owner of a properly who builds or improves thereon, and who does such work himself/herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however the building or improvement is sold within one year of completion, the owner will have the burden of proving he/she did not build of improve for the purpose of sale). I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Section 7044, Business ❑ and Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon and who contracts for such projects with a contractor(s) license pursuant to the Contractors' State License Law). I am aware that proof of their Worker's Compensation insurance should be provided to me. © I am exempt under Section: B. S P. C. for this reason: Date: Owner I do hereby certify that I am aware of and understand the requirements of Catifornia,Health and Safety Code Sections 25505, 25533, and 25534 and that I or any future building occupant will/will not (circie one) need to comply with said state codes and the requirements for a permit for construction or mod3icalion from the Air Quality Management District. Residential construction applications are exempt from these provisions. Date: Applicant: I hereby certily that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction and hereby authorize representatives of this city to enter upon the above-mentioned properly [or inspection purposes. Date./ 2 / ?— Signature:— Driver's License or Social Security M 1641-46 Whilo—Bu4dinq: Green --Code Enforcement Canary—Aoolicant', Pink—Revenue: Goldenrod—Assessor CITY OF COSTA MESA - BUILDING PERMIT PERMIT NO: P 060216 PLAN CHECK NO: N CONSTRUCTION TYPE: PERMIT TYPE: PLU JOB DESCRIPTION : INSTALL.EXPRESSO BAR COUNTER, #B60179 CLAIM VALUE: CALC-VALUE: PERM NO: P 06021 GOVT: N SUPP: N PURPOSE: ALT SQ FT: GROUP OCC: B-2 / COMMENTS: ANTONELLO'S ESPRESSO BAR TO REPLACE AMATO'S CAFE Z O N I N G S E T B A C K S R E Q U I R E M E N T S ------------ MAIN BUILDING ---------- --------- ACCESSORY BUILDING---------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RIGHT: FT IN LEFT: FT IN RIGHT: FT IN PARKING REQ: PROV: PARCEL: 00000000 ZNE: REF NO: PLANNING NOTES> 1 WASH BASIN > 1 WATER HEATER AND/OR VENT �F�tit�*itititit*�t**�!*lE�t*At�t�t*lEiEiE�lEiE�**,jE*ib At*�*>rt�!*���E1k��ItiE*�Ei6*1EiEiEiEiFif�E1E�**�**�iFiEiElF�t*iF*iflE�iF D E V E L O P M E N T S E R V I C E S;?' R E Q U I R E M E N T S ZONING APPROVED BY 'END OF FEES DATE: BUILDING APPROVED BY : v DATE: APPLICATION ISSUED BY:--:ir !r DATE: Z LEGALIZATION:N F E E S U M M A R Y STRUCTURAL SEGMENT:N BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT 28 00 SMIP/NON-RES PLAN r ISSUE FEE 20.00 BUILDING -DIV-> PERMIT ISSUE PLAN;CHECK TOTAL PAID DUE TOTALS----> 28.00 20.00 0.00 48,00 48.00 .00 REVENUE DIVISION TOTALS--> COLLECTED: 48.00 OVER/SHORT: ,00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN -CHECK 48,00 �EiilE9l�E�l1E�F�Eii�fif*�t�IFit•iF�kiE�iE�l��lil9!*�iE9F,tiE�E�E*�E�il�!*dFiE1l�Ell1E�t**�tiEl6iliF9E*�tiE�F�k*�Eitit��t�EiE�E9FiEiEiE9E�E9E1F?al�E�F I N D I V I D U A L' F E E B R E A K D O W N TYPE QTY D E S C R I P T I O,N, UNIT COST TOTAL COST PLU 1 SINK, KITCHEN PLU 1 WASH BASIN PLU 1 WATER HEATER AND/OR VENT PLU 1 SINKS, FLOOR 'END OF FEES v !r 700 7.. 00 7.00 7.00 7,00 7.00 7.00 7.00 CONSTRUCTION AND PLANNING POOL &SPA APPROVALS Permit # Date Inspector APPROVALS Permit .+ Date Inspector 1. Temporary Electrical Service or Pot4 0 52. Pool & Equipment Location Pipe-U,cl rnd. rs tT] 53. Steel Reinforcement . < 3.`�ctrical Condik-t,Wlity-Undrgrn'. 514. Forms �'4. Electrical CondUt drgrnd. 55. Electrical Bonding !� i 1,rn zi �� '`:S Steel ReinforcerF�et 56. Rough Plumbing &Pressure Test ,- .•�Electrical UFERFrnd. o 57. APPROVAL TO COVER-GUNITE . _, ootings ry' 58. Electrical Conduit-Undrgrnd. n M. N t_'iFound a tion ' ' 59. Gas Pipe, C Undrgrnd., Test r- f 9. Water Pipe-UndF rnd. 60. Backwash Lines, P -Trap, 0 Undrgrnd, 10. Structural Floor System 61. APPROVAL TO HECK 11. Property Sewer Lir)& Hc4'use Conr%ction 62. Backwash & Receptor -Final 12. Sewer Capa, o C , 63. Heater & Vent -Final 13. Roof Drains 64. Plumbing System - Final 14. Rough Plumbing " j2;, Z.L4D 65. Electrical -Final 15, Rough Electrical -Conduit 66. Solar System -Final 16. Rough Electri tWiring 67. Fencing & Access Approval X17. Rough Wiring 5j4p M 68. APPROVED FOR PLASTERING 118. Rough Electri,41-T Bar Ceiling 69, POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT - tr tar � W W x Y tr PPR1°3VA 5!=� 'er it # > ., 20xrRo9h Qctd' F eplace i 3Z*i�: <-1 j �: Cw u .k w 3J 1. I S rr , < S r -i Cr' k X. r��"7 ►.+ V �� yl . �: H C-` >'te _171 J 21. i3uct$, iT;Sti�IctuPegz i r ... S ; �-i � x IT wle_i 164 -+70. L3ndergrotb Hydro x `•• 22. tau ,Vent€tatin -� 4 Producl_ +9 G•l�s CPOii {71. r' 23.;Ga0ip�Ro�h &'test Or aac x - Undergro'riO Flush-,+, '�15 cr e v�; , ,72. 24rRooi Framirn3 S- > 0 0- 73ttrUndergrnd' Stor i ank TJ Gas D OI"" l � 25. Road �x Sit athing • 74 IydraJ S * d v x c7 > xx * ,,Overhead x 26seT-Bat Ceiling (Struotura€) &W. ortecoat CII t• Mx 'r' 75UDry Chemical Y '-+ v ^0 27r'Frame a4d FlashP S ' 76:�Dr Stan�dn Ae Gam" � -S 11 S11- 'S --28"Lathing Siding7- r. x X •* 77?" FIXED ELYg1ENJ�AAL* to InsulaticSa; w x 1 7$z ARE PQEV. FI T30. Drywall Nailing 7;a A *' r�V-u-HEALTHrDEPT-: R-EQUIRIEMEA1'>= � • rt r rn rr! Q31. Plaster Eiown Ca_ 'S n k * P CTI(N ,r it r79"'i�IVyAL�4€ T < ;J32LElectricat Powe,�Mezet:Finall * :v _ .80.r1OOD CERTIFLOATE ISSUED 33iEtri*� x `` y `'Ncs s: '� tom.. • ' . t-! ow t•. :54,-F-4 Hftti,4& ,4 %, opditign s t', ... - . �� x !+ * '�"""""" . l c , _ W 35•Tin t Gas Pipe T'"t ~ n n I"� .5 to S �' ai �_'• A l 4 C__ r �,365lood o4tC' anopyj.n e ;rte a .Z •: _ ;� :�o [r' .,, re, :�37 CFirrfl Factory Fir€ ace^ I S lr --38. Find Plijtnbing tx ^i'U t C�39. Water Service-Final, 0. Gas Ser'vibe-Final" T KL . ^; .., ;:o;, G V x Z41. Solar Domestic -Finals .� �' h 6• � r Q rJ K.• � rj �_42.'tiackflo5j Preven 43. Backflow Iri atiorr' * T�44. Landscape I rigati* System CIOritr} D, J s3 -t * a _ i; ; ;:tT. w: v 00 n .. A5''S.ound Att# uation7 t:Zc i" x ,"C? 'T'i a: X �' z' • �` '` ` ••� x 6 Handicap Regulations 47,-,F I NA L STR-UCTURE & BUI7L.DING ' N 'S x X _ 48.. If AL PLANNING `� r ^, x .r7 L• c. 1_49,; I,.g'tric Release to -Edison r x x .c x is r x -SGas�Retease to Sou here Catilp?q* Gas Co ,$,0 ,51. CEKTIFICATE O „;OCCUPANT s No. Date _ ri a _I 'ERIiECTRODRES& 3333 BRISTOL ST OWNER'S NAME: C J SEGERSTROM ADDRESS: 3315 FAIRVIEW RD C.M. ARCHIENGINEER: ADDRESS: UNIT: 2887 Dl_ (06 Z_/200 REG.NO.: UNIT: PERMITTEE: REUTERS GEN CONTRACTING (714)251-0181 ADDRESS: 2698 WHITE RD 100 IRVINE CA 92714 LICENSED CONTRACTOR DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Dmsion 3 of the Business and Professions Code. and my license is in full force and effect. CITY LIC.:054 368 STATE UC -:58 4 836 CLASS: B /07 JA, Date: _ 12 ) 0 ;,D Signature: WORKERS' COMPENSATION DECLARATION: I hereby alfirm that I have a certificat onsenl to self -insure or a certi irate of Workers' Compensation Ins rance. or a c rlifi py thereof (Section M. Lab. POLICY NO.: 1 �l 0070 — 7 L EXP. DATE: 7/ 0 1/ 13 3 COMPANY: STATE I Certified copy is hereby tumished. IN Certified copy is filed with the city Buildin Oivisi Date: h9 ) 0 11 2 Applicant: EXEMPTION FROM WDRXERS' COMPENSATION DECLARATION: (Thus sectim need not be if the PwM is Wr one hundred ($100) or less). I certily that in the performance of the work for which this permit is issued. I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California. Date: Signature: NOTICE: If. after making this declaration, you should become subject to the Workers' Compensation provisions al the Labor Code. you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Section 3D97, Civ. C). LENDER: ADDRESS: OWNER BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractors' State License Law for the following reason (Section 7D31.5 Business and Professional Code: Any city of county which requires a permit to construct, atter, improve, demolish, or repair any structure. prior to its issuance, also requires the applicant for such permit to file a signed statement that he/she is licensed pursuant to the provisions o1 the Contractors' State License Law (Chapter 9 (commencing with Section 7DOO) of Division 3 of the Business and Professions Cade) of [hat helShe is exempt therefrom and the basis lot the alleged exemption, Any violation of Section 7031.5 by any appticant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (5500). I. as owner of the property of my employees with wages as their sole compensation, will do the work, and the ❑ structure is not intended or offered for sale (Section 7044, Business and Professional Code: The Contractors' State License Law does not apply to an owner of a property who builds or improves thereon, and who does such work himselflhersell or through his or her own employees, provided that such improvements are not intended or offered for sale. '.however the building or improvement is sold within one year at completion• the owner will have the burden at proving he/she did not build or improve for the purpose of sale). ❑ I, as owner Of the property, am exclusively contracting with licensed contractors to construct the project (Section 7044, Business and Professions Code: The Contractors' State License Law dries not appy to an owner of property who builds or improves thereon and who contracts for such projects with a contraclor(s) dcense pursuant to the Contractors' State License Law), I am aware that proof of their Worker's Compensation insurance should be provided to me. El I am exempt under Section; B, E P. C. for this reason: Date: Owner: I do hereby certily that I am aware of and understand the requirements of Calilomia Health and Salety Code Sections 25505, 25533, and 25534 and that I or any future building Occupant willlwill not (circle one) need to comply with said state codes and the requirements for a permit for construction or modification from the Airlily Management District. Residential construction applications are exempt from these provisions. Date: Applicant: I hereby certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction and hereby authorize representatives of this city to enter upon the above-mentioned property��lot inspection purposes. ti� Date: �_L-1 a !_ 1 Signature: A. ,Driver's License or Social Security 1641-46 While—Building: Green—Code Enforcement; Canary—Applicant; Pink—Revenue; Goldenrod --Assessor CITY OF COSTA MESA - BUILDING PERMIT PERM NO: BE 060284 PERMIT NO: BE 060284 PLAN CHECK NO: 04820-92 S GOVT; N SUPP: N CONSTRUCTION TYPE: PERMIT TYPE: ELE STR PURPOSE; ALT JOB DESCRIPTION : INSTALL EXPRESSO BAR COUNTER SQ FT: 2,00? CLAIM VALUE: 2,000.00 CALC-VALUE: 2,000.00 GROUP OCC: B-2 / COMMENTS: ANTONELLO'S ESPRESSO BAR INSIDE THE MALL LUMINATED WALL SIGN Z O N I N G R E Q U I R E M E N T S i S E T B A C K S ------------ MAIN BUILDING ---------- --------- ACCESSORY BUILDING---------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN PARKING RE • PROV: PLANNING N TES> PARCEL; 00000000 ZNE: REF NO: TOTALS ---- > 60,50 > 104.75 104.75 .00 REVENUE DIVISION TOTALS--> COLLECTED: 104.75 OVER/SHORT; .00 �lE�Fit***�iF*if 9E*lf��iEiE1E�EiE9E�E�E�E�EiE9E�E�E�E9tiE_iE*if ELECTRIC MECHANIC DEVELOPMENT S•E R V I C E S R E Q U I R E M E NST S 29,25 ZONING APPROVED BY DATE: BUILDING APPROVED BY : DATE: '1 APPLICATION ISSUED BY: DATE: 1'L' *�E�EiE*�E�i***it•�t�tiE**�*it*ltiE�tlEiE�*iF*�*iE**�**��1E1EiF***iFiEif�it**��t******�*���il•�*iE�t�tiEiF*****� LEGALIZATION:N F E E S U M M A R Y STRUCTURAL SEGMENT:Y BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT 45.00 15 00 tot SMIP/NONO-RES PLAN 29,25 ISSUE FEE 15,00 BUILDING -DIV-> PERMIT ISSUE PLAN -CHECK TOTAL PAID DUE TOTALS ---- > 60,50 15.00 29.25 104.75 104.75 .00 REVENUE DIVISION TOTALS--> COLLECTED: 104.75 OVER/SHORT; .00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN -CHECK 45.00 30.00 .50 29,25 ***iflFif*�*9t�1E14'1t9EdF1EaF1F�EitF�F�E�f***it�f****i6lt�!***�**lE�***lF�EiE�fiEiF*�F�E*iF*if*ltiFiF*****if*�#4�*9t**�4 I N D I V I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST SFC 2000 INTERIOR ILLUM SIGN BY VALUE NOZONE 1.00 2,000.00 ELE 1 SIGN/ OUTLINE LIGHT SYS ON 1 BR CIRC 15.00 15.00 END OF FEES iT •CONSRUCTION AND PLANNING POO SPA !- APPROVALS Permit` Date Inspector APPROVALS Permit Date inspector 1. Temporary Electrical Serve a or Pole 52, Pool & Equipment Location 2. Soil Pipe•Undrgrnd. A. 53. Steel Reinforcement 3_:' Electrical Cond4elltility-Undrgrricr- ' 54. Forms 4' Electrical Conduit•.Uadrgrnd. 55, Electrical Bonding s ;Steel ReinfprceWtpt 56. Rough Plumbing & Pressure Test ' r- .'afi:-ElectricalUFERBrnd. 57. APPROVAL TO COVER-GUNITE ��,Z.00tings �T 58. Electrical Conduit-Undrgrnd. vAr'-Foundation Z; U' 59. Gas Pipe, 0 Undrgrnd., Test 9,r Water Pipe-Undrmrnd, 60. Backwash Lines, P -Trap, 0 Undrgrnd, 10. Structural Floor -System 61. APPROVAL TO DECK 11. Property Sewer -'Lina'& Hoose ConnZction 62. Backwash & Receptor -Final 12. Sewer Cap ?, 63. Heater & Vent -Final 13. Roof Drains _ 64. Plumbing System - Final 14. Rough Plurnbiog 65. Electricaf•Final 15, Rough Electricai-Conduit 66. Solar System -Final 16. Roughkiectric Wiring 67. Fencing & Access Approval "a 7. Rdugh Wiring S 68. APPROVED FOR PLASTERING X18. Roug`hiElectrical•T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVA49;•:Perot 20.•rRo9h F3lctor? Fireplace + a_Cn It.. J :, _ O7n T 21.L uCts, in,Stractur ,.. $>: , y� « 3 ` -.A :70. Underground]Hyilro 22, pu , V'ntiati X ` _Sn '211. Product Pei[tg ©G$s Q0il tx r v 23.�a� Pipt�`Rou�h $i` est '� U .j `72. UndergrC ound Flusl,�.a, x - 24. IoW Framing x I r-,; �•_T Y Y x ;73. Undergrnc Storm@'Tank E3 Gas r0 Ciir ' F i _ 25. Rood Shkathing a K 'L 74. ;OverheadIydra!� S V _ �;x .� 26. _T Bar Ceiling (Strocturai) &7 ,Mon < r'r 1( 75• Dry Chemical 27.'r -,-Frame and Fjiashir Y A ipe76. Dy tandr �5 ,-28. Lathin 5ufing :4 77." FIXED 5Y EM:I'1NALY I -r � 1 >29. Insulati6h * n K::i at 78,.'F IRE PR EV. FINArL x x -c r30. Drywall NailYAg HEALTH DEPTI'REQUIREMENT ' C31. Plaster I31own Clot* ; 79.^FINAL INSPtCTIQtF. .� _,, 32. -Electricat Power tdeten?FinaI, 80. FOOD CERTIFI•LATE ISSUED ' 'Finq Extric - 5' ffi.t Notes: r _ T _ `^ ,,33. ;,34 ;-Fine! Hegting &Air Conditioning 1 x r A ,. '.y C T- x s 1: ' 35._7iKal Gas Pipe Te9t' _ -s -= - �" . _-,L )i• .r r36. Hood or -Canopy rlt T' :37.' -Final Factory Fir oiacex =38. -Finpl Plumbing _ • •. T -, 1 - �,.� - '"39.- Water Service-Fin5l- ,40.'Gas_*Ser vice, Fina i 41.4Solar DomesVc-Mbal e x A : 42.•`Sackflow Prevent'4rXY' 43. Backflow Irqgatibn*� -44. Landscaee fr. ion System_ i r - `Cf 0c, �l5.CSound AtteQuati6rr x- "• 3 r -- ■ ,+ rt - r K sc • �6. Rigylat-r4s r - ; •5 ,. ,Handicap 47..FINAL STRUCTURE & WILDING " `48.''-FiN-AL PLAidNINd -49 zElectric Release to .Edison I -50..GatAelease to Souihern California Gas Co A :51. CERTIFICATE OF;OCCUPANCY No. Date PROJECT ADDRESS: 3333 BRISTOL ST UNIT: 2887 OWNER'S NAMEt C J SEGERSTROM ADDRESS: 3315 FAIRVIEW RD C.M. ARCHIENGINEER: REG.NO.: ADDRESS: UNIT: PERMITTEE: C. J SEGERSTROM (714)546-0110 ADDRESS: 335 FAIRVIEW RD C.M. CA 92627 LICENSED CONTRACTOR DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in lull force and effect, CITY LIC.: STATE LIC.t CLASS: Date: Signature: WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure or a certificate of Workers' Compensation Insurance. or a certified copy thereof (Section 3800. Lab. C), POLICY NO.: EXP, DATE: COMPANY: ❑ Certified copy is hereby furnished. ❑ Certified copy is toed with the city Building Division. Date: Apprrcant: EXEMPTION FROM WORXERS' COMPENSATION DECLARATION: IThis section need not be tampleted if the permit is for one hundred {3100) or less). 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of Gelifomia. Date: %2 ' 3 "y 'Z— Signature: NOTICE: if, after malting this declaration, you should become sub ct to the Workers' Camp tion provisions of the Labor Code, you must forthw th comply with such provisions or this permit shall be deemed moed. CONSTRUCTION LENDING AGENCY: I hereby affirm that there i5 a construction lending agency for the performance of the work lot which this permit is issued (Section 3097, Civ. C). LENDER: ADDRESS: OWNER BUILDER OECLAFIATION: I bereby affirm that I am exempt from the Contractors' State License Law for the following reason (Section 7031.5 Business and Professional Code: Any city of county which requires a permit to construct, alter. improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he/she is licensed pursuant to the provisions of the Contractors' Stale License Law (Chapter 9 (commencing with Section 7000► of Division 3 of the Business and Professions Code) or that he/she is exempt therefrom and the basis lot the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (S500). f, as owner of the property or my employees with wages as their sole compensation, will do the work, and the ❑ structure is not intended or offered lot sale (Section 7044, Business and Professional Code: The Contractors' State License Law does nos apply to an owner of a property who builds or improves thereon, and who dares such work himselilhersell or through his or her own employees, provided that such improvements are not intended or offered lot sale, It, however the building or improvement is sold within one year of completion, the owner will have the burden of proving he/she did not build or improve for the purpose of sale), 1, as owner of the propery. am exclusivey contracting with licensed contractors to construct the project (Section 7044, Business and Professions Code: The Contractors' Slate License Law does not appy to an owner of property who builds or improves thereon and who contracts for such projects with a conuactor(s) license pursuant to the Contraclom' State License Law). I am aware that proof of their Worker's Compensation insurance should be provided to me. 1 am exempt under Section: B. 8 P. C. Ion this reason; Date: /2 ` �, - 22-- Owwnec I do hereby certify that I am aware of and understand the requirements of California Heaitt and Safety Code Se ons 25505, 25533, and 25534 and that I or any future building occupant willlwill not (circle one) need to comply with said slate codes and the requirements lot a permit for construction or modification from the Air uality Management District. Residential construction applications are exempt from these provisions. Date: Applicant: I hereby certify that I have read this application and state that the above information is correct. I agree to comply with all city and county Ordinances and state laws relating to building construction and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes, Date: 9-1 '� '57-2— /-2— f� Signature: L Driver's License or Social Security K: 164146 Whne—Bmldmp; Green—Code Enforcement: Canary—Appkcant: Pink—Revenue: Goldenrod—Assessor CITY OF COSTA MESA — BUILDING PERMIT PERM NO; B 060179 PERMIT N0; B 060179 PLAN CHECK NO: 04706-92 L GOVT; N SUPP: N CONSTRUCTION TYPE; PERMIT TYPE; STR PURPOSE; ALT JOB DESCRIPTION ; INSTALL EXPRESSO BAR COUNTER SQ FT: 50,000 CLAIM VALUE: 50,000.00 CALC—VALUE; 50,000.00 GROUP OCC: B-2 / COMMENTS; ANTONELLO'S ESPRESSO BAR TO REPLACE AMATO'S CAFE Z O N I N GS ERTEBQAUCIKRSE M E N T S ------------ MAIN BUILDING ---------- --------- ACCESSORY BUILDING--------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR; FT IN LEFT; FT IN RGHT; FT IN LEFT: FT IN RIGHT; FT IN PARKING REO: PROV• PARCEL; 00000000 ZNE; CiS REF NO; PLANNING N TES> INSTALL ESPRESSO BAR COUNTER AT SOUTH COAST PLAZA BETWEEN > UNITS 2881. AND 2889. D E V E L O P,M E N'r.T SERVICES R E Q U I R E M E N"T S ZONING APPROVED BY DATE; k L" �— BUILDING APPROVED BY ; .'?- DATE; APPLICATION ISSUED ABY:if 4� DATE; 'If^iE�iF��F>tkil�iE���ifiE**ifififlE�ifiE�f*iliF1F�� *iE *IE��E�iikilit�!***it��***!E*iF*�*��l�*****�t9tFlklElk�F�t*��*lfi�!*it���*it�l�!*�*�lF��kif�!lki19F��[•9F�t�!lF�i[•**�** LEGALIZATION:N F E E S U M M A R Y STRUCTURAL SEGMENT:Y BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SHIP/RES GRADING PERMIT 414.50 SHIP/NON—RES PLAN 269.43 10.50 ISSUE FEE BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE TOTALS----> 425.00 0.00 269.43 694.43 694.43 .00 REVENUE BBLDGVPMTOPLUMBING—ELECTRICOMECHANDI� FIRE4.SNIPO/TOT/SGORADING PLAN -HECK 414.50 10.50 269.43 flet!*iE����*********�***iFltit����l�l�F�fr�*lEiEiF�E!!ilikiEiF�ElE*!F'1litlE�t*�!�!lE�E�FiEiliE***�E�EiElEiki!*9Fil�itit*flit*� I N D I V I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST SFC 50000 ALTER BY VALUE COMMERCIAL NOZONE 1.00 50,000.00 END OF FEES I CONSTRUCTION AND PLANNING PpOL P' i APPROVALS Permit # Date Inspector APPROVALS Permit # Date Inspector 1, Temporary Electrical Service or Pole 52. Pool & Equipment Location 2. Soil Pipe-Undr rnd. 53. Steel Reinforcement 4ctrical Condrjr�Ility-Undrgrnd. 54. Forms wA7. Electrical ConduirJJndrgrnd, 55. Electrical Bonding neT, :0 °3$eel Reinforce�,�it x 56, Rough Plumbing & Pressure Test S ,.Al -Electrical UFERMrnd. 57. APPROVAL TO COVE R-GUNITE _z e15 -'15 x 58. Electrical Conduit-Undrgrnd. ci .tfoundation X r` 59. Gas Pipe, El Undrgrnd., Test °' 9. Water Pipe-Undrgrnd. 60. Backwash Lines, P -Trap, © Undrgrnd. 10. Structural Floor System 61. APPROVAL TO DECK 11, Property Sewer Lin6)& House Connection 62. Backwash & Receptor -Final 12. Sewer Cap y 63. Heater & Vent -Final 13. Roof Drains _ ro 64. Plumbing System - Final 14. Rough Plumbid 65. Electrical -Final 15. Rough Electrical -Conduit 66. Solar System -Final ` 16. Rough Electri*iring 67. Fencing & Access Approval 7, Rough Wiring Egn 68. APPROVED FOR PLASTERING "18. Rough Electricg-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT • 131 tr"tT, c•. cr, x Y N 20,t"Raur, h rr':a'ct F��place r -ZrY Q"1 z O 7 rs'* * PPR13VA� DCPer Sit # 1 21., u(p, C; ; iIr * _ 0. tjadergra�AcHy_ o �x 22. Du Viintilatin, x t CJ5 * S •S* r 1• Produc �ing LMS �il _ 23.Cfas�,ipg�ough 8i' est 1 * tr ti fi t { y 72• Under rotmu FIr, 16 t trlS * C21 t7• * a O� g;= yr \ 24.3Roa Frirmirig 5 * i -= • •• O 3�tindergrnc�r'. Stora l Gas ©ter is �x • Whk r Roc Sh Sthing 5 d v jr,25. t� p C3*. 4� ert ad Ylydro"` > * r ural] &artacoat 26. T•Bm Ceiling (St M'K3'l rnIK :! 75J•Dry Chem�rral r, Q �-3 27 Frame and `shN •r r7'A OX 76. l�y S ant�rp 'roe O�'� i-- of a * Ln .` S. Lathing% Siding"* rn -: oc Y ••x r' 774'FIXED Sr EraA�NAL* _ ,= -r r r y .� 9. Insulatip`�tj t, x 5 > .rr5 is x * ; * r r. 78�FIRE PR EV, FINlrk{ * J x ?• V04 -30, Drywall NaiKng ear J 8 HIE A LTH E EPT*FiEQli1REAVIENT 5:31. Plaster B bw'a,Cc>yl P9 ! -t- IN l CT16_N * t7 2.,-Electrica#;Poaver �dnterlFinal; .1c p] ,c 80.1rFOOD CERTIFICA7E ISSUED r r. 33,in tricry �" r �{'o•^� ;r NoMY�■s: 'r• '' O ..• .� L • 1 t ^t r y iii �' L • ••i J .TJ :tB4-(-f in HeAtinq�& A5 rR onditiore�n n� •* sic t� C`, * S M75 , C. incl Gas Pi -T-- * :t± jr _jKr *i Cl t,rc `TS ,r 00 t35.=,"F, J ; r,.36.�-1o§d or ' nopy= c -3 CF n x X Ra "7rr• Z) ! r^ 7. ink FAory Fii,patjx Ox M jK 1 3gm n 48.cFinOj; PI=biog 2: :.I r 0i-• x x z' G t�9 t-WatN Service:Firr ix t �N * :l arK3 x x fJ c, F+ x s i D r z 'b x S O 'iGas Servicenalr =1 Solar DomesVc-Fina15 n <4. X12. Sackf low Preve4 LIU 43, Backflow Ir r atiow* %.5 S s * tr, 0 r O Y x x i w 'rrG4. Landscape I Systerrz�xjn r _ xr -4 � gatioFt jC -; ; � G _/ x * Z X rp � \ V lr V =5.�Zound Atteaatiorf SME- :rf L F•s r+ r, L x� x rt r z •r ►r, Crs r. Cr ? E- N6.•�fandicav,Rd91ilati4s ,� ,. � y ;Jr�, ' s t ►, •47.--cFIrtt9,L STRUCTURE & BUDDING J� � is '1 N 5O 3k r' it I C r t•, 48.2'F r 6C L P,�AWN I N C; `crt, r , d �; Y r 1.4 q c_:i9'.rElemj G is Release to idison i x x ; x x Y -: c So..Ga diel se to Sourtern California Gas Co al. CERTIFICATE OF OCCUPANCY � �..r• 0 NW,� - o No. Date (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Suite No 1242 Vicinity: SPACE 1242 Parcel Number: 41250107 Applicant: Address: Owner: Address: BEV, ANTHONY" r 1172 EDINBURGH RD SAN DIMAS, CA SOUTH COAST PLAZA %C J SERGERSTOM- COSTA MESA, CA MECHANICAL PERMIT Phone: (626) 963-3233 ; Zip: 91773 Phone: Status: ISSUED Applied: 04/16/2001 Issued: 04/16/2001 ISSUED BY: 3315 FAIRVIEW RD Zip: 92626 Contractor: BEVAIRE MECHANICAL INC ` Address: 1172 EDINBURGH RD L , --,Phone: (626) 963-3233 SAN DIMAS, CA Zip: 91773 License: 764799 SCOPE OF PERMIT i MECHANICAL PERMITFOR INTERIOR STORE T.I. FOR "ABERCROMBIE & FITCH" (SPACE „ 1242). INSTALL 5 VAV BOXES ALTER 5 HEAT/COOL SYSTEMS. -j 4 , REF: B00-0152$ .FEE'SUMMARY' .-Quantity I i Quantity, ISSUE FEE J ) $23.50, Repair./Alt'Absorblion Unit $0^00 0 rJ Inst FAU 1100 k BTU ' $0.00, 0 Repair /_AIt' Refrigeration Unit I� $0.00-�; !! Inst FAU X100 k BTU $0.00 0 Ventillalion System f7 ' $0,00`J O Repair /:Alt Cooling/Heat $68.50 5 Evaporative Cooler j ! i0.00� 0,` ; r Inst I Rep. Recess Wall Htr, $0.00 0.7Commercial Incinerator `$0.001 0 Refrig Sys X106 k BTU $0.00 0 -�. �'�''' Domestic Incinerator �� $0.00 /'0 Refrig Sys >100 k BTU $0.00 0 ' ' '' 'l �„ , . f � , , Compressors !Absorption Systems," Gas Piping �. $0.00 0 „Up to 3 hp 1100 k BTU_ ,�/ ti 50.00 � �� 0 Factory Fireplace..� 3 To 15 hp l 500k BTU.. r�� �� $000�� 0 Hood wlMech Exhaust `$0.00 0 15 To 30 hp 1 1,000 k BTU"%= �` 50.00/0 VAV Box � �A fir. �� .$53:25 �5 ° (; 36 To`50_hp 1 1;750 k.BTU � SOHO 0 Vent Fan / Single Duct / �/ $0.00\;4 ` °_ ' ` Over 5D,hp I Ove ;750,BTU ��� �, 50.00 0 Appliance //40,00, D'���_ Boi)ers 3 ✓ /.��`�/� / Fire Dampers , _ $D.00 0 l" 'Up to 3 hp" �\ > > C// / 0.00 0 Smoke Dampers \l $600 i0 . 3 To 15 hp \ \ j $0.00 0 Inst or Relocate Appi Vent $0.O0/�r0 _' ` �� 15.to 30 hp - . � 1 l ` /, / $0.00 D Air Handlers < 10000cfm $0.00 `0 30 to 50.hp $0.00 0 Air Handlers > 10000cfm $D:00 ;�0 \t - . Over 50 hp $0.00 D Floor Furnace $6:00 ' 0; Other Mechanical Fee; Floor or Suspend Heater $0.00 "0 . _ Investigation Fees" $0.00 Plan Check Fee $0.00 Reinspection Fee $0.00 TOTAL CALCULATED FEES $145.25 .COMMENTS / SPECIAL CONDITIONS NOTICE: The worts authorized by this permit shall comply with ail applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92.28, § 1, 12.21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and"all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration.of this permit./ FOR INSPECTIONS CALL: (714) 754-5626 V 2446-4e (6100) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the _Wiork for which this permit is issued. J®rl have and will maintain workers' compensation insurance, as required by section 3700 of the labor Code, for the performance of the work for which this permit is issued, My workers' compensation Insurance carrier and policy number are: 'Gamer _-sl[$-F- e =Pait umber. -- /92Z (This section head not be complet ii the permit is valued at one hundred dollars ($100) or less.) ❑ 1 Certify that in the perfomza a of w for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Calif ia, nd agr a that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provision -Applicant Signature: _ L�uate:- _ 1 F f f- -WARNING, FAILURE TO SECURE WORKE COVERAGE IS UNLAWFUL AND SHALL. SUWECT AN EMPLOYER TO CRIMINAL PENALTIES AND OVIL FINES UP TO ONE HUNDRED THOUSAND DOLIARE ($100,000), IN A0D1t7ONTO THE =Tk COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that-1 am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of.the Business and Professions Code, and my license Is in full force and effect: Lic-#— . i Coast; #y Contr�acto�s,5ignawre: 1– Da1e: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of pedury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions o1 the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Cade) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for safe (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or Improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors license Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION- 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _........................................ .......................... .............................................................. ... ...................................................... 2 does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater then a weight of 500 pounds, or a volume of 55 gallons, or 2D0 cubic feet of compressed gas at standard temperature and pressure). .......................................................... ........................ ...........................-•--••------........................................ -............----.--....................................................................................................... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ..........................................................................-............................................................................................................................................................................................................................... -.................................... 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes [3 No _.......................................... -....... _.-................... _.......................... .................... ............................................................ .............................. ............................................................................................. 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this a plication a ffrmit for such construction or modification from the South Coast Air Duality Management District or from any other air pollution control district or agency. Yes No (Section 65850.2 of the California Government Code requires that the requested Information be furnished on applications for non-residential building permits). ...... ..................... ....- ............. ...... _.... ....................".......................................................................................................................................................................................................................................... fi WIII any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if -yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ...................................................................... ..... ..............---............................................................................................ 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ..................................................................................................................................................................................................................................... 8 (If yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION. OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. 5i ature Of eget O r D to �e I r An zed Ap icant ate CODE P INSPECTIONTYPE 2&11- INTMAL CQQE iNSPECTIONTYPE JJ hhl 1616 Fixed System Final Fire Prevention 206 Final Mechanical tG ` CX ' c!) t f 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Root 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 PLUMBING PERMIT Job Address: 3333 BRISTOL ST Suite No 1242 Vicinity: SPACE 1242 - ABERCROMBIE & FITCH Status: ISSUED Applied: 03/23/2001 l slued: 03/23/2001 b - Parcel Nunmber: 41250107 - , _ _ ISSUED BY: Applicant: HETTICK,.RICK- Address: 3705 LONE DOVE LN Phone: (858) 756-01197' ENCINITAS; CA ! -` Zip:., 92024 _ Owner: SOUTH -COAST PLAZA Address %C J SERGERSTOM ESA, / COSTA MESA, CA Phone: 3315'FAIRVIEW RD Zip: 92626 L / f V ���1/�%����'--tit 1 „ NON-STO contractor`: , P _ `� r 1' �r 1, , - r / % (Address: , j�3705-LONE DOVE LN ' -- Phone: (858) 756-0197 \� %ENCINITAS, CA Zip: 92024 j�j i \ f % %/ License: _ 585146 i 4 r I'; %ir��,"r��rry f �l�irih+rrq Arch / Eng 1 i - �, I I Addrew"i L� Phone: License: - µ � � � �61,`-"=� lief SCOPE OF PERMIT \, PLUMBING PERMIT FOR INTERIOR STORE T, 1, FOR "ABERCROMBIE &FITCH" (SPACE 1242).//, / )INSTAL! 1 BACKFLOW PREVENTER, 3 FLOaR'DRAINS, 1 MOP SINK, 2 WASH BASINS, 1,WASTE'& C VENT SYSTEM, 2 WATER CLOSETS,'&>1 WATER HEATER... t�/ %} �REF: 600 01528 " '� • � •, ' ' `'� _ � ''� � -., ,� f�'= l,t y' `. `,a, v v � � l� � l p u � ^r'-.-'t�� %'•ja,��;7 ISSUE FEE ----�L'`h dry Tub I,Wash6r(-1 0 0� �' Sul 1 Pi mp /� $0.00 0 Backflow irrigation �$D.00 1 „Landscapehrigafori _ x$0:00 - 0 \�\Swimlming Pool/ $0.00 0 Backflow Preventer $9.SD 0 O �P Trapp - _$0.00 0 Trap Primer) $0.00 0 Bathtub Clarifier System $0.0o� 0�Pressure Regulator woo-c--lt7 $0.00" 0,- \.Process Piping'(per.10ft)�',$Or00 -qt � 0 Vacuum-Brkr Bkflow(1-4) $0.00 0 Brkr Bkflow(5+) Connect (Ice,Soda,etc) $0.00`0,, Wash Basin Receptors "`' j$0.00 Dental Units $0.00 0 _ SeptigTank $9.80 Dishwasher $0.00 O� Cap for. Demo ---$0.W'_-0-" Drain, Floor $29.40 3 Sewer Connect-"' f' "$0.00- bb -o-- Drain, Rainwater $0.00 0 Sewer Private Line $0.00 0 Drain, Roof $0.00 0 Shower $0.00 0 Drinking Fountain $0.00 0 Sink, bar $0.00 0 Expansion Tank $0,00 0 Sink, commercial $0.00 0 Gas Earthquake Valve $0.00 0 Sink, Floor $0.00 0 Gas (1-4 outlets) $0.00 0 Sink, kitchen $0.00 0 Gas (Over 4 outlets) $0.00 0 Sink, service/mop $9.80 1 Gas Repipe $0.00 0 Spa (private) $0.00 0 Gas Service $0.00 0 Spa (public) $0.00 0 Interceptors (Grease, Oil) $0.00 0 Interceptors (Sand Auto ) $0.00 0 regulations. (Ord. No. 92-28, § 1,12-21.92) COMMENTS 1 SPECIAL CONDITIONS Urinate 1 1Vacuu"m $0.00 0 Vacuum-Brkr Bkflow(1-4) $0.00 0 Brkr Bkflow(5+) $0.00 0 Wash Basin $19.60 2 Wash Basin Set $0.00 0 Waste and Vent System $9.80 1 Water Closet (Toilet) $19.60 2 Water Heater ! vent $12.30 1 Water Piping (Inst or Rep.) $0.00 0 Water Re -pipe $0.00 0 Water Service $0.00 0 Water Softener $0.00 0 OTHER $0.00 VIOLATION $0.00 PLAN CHECK $0.00 REINSPECTION $0.00 0 EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days, or if work is suspended or abandoned for a period of 160 days. INSPECTIONS: In order for the work authorized under this permit to be Considered legal, such work must comply with all applicable codes, and all, required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration.of this permit FOR INSPECTIONS CALL: (714) 754-5626 r 2446.46 (SM) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. ❑ I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: Policy Number: (rhis section need not be completed!f the peradt Is valued at One hundred dollars (S f 00) or lass.) I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' —compensation laws o1 Califomia 1 t If I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these p ApplicunJ ignature Date 3 r WARNING: FAILURE T 'COMPENSATION COVERAGE tS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMNAL PENALTIES AND CIVIL RNES UP TO ONE HUNDRED THOUSAND ,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR OOOE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am_ licensed under provisions o1 Chapter 9 (commencing with Section 7000) of Division 3 of.the,Busigess and Professions Code, and my license is In full force and effect. L C. # Clasa rte G 3G k___Y ContI ractors Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ f hereby affirm that there is a construction lending agency for the performance of the work for which this permit is Issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Coda: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to Its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) Cr that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of net more than five hundred dollars (5500).): ❑ I, as owner o1 the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or Improves thereon, and who does such work himself or herself or through his or her awn employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner o1 the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (SBC. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes Cl No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more test in depth into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, faisework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 6, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to fila and certlty a Business Pian for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some axcepUcns, that a Business Plan be filed wish the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 foes ll the applicant or present oateria❑ n tuture building occupant need to file a registration form for acutely hazardous materials? ❑ Y Tr wies No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater then a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ......................................................_......................................................_._.._................ _—..................... —.................... _.............................. ........... ................................ ...................................... ....... ........_ ............ . 3 eor will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? No Section 25SU of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certificallon and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. _.. ...... _..._ ............ ....._..................................................... _..... ........_.—........... —_ _. ....... 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a armit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? j Yes No (Section 65850.2 of the California Goverment Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the fadlity to be constructed under this permit be within 1000 feet from the outer boundaries o1 a school? ❑ Yes ❑ No (if 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). — ...................... ... – ---- -....---.............................................................. _... _�_ _._._. 7 If apermit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all o1 the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 6 (If yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORI ATION.OF ENTRY: f certify under penalty of perjury that I have read this application and state that the information given is correct I agree to comply with ail state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for Inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. SI _ Date Q {Cn u oHz Applicant r Pie CODE 1. INSPECTION TYPE 2M' Its CODE # IUSEECTION TYPE Q&. INTITALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa FInal 208 Final Plumbing 200 Final Ro-Roof 210 Final Electrical ia-,�35 - d 1 1 201 Final BlocklRelalning Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demofi ion 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www,ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT Job Address: 3333 BRISTOL ST Status: ISSUED Suite No 1242 Applied: 04/06/2001 Vicinity: SPACE 1242-ABERCROMBIE & FITCH Issued: 04/06/2001 Parcel Nunmber: 41250107 Applicant: AYALA, HENRY ISSUED BY: _ Address: 10930 LITTLE LAKE ROAD ' Phone: (562) 929-6615 DOWNEY,,CA, Zip: 90241 Owner: ' 'SOUTH,COAST PLAZA Address '. %C J SERGERSTOM COSTA MESA CA-. " Phone: +� ' 3315 FAIRVIEW RD Zip: 92626 ' ,� ' , • V, • ti t• � ,Contractor:) ' CALIMA ELECTRIC COMPANY Address: 10930 LITTLE LAKE ROAD , \ '• 1 Phone: (562)929-6615 ` t DOWNEY, CA Zip: 90241 r License: 357034 \11 SCOPE OF PERMIT ._ 3 ELECTRICAL PERMIT FOR INTERIOR STORE T.I. FOR'"ABERCROMBIE,& FITCH" (SPACE 1242). .INSTALL 383 LIGHTING FIXTURES, 63 RECEPTACLE OUTLETS, 7 SWITCHES, .1 ELECTRICAL SERVICE TO 1000 AMP, AND 2 SUB PANELS. REF: BOO -01528 ,'� 1� FEE SUMMARY l Quantity Quantity ISSUE FEE. t r ' \ , ' $23.50 .Temp Dist System 1 Lighting $0.00 10%/ Temp service test $0.00 i ,- Busway 1100 fl $0.00 Res:'alc'package $0.00 ! = Standing_ Section $0.00 New Res' 1=2 units ( ) .i$0:00 0 Misc Elecfrical Equipment $0.00'/- 0 , r New Res (3+units) r $0:00 0.,. ' Transformers up't6-1,kvalkw• L - so o/ 0 r ` Pool 1 Spa �;� >> $0:00, 0 ;- .'..-.._-.up to 10 kv A' .'. $0.00 0 Lighting Fixts l' ✓ $286.99-" \383 �� ':: ....up to 50 kva/kw - �$0.00� 0 Recept Outlets \�� /%$53.39 \�fi3� �.°> ' ...::.........lip to 100 kvalkuy//% $0.00 /Oi Switches -; \ $7.70,, ��-7��� ;.;� - over 100 kvalkw � $0.00�� CO�, Non Res Appl $0.00 0 Low Voltage Equipment Res Appl $0.00 / o-, Low Volt Wring System I Ckt�� $0.00%0,'/ Service to 200a 0' ' ; ' Misc, Conduit \ \t.C$0.00 0� Service to 1000a $62.15', 4 . T ' - Misc: Conductor � � °• � $0:00' � � 0 Service over 1000a $0.00 =-, ^� 0` Circus ( gen or ride)_. r !/$0:00' 0 Motors to 1 hp $0.00', , �0 LT ; '' 'Circus (meth `ride or lights). l:- y,$0.00 0 Motors to 10hp $0.00 o Christmas Tree Stand %'_" - $0.00 0 Motors to 50hp $0.00 o'- Fireworks Stand $0.00 0 Motors to 1 00h $0.00 0 --Other bectrical Fee $0.00 Motors over 100hp $0.00 0 Communication drops $0.00 0 Investigation Fee $0.00 Sub panel to 200a $61,00 2 Plan Check Fee $0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $0.00 0 Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $494.73 Intermed Pole $0.00 0 COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days.' INSPECTIONS: in order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all requited inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration.of this permit. FOR INSPECTIONS CALL: (714) 7545626 2448.48 (WO) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the fallowing declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. I have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: �Ui. Policy Number; (This section need n r be comp! ted if th ermit is valued at arta hundred dollars ($100) or fess.) ❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Californiaii, and agree that If I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these pr Appl-�gnature: . Data: _r . 2-p WARNING: FAILURE TO SECURE WO ERS' COM ENSA COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions f Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Prot ions Code, and my license Is in full farce and effect. Lic. # Class # i Contr4mors Signature: - CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lenders Name: Lenders Address: Signature: Date: OWNER-BUILDER DECLARATIONS, I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Coda: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he Or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner o1 the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or improvement Is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner iD verified by drivers license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type at document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: © I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ...................................-_...... _- --....--.................._—................._................. _................ ---.................................................. -----..................................................... ..... ................. 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes 0 No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _.................. __...._.......................... .................... .....-.... --................. -........................ ...................... -.................. _............................................................... ..... -_.-.-... ............................................... ........... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire bepartment of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ............._...........................................................----....................._.............-•--------....,.............................----•-------................................................................................................ ......................... ............-..................... 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No .........._........ .... ....... _._................ ......_...........- .....--------.-----............... ....-............-........... .............. ...... _...................... •--•........... _._....................... __.......................... _.......... 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this application a mit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes 1erNo (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). _.....................................................ad - -------.-..._-i's, ..................----------- • •--•----......................-.....-..- ---- -----.................................................................................................................... -................................. .... fi Will any part of the facility to be constructed under this permit be within 1000 feet tram the outer boundaries of a school? ❑Yes ❑ No (11 'Yes', the facility must meet the requirement of Sections 25534 and 42303 of the Califomia Health and Safety Code). ........... _ ........................................._....................... _... _.--................... ............... --.................. —................................. --•-•-•---.... _..................................... .................................. .................. 7 If a permit from the South Coast Air Quality Management District or other air pollution central district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ............. --r...................................._...---...............--—._..........-- - �...._............-.-._� .... __................ _._... _...................... _ 8 (If yes', attach certificate of compliance from the appropriate air pollution control Officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the Information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION-OF ENTRY: I certify under penalty of perjury that I have read this application and state that the Information given is correct. I agree to comply with all state taws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. 5iOwn Le al r D to - �� And/O thorized• nt_ Data CODE f• INSPECTION TYPE DATE' INTMALS CODE + INSPECTIONTYPE PSIE IflTITIAL4 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 206 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Finai Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 BUILDING PERMIT Job Address: 3333 BRISTOL ST Status: ISSUED - Suite: 1242 Applied: 01/30/2001 Vicinity: ABERCROMRIE & FITCH (STE 1242) Issued: 01/30/2001 Parcel Number: 41250107 Zoning: PDC PDC Applicant: GREENE, STEPHEN ISSUED BY: Address: 140 LOMAS SANTA FE ' SUITE 200 Phone: (858) 793-9104 SOLANA BEACH, _CA - Zip: 92075 Owner: SOUTH COASTRIAZA ` Address /%C J SERGERSTOM . $396.50 'COSTA MESAi,CA Phone: ` , i%r 3315 FAIRVII'xW RD: Zip: 92626 \��\ti'��I •' `: �'� ZONING' SETBACKS .:PLANNING;& Contactor. DICKINSON CAMERON CONSTRUCTION CO INC MAIN STRUCTURE Front ' 0 0 Reari- _0- 0 'Address! 140 LOMAS SANTA FE ACCESSORY SUITE200' Phone:,. (858) 793-9104 \ ` �;,`, i �'• f ,SOlr4NA`BEACH, CA / Zip, l' 92075,<, License: - "690239 r� PARKING J - - \\ ` - . Arch,: --J , ! Eng:, r�"! „ ,Address: �./ ,� Address: NOTES: .�; Phone: Phone: I � Zip: '`✓/~\ License: License: SCOPE OF PERMIT- ERMIT S, „DEMO PERMIT OF NONBEARfNG•WALLS, CABINETS, ETC. FOR 9475 SF INTERIOR STORE_ TI FOR "ABERCROMBIE & FITCH" IN STE1242. i REF: BOoo1528 ----FEE, SUMMARY' Plan -Check: $0.00 i Calc Valuation: / / $25,000 .00 Permit: ' ` $391.25 Claim Valuation: �� L' $25,000.00 �'SMIP.Res\ � $0.00 �SMIP�Com`: �, 1`$5.25 `�� Other:/ $0.00 4 : , f Inspection. $0.00,, Total• $396.50 .�.°\ \��\ti'��I •' `: �'� ZONING' SETBACKS .:PLANNING;& l MAIN STRUCTURE Front ' 0 0 Reari- _0- 0 Left 0-0 - Right \�O- 0X z ACCESSORY Front 0- 0 Rear) 0- 0 Left, 0- 0 - Right'0- 0� PARKING Existing: 0 �Reguired:r -0 Proposed: -_-0 NOTES: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12.21-92) EXPIRATION: This permit shall autornatically expire and become void it work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration, of this permit. J FOR INSPECTIONS CALL: (714) 7545626 2446-46 (6100) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: - N ❑ I have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the for which this permit is issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' Compensation Insurance carrier and policy number are: Carrier: -r-, 4V I !�L A —C- - _ ,9S�D& , Policy Number: (ihis section need noWe completed i the permit is valued of one hundred dollars ($ f00) or less.) ❑ I certify that in the perform the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Califf i and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provis s. Applicant Signature: Date: 3v- a I�/ WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed der provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic. # Class # Contractors Signature: Date: 7-- CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or Improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or doed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsowork, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Pian be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ................................................................................................................................................................................................................................................................................................................................. 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ................... .................................................._....................................................................................................................................................................................................................................................................................................... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire apartment of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department, 4 If an RMPP Is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No ............................................................................................................................................................................................................................................................................................................................ . •.--........... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? j] Yes No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ......................................................................................................................................................................................................................................................................................... .......................................................................................... fi WiEI any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ............................................................................................................................................................................................................................................................................................................................................................................ 7 I1 a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by Callfamla Health and Safety Code Section 42303 been made? []Yes ❑ No ................................................................................................................................................................................................................................................................................................. ...................................................... .................................. 8 {If "yes", attach Certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION. OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree !A comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-descrih Oroperty for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature gahAwner(5) Date And/Or Authorized Applicant Date CQI)E I. INSPECTION TYPE INTRIALS CODE N INSPECTION TYPE DATE INTRIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final_ 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy d 4 (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT Job Address: 3333 BRISTOL ST Status: ISSUED Suite No 1242 Applied: 03/26/2001 Vicinity: 1242 Issued: 03/26/2001 Parcel Nunmber: 41250107 Applicant: COMMERCIAL SIGN & LIGHTING INC. ISSUED BY: Address: 7422 VARNA ST Phone: (818) 764-6791 NORTH HOLLYWOOD, CA Zip: 91605 Owner:SOUTH COAST PLAZA ' Address %CJ SERGERSTOM COSTA MESA, CA Phone: 3315 FAIRVIEW RD Zip: 92626 Contractor: ; COMMERCIAL SIGN & LIGHTING INC , K� Address' 7422 VARNA ST' Phone: (818)764-6791' NORTH HOLLYWOOD, CA" - - Zip: 91605 _ +� License: 263327 ; • SCOPE OF PERMIT STORE FRONT ILLUMINATED SIG UNIT; 1242, FOR ABERC6MBIE.1: FEE SUMMARY' Quantity - Quantity /!' f' ISSUE FEE $23.50 Temp Dist System 1 Lighting $0.00 0 XII ! J T! 1 Temp service test + $0.00 Busway,/100 ft / $0.00 0 f / Res. a/c package ' ' $0.00 Standing Section . • $0.00 0% V',/ New Res (1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0 4' New Res'(3+6nits),- $0.00 0 i. -Transformers up to 1 kvalkw $0.00 Pool I Spa $0.00 0 r% up to 10 kvalkw $0.00 Lighting Fizts', " $0.00 0 `•- ::-:up to 50 kvalkw $0.00 '/,o� Recept butlets•� `� $0.0o 0 p w $0.00%'/ 0 .0 to'100 kva/k , Switches $0.00 ,, s-_ O..F ..............:.over 100 kvaHiw;; , r'so.00% 0 L Non Res Appl `�, 1 $0.00 , D Low Voltage Equipment - , ,$i).00 �0 Res Appl \�` G -,-,so .00 �\\\�0 �. Low Volt Wiring System Ckt; $0 00 0 Service to 200a V� $0.00`��0, o "Mise. Conduit` / $O.OQ /0) �•f Serviceto 10o0��`�� r $0.00 "�0\1 �-Misc Conductor -✓�$0.00�� �fl over 1000a $0.00 0 �' ,.Circus error ride). - Service! ' ' �/ (•9" $0.00 O, G Motors to 1hp \ . $0.00 ' 0, Circus:(mech ride or lights) �� $O.00f /0' Motors to 10hp �; $Q00 0 ` Christmas Tree Stand, ,x$0.00% 0 Motors to 50hp $0.60-1-1, 0 Fireworks Stand ,,\ , '� $0.00 "o Motors to 100hp $0.00` ``0 \ \Other -Electrical Fee, __' Motors over 100hp $0.00 -0- Communication drops $0.00 -.4 investigation -Fee ;-; %1 $0.00 Sub panel to 200a $0.00 0 - _Plan.Check Fee - r $0.00 Pole Light Pkg $0.00 0 - - --Reinspection-Fee $0,00 Sign Circuits $24.60 1 Temp Pwr Pole $0.40 0 TOTAL CALCULATED FEES $48.10 Intermed Pole $0.00 0 COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become Vold if work Is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiratlon of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446-46 (SM) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-tnsure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ f have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. NrMy workers' co�mps%fall Ins nce ca or and policy number are: / der. �o-�-LI _ Policy Number: _ _ 1 Q ��� 0 Z_D (This section need not bV completed if the permit is valued at are hundred dollars ($100) or less.) ❑ 1 certify that in the performance of the work for which this permit is issued. I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should became subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith with these provisi et _ !� _ Date: :W:1R1f1NFA 'OS WORKERS, OOMPF?dSATION COVERAGE IS UNLAWFUL AND SWILL SUBJECT AN EMPLOYER TO CRIMINAL PE TIES ANb CMR FINES UP TO ONE HUNDRED E is, 00,O oD IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. LICE 'CONTRAC OAS DECLARATION: I eby affirm that I licensed under provisions of Chap 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license Is in full once and off c. 0 z Class a C r Cas Signature: Data: CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is Issued. (Sec. 3097, Civil Code). Lenders Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or County which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sote compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Coda: The Contractors License Law does not apply to an owner of property who builds or Improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or improvement is sold within One year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (See. 7044, Business and Professions Code: The contractors License Low does not apply to an owner of properly who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more foot in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high, (Chap. 3.2, Grp 2, Art 2, Sec. 341, Tltlo 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 65 gallons, or 200 cubic feel of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic foot of compressed gas at standard temperature and pressure). .. ........... _............... _........ ...................__..... .._.._..............---.........._.—_................ ---.............. _...-............................... ,......,........,............................................................. _............... —.......... — .... _...... _......... 3 Does or will the appplicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required, has Section 25534 of the California Health and Sefesy Code boon fully complied with? ❑ Y a s ❑ No ................................. _.............. _.................................................... ... ............._..................... _.—_.................. —................................................................................................................................................... ---........................... _........... 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this 2pplication a�ermit for such construction or modification LI the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non•residentlal building permits). ................................................................... .............. 6 Wilt any part of the feGlity to be constructed under this permit be within 1000 feet from the outer boundaries of a school? j� Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). —._.......----- --- - --..... ..._.... _.... ---... _......... —................................ ........... _.......................... _.. _ 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ...................._.........----.._............_..._. _— _ .................._ _ ..................... _................__..... ............................................................................................................ .......................... .__.. .......— B I1 ...�....es", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION. OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and City ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signesur egai Owners Date An Date CODE_9 INSPECTIDHlYPE DAM IH>•1IL91<5 CODE 1 INSPECTIONIYP_E 1daIE INTMAL I 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1268 Pool $ Fina! 200 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Fina! Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final BuildinglOccupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 FIRE SUPRESSION PERMIT Job Address: 3333 BRISTOL ST Status: ISSUED Suite: 1242 Applied: 03/22/2001 Vicinity: SPACE 1242 - ABERCROMBIE & FITCH Issued: 04/1712001 Parcel Number: 41250107 Zoning: PDC -.PDC ISSUED BY: Applicant: LOONEY, SHEILA ' Address: 5200 E HUNTER AV Phone: (714) 993-2822 ANAHEIM, CA Zip:- 92807 1, •\ Owner: /,SOUTH COAST PLAZA' Address ' , %C J SERGERSTOM COSTA MESA, CA Phone: 3315 FAIRVIEW RD Zip: 92626 Contractor:,, 'ALERT FIRE PROTECTION INC Address: 5200 E.HUNTER AV Phone: t(714) 993-2822 l . ' ANAHEIM, CA, r i.Zip: _ 92807 t1 License: 316324 SCOPE OF PERMIT ,FIRE SPRINKLER PERMIT FOR INTERIOR STORE T.I. FOR "ABERCROMBIE & FITCH" (SPACE 1242). RELOCATE 76 EXISTING HEADS, INSTALL 9,NEW HEADS, & PLUG OFF 11 HEADS. , REF: lJoi:i-o152811_ 2. FEE SUMMARY Plan -Check: $126.91 ,r Calc Valuation: $11, o.00� Permit:, $195.25aimed Valuation:,, $t 1,o'oa:oo _Other: $0.00 _ r,�., -�h .._ V�� J Total: %'$322.1G i+• / V�V A �, .. ski: • ,> ,� _ - NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period d4804a)fa. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration,of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446.46 (6/00) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the —work for which this permit is issued. _V `I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compen Ic Insur ce carrier and policy number are: O -Carrier' Policy-Number: 1? JThls section need noTha completed if the pbrmit is valued at one hundred dollars ($100) or less.) , ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, agre that if I should become subject to the workers' Compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisions.Applnt Signature"' a A�x Date: 7 �7 WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND Si1ALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that m licensed and provisions f Chapter 9 (commencing with Section 7000) of Division 3 of the Business nd Pr fessions Code, and my license Is in full force and effect. LIc. # ,Class #. D �/ 4 Contractor's'5ignature: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or County which requires a permit to construct, after, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (Commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of properly who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant 10 the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No, Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION. ❑ I hereby certify that no excavation five (5) or more feel in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, fatsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 6, California Administrative Code). ❑ As owner-builder, I wilt not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .............................._................................................................................................................................-...................................,........-......-.....................................................-�-•------------........................................._.....-�------........... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ......................................................................................................................................................................................................................................•.......,....................................................................--------................................................. 3 Does or will the applicant or present or future building occupant need to prepare an RM PP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ........................................................................................................................................................................................................................................................................................................................................................................... 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No .............................................................................................................................. ---........................................................... ................................. ................................................................................................. 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? D Yes No (Section 65850.2 of the California Government Code requires that the requested information be fumished on applications for non-residential building permits). .......................................................... .............. ................ ....................................................... .............................................. I'll ...I............................................................................................................ --------......... -...... ......................... 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ............................................................. ............................................................................................................................................................................................................................... ............................................... ................................................. 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ................................................................................................................................... I................................................................................................................................. ...................... I........... ................... ............................... 6 (If yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION.OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree t0 comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. ZSignatur LegalOwner(s) 1225&Z 2! D 19 An r uthorize plicant /! Date CODE P. INSPECTION TYPE [DATE CODE ► INSPECTION TYPE PATE INTITIAL 1616 Fixed System Final Fire Prevention �� C) . 1 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final BuildinglOocupancy CITY OF COSTA MESA Development Services, Division of Building and Safety CERTIFICATE :OF .00CUPANCY This certificate is issued pursuant to the requirements. of the Uniform Building Code, Section 308 adopted by the City of Costa Mesa certifies that at the time of-rts issuance_the building structure herein below described was inspected and approved for occupancy as follows-/,' Building Address 3333 BRISTOL QST' SUITE 1242.'- Bldg: Permit Number BOO -01528 � USQL RETAI � � PDC Group Type of Construction II; i,�aa� �Fire�Zone Use Zone South , Coast "Plaza r�✓ ti� -_ "ABERCROMBIE b FITCH" Owner of Building — = '-.:' Tenant ' om 3315cFairvieWeRoad';,rCos`ta Mesa CA 92626 /y/� � -% Address t' 'Ad ?i ��_�..� ;�{ Y/- BUILDING OFFICIAL-Rick\A C.B.O. -10/8/28/01 \� c " Date�� /r REQUIRED TO BE POSTED -IN -A CONSPICOUS PLACE (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.WLDING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 ,lob Address: 3333 ' BRISTOL ST Status: ISSUED Suite: 1242 Applied: 09/27/2000 Vicinity: ABERCROMBIE & FITCH (STE 1242) Issued: 02/15/2001 Parcel Number: 41250:107 Zoning: PDC PDC Applicant: GORDINES, RON ISSUED BY: Address: 140 LOMAS SANTA FE DR #200 Phone. (858) 793-9104 SOLANA BEACH, CA Zip: 92705 Owner: SOUTH COAST PLAZA Address %C J SERGERSTOM COSTA MESA, CA Phone: i 3315 FAIRVIEW RD Zip: 92626 Contractor. DICKINSON CAMERON CONSTRUCTION CO INC Address: 140 LOMAS SANTA FE SUITE 200 Phone: (858) 793-9104 . SOLANA BEACH, CA Zip: 92075 License: 690239 Arch.: ROY J YODER Eng: SRA Address: 4111 EXECUTIVE PKWY Address: 7646 SLATE RIDGEBL Phone: 614-794-7320 I Phone: 614-755-2562 WESTERVILLE, OH REYNOLDSBURG, OH Zip: 43081 License: 43068. License: SCOPE OF PERMIT 9475 SF INTERIOR STORE TI FOR'ABERCROMBIE & FITCH" IN STE 1242. - NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval most be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2416-46 (6=) FEE SUMMARY Plan Check: $1,319.34 Calc Valuation: $284,250.00 '+ Permit: $2,029.75 Claim Valuation: $284,250:00' SMIP Res: $0.00 SMIP Com: $59.69 Other: $0.00 - .Inspection: $0.00 Total: $3,408.78 .. PLANNING & ZONING SETBACKS' `•� ' /.� ,;, MAIN STRUCTURE Front 0-0 -Rear 0- 0 Left 0-0 _Right 0- 0,;/ ACCESSORY — - Front 0-0 Rear 0-0 Lek 0-0 Right' 0-0 PARKING Existing: o Required: '0 Proposed: 01, '. NOTES: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval most be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2416-46 (6=) DECLARATIONS WORKERS' COMPENSATION DECLARATION: _ I hereby affirm under penalty of perjury one of the following declarations: , ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the ork for which this permit is issued. Irhave and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued, - My workers' 'ccompen ation Insurance cc4merr and policy number are: / (Carried Owl (��. of /'r �.av C l a re 5 Polley Number 1 i(This section need not be completed if the permit is valued at one hundred dollars ($100) or less.) ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that If I should become subject to the workers' compensation provisions of Section 700 /!fhe tabor Code, I shall forthwith compywith ons.�- � 501 Applicanf,Signat WARNING: FAfLU TO SE E WORK ' C6MPF1dSATiON COVERAGE IS UNLJ4WFLIL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL P TIE AND CML FINES UP TO ONE HUNDRED THOUSAND (5700, ►, IN {TION TO THE COST OF CCMPENSATVON, pAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that -l -am licenseld under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license Is in full force and effect�Lic: J O a ClasS4 ` r ContFactors'Slgna re: Data: - l CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is Issued. (Sec. 3097, Civil Coda), Lenders Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ t, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a conlractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sac. Business and Professions Code for this reason: Signature: Data: Owner ID verified by drivers license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person Is required to descend, will be made In connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone 10 do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safely Permit Number. HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and cortity a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code. with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic foot of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. a If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? C3 Y a s ❑ No 6 Does or will the applicant or present or future building occupant require for the work which Is the subject of this a plication aggermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). _ ............... -i..................... ..._......--------...........—.........._— .._. _. 6 Will any part of tha facility to be constructed under this permit be within 1000 toot from the outer boundaries of a school? ❑ Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). _..._............................... ..... ........ __,__.—..- ......... _...-- ----. — 7 If a permit from the South Coast Air Quality. Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 boon made? ❑ Yes ❑ No 8 (If 'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given Is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature Of Legal Owner(s) • D e And/Or Authorized Applicant-'- I [-/Data_ CODE It INSPECT! InE pill INTITIA CODE I INSPECTION TYPE UN eta 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site �j 204 Final Demolition 250 Final BuildingrOxupancy f- (714) 754-5273 • Fax (714) 754-4856 • www.cl•costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 BUILDING PERMIT Job Address: 3333 BRISTOL ST Suite: 1242 Vicinity: 1242 Parcel Number: 41250107 Zoning: PDC PDC Applicant: COMMERCIAL SIGN & LIGHTING INC. Address: 7422 VARNA ST Phone: (818)764-6791 NORTH HOLLYWOOD, CA Zip: 91605 Owner. SOUTH COAST PLAZA Address /-k d SERGERSTOM COSTA MESA, CA Phone: 3315 FAIRVIEW RD Zip: 92626 Status: ISSUED Applied: 03/26/2001 Issued: 03/26/2001 ISSUED BY: Contractor: COMMERCIAL SIGN &LIGHTING INC.01_ 90%���n r� U Address: 7422 VARNA ST v �f Phone: (818) 764-6791 9 NORTH HOLLYWOOD, CA '• Zip: 1 91605 'License: 263327, Arch Eng:". ` Address: Address: ' Phone: Phone: .Zip: License: License: " - SCOPE OF PERMIT; { INSTALL 2 INTERIOR SIGNS, STORE FRONT SIGN IS ILLUMINATED: ABERCOMBIE'AND FITCH. FEE SUMMARY. Plan,Check: $41.05 _ _ `: > Calc Valuation: $1.800:001 'Permit: $63.15 - , - - - Claim Valuation: ] ` - X1.800.00' -SMTP Res: $0.00 SMIP Com.. 30.50 Other: `$0.00 .. � Inspection:' -$0.00 r. Total: $104.70. PLANNING ;& ZONING SETBACKS,. MAIN STRUCTURE Front 0�0� Rear. 0= 0 Leff : �0 0 _� Right 0, 0 ACCESSORY Front, ` 0-0 `. Rear'' 0-0 Left 0-0 Right ' %0- O', PARKING Existing: 0 , ' �� �Reguirecl: 0_ Proposed: 0, NOTES: ' NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12.21-92) EXPIRATION: This permit shall automatically expire and become vold it work Is not commenced within 180 days, or If work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 2446-46 (6=) DECLARATiONS WORKERS' CQMPENSATION DECLARATION: r- - -�• _ ' I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to setf-Insure for workers' compensation, as provided for by section 3700 Of the tabor Code, for the performance of the work for which this permit is issued. � I have and will maintain workers' compensation insurance, as required by section 3700 Of the labor Code, for the performance of the work for which this permit Is Issued. My wo rs' mp SatInsur Ce cam d poticy number are: Carrier: Policy Number: VI1 Q TZ lcfZ (1 -his section need not 0 completed it the permit Is va sd of one hundred dollars ($100) or less.) ❑ 1 certify that in the performance of the work for which this permit Is issued, I shall not employ any person in any manner so as to become subject to the workers' compass of California, and agree that if I sh Id become subject to the workers' compensation provisions of Section 3700 0 the Labor Code, I shall forthwith comp a revisions. r 26 ,d Arlignature: Date: W FAILURE SECURE WORKERS' ENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL ENALTIES AND CIVIL FINES UP TO ONE HUNDRED T 00 E (Si OD,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECT)ON 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENS 0 CTORS D CLARATION: I her a that I am lice d under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business�dPr fens Code, and my license Is in full to e a effect. Lic. a Z' Class a _ on actor's Signet Data: 'abwjUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lenders Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under, penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason {Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct. slier, improve, demolish, or repair any structure, prior to Its Issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions o1 the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Prafessions.C6de) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to E`civil. penalty of not more than five hundred dollars ($500).): El 1. as owner of the property,'o� my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sac. 7044, Business and Professions Codi. The Contractors License Law does not apply to an owner of propony who builds or Improves thereon, and who does such work himself or herself or through his or h6i Own employees, provided that such improvements are not Intended Or offered for sale, It, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or dead): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth Into which a person is required to descend, will be made In connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more then thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341s, Title 8, California Administrative Code). ❑ As owner•buildet, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires. with some exceptions, that a Business Plan be tiled with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure), ........................._...................-...... _ ... .._......_.--...._.......—_.._.............__..................... _.................................................................................. _......................... _.............................................. 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 Of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight o1 500 pounds, Or a volume o1 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No Section 25534 of the California Health and Safety Code provides that the Costa Masa Fire Department may require the preparation, certification and tiling with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP Is presently required, has Section 25534 of the California Health and Safety Code been fully, complied with? ❑ Yes [I No ----..._._........................................ .. ... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes j� NO (Section 65850,2 of the California Government Code requires that the requested information be furnished an applications for non-residential building permits). -.........._._----....._....._ _...... _......_._......................................................._.............................._._...................._._. — ............... fi WIII any pan of the facility to be constructed under this permit be within 1000 feet from the cuter b0undarfas of a school? ❑Yes C1N0 (if'yee, the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ---... ...... _..-_..................................... _............ --- ........... __..... --•••—_.._._......- -- - 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No .............................................. -......................... _............................ _.......................................................................................................................................................................... _. _.................... 8 pf yes , attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above IS correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION. OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. C ygtature Of Legal Owner(s)75/ � f Date {A/ r uthorized AppGca t` CODE 1. IHSPECTIONTYPE ISIIDA1n"t CODE I INSPECTION TYPE PITIF. )NIS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final SlocklRetaining Well 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final BulldinglOccupency CITY OF COSTA MESA _ BUILDING DIVISION t DEVELOPMENT SERVICES DEPARTMENT E98-00719 PERMIT PERMIT NUMBER (714) 754-5273 • Fax (714) 754-4856 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT ,lob Address: 3333 BRISTOL ST Suite No Vicinity: ROBiNSON-MAY ENTRANCE STAIRWELL. Parcel Nunmber: 41250106 Applicant: Address: ROBERTS, STEVE status: ISSUED r� Applied: 07/09/1998 V Issued: 07/09/1998 Phone: 949-469-1270 Owner: SEARS,,ROEBUGK-&'COr' = Address D/768TAX,62-116A� , �J HOFFMAN'ESTATES,IL --Phone:=�.= RD � �rzip:Contra,�3333'BEVERLY S/ ,E \ ✓�� Address: 12 SAND,POINT Phone:714-495-3541 �LAGUNA'NIGUEL, CA Zip: 92677 •License:ri380116•� �� j r r r• �' �,'+;1' , ]71 A/% fI f ,.rf �1 J 1r '� 1 /�,��� ,, ;c3 'SCOPE OF PERMIT -'� -� / 1` RELOCATE.L[GHTING PANEL AT STAIRWELL AT ROBINSON-MAY ENTRANCE. FFEE SUMMtAR00, L7 Y�I 4I._Qua'ntity-- _ _ - _ _-- - _ 1 Quantity *� ISSUE FEE $22.00 Temp Dist System7.0ighting ? $0.00 0 c , �? Ter'np service test '�I ;� $0.00 rh` Busway 1100 ft $0.00 0 ' V i Res: a/c acke a 1' i1� $0.00 'U��;�,s_ p g 5 i �, Standing` Section L $0.00 0 New Res (1-2 units) I� rel i $0.00 - .0 - - - -- _Mise Electrical Equipment $0.00 0 - ' 1 New Res (3+units) �+�;? $0.00 0 - =`Transformers up to I kvallcw , $0.00 0; Pool 1`Spa 1� $0.00 0 ................up to 10 kva/kw $0.00 0� f :, Lighting Fixts $0.00 0 ��1`up-to_50 kva/kw x,$0.00 Recept Outlets r 4 `� $0.00 j 0 .......... .......up.to.100 kva/kw 1$0.00 /",0 Switches �\\ `� 1 \ l� $0.00 0 ..................over 100 kva/(w j $0.00 Non Res Switches, �" / `$0.00 0 4Low Voltage Equipment 1$0.00 ffj'0 Res Appl \`J �� " $0.00 0 �y� jLow Volt Wiring System / Ckt $0.00 �/ �0 �$.. , Service to 20pa$O.Oa 0 "` Misc:'Conduit $0.00 0-% Service to 1000a\ $O.QO� ! 0 ��� ��Misc: Coritluctor $0 00/ 0� ' / k Service over 1000a $0.0D 0) c� ~C `"'' .ti ...� // ^0„ �;�,, Cercus(gen,or-ride) t, /$0.04, 0 Motors to 1hp A �, /$0.00 �� �0., �'r,. �� ` Circus;(rrrech ride or lights)'- j�$0.00%� 0 j Motors to 10hp ✓ $0.00 .0�� .v \� y Christmas Tree Stand� � E00 l 0 �{ f Motors to 50hp �. `�$0.60,� j , �0� � .`' c.� Fireworks Sterid= %� $0`.00' �0 Motors to 100h $0.00 0 �� `1 Other ElectneaI Fee- � P �•-� s i $0.00 Motors over 100hp --so-60">/ 0'�. Communication drops $0.00 i��/ �0 Investigation; Fee $0.00, Sub panel to 200a $27:25 =.\ -�,, C ,'r r r -Plan Clieck'Fee�11'� $0:00 Pole Light Pkg $0.00��_ �0 - r r ` 'Reinspection Fee $0.00 Sign Circuits $0.00 _ -�- r Temp Pwr Pole $0.00 0-� � ;, � �,-.,,TOTAL CALCUIJ#tE_D.FEES $49.25 Intermed Pole $0.00 0 COMMENTS 1 SPECIAL CONDITIONS EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work Is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL- (714) 7545628\ 1 DECLARATIONS WORKERS' COMPENSATDON DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for.the performance of the work for which this permit is Issued. ❑ I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. My workers' compensation Insurance carrier and policy number are: Carrier: Policy Number. (This s on need not be completed if the pe is valued at one ollars f$ f 00) or Jess.) I certify that in the performence work for whi is pe Is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Califoml agree th s e subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisions RRlicant Signature: Date: WARNING: FAILURE To RE ORKERS' COMPENSATION &VERAGE IS UNLAWFUL AND SHALL SUEUECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000}, IN ADDITION TO THE DOST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 37M OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licenserovislons o ap�03 encing with Section 7000) of Division 3 of the Businessnd Professions Code, and my license is in full force and effect. Lic. # ll Class a Contractor's Signature: 4 r Date: CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is Issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commending with Section 7000) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL 00 THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors Ucense Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not Intended or offered for sale. If, however, the building or Improvement Is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers fcense. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, Califomia Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number. HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every ,business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ........................................................................................................................................................................................................................................................ 2 Does or will the applicant or present or future building occupant Head to file a registration form for acutely hazardous materials? ❑Yes ❑ No (Section 25533 of the Callfomia Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .......................................................... ................ .......................................................... .......... ............... .................................. ............. ............. ..................... I ........ .——............... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the Califomia Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ........................................................................................................................................................................................................................................ 4 if an RMPP Is presently required, has Section 25534 of the California Health and Safety Code been fully compiled with? ❑ Yes ❑ No ......................................................................... ........................................................................................................................................................................................................... 5 Dass or will the applicant or present or future bulldi'ng occupant require for the work which Is the subject of this a�gplication a�ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency ❑ Yos ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ........................................................................................................................................................................................................................................................................... 6 Wiil any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if yes', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). .................................................................................................................................................................................................................................................................................... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency Is required for the work which is the subject of this application, have all o1 the disclosures prescribed by California Health and Safety Code Section 42303 been made? [3 Yes ❑ No ................................................................................................................................................................................................................................................... 8 (If yes', attach certificate of compliance from the appropriate air pollution control officer), CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Dale: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and inances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described pr arty for inspq pu s agree not to occupy or allow occupancy of any building authorized by this permit until final Inspection. SIgA We 2!Ed'OWn8r(8) _ Date,;; A d1Or Auth n ed Applicant - Date CODE f. INspF&aQy DT om INTMALS CODE l IN4UgnoH n De>F INTnIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final - 208' ' Final Plumbing 200 Final Re -Roof 210' Rnat Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy 2x4646 AMESS OF MALDIRO; 3333 BRISTOL S T u�T- ADM I N OMFrSNAYEIFKNOWW-•C J SEGERSTROM FLOOD: AO -38 =Rm 3315 FAIRVIEW RD COSTA MESA,CA 92626 J 435-2019 APPL. MAILING AODREM ARCHITECTOROMEER: DAVID OLSON uc.NO.: C19424 ARCH. OR E110.'S ADDRESS: 6 MORGAN ST Ulu: 100 IRVINE CA 92716 cONrRAcI'ol IW—' WATSON60 (714)662-7933 cONTRAcroRs M Res- COSTA MESA CA 546538 OGAN AV AgDREss 92626 u,r.. B —1 LICENSED CONTRACTORS bECLARATiON: I hereby allirm under penalty pamthat I am licensed under proviaiona prtttapter 9 joommencing with Section 7000 of Division 3 d the Business and Professions , end m license is in fu and off cffY uc. cNO.: 4 7`14 uc. class: B LIC,No.: 6 3 9 B Date: Y ` + Contrador. NER BUILDER DECLARATION: I hereby affirm under penaAy of penjoy that I am exempt from1h.Condractam License Law fo the lottowig n reason (Section 7031.5 Busess and Professions Coda: Any cty or scummy which n"4rdtes a Permit to construct. afar. improve, imd e'sh, or repair any structuts, prior to its issuance. also requires the applicant for such permit to fila a signed statement that he or she licensed pursuant to the previsions of the Contrectons Licen" Law [Cheerer 9 (oommeridng with Section 70DO) of Division 3 of the usiness and Piles r ons Codef or than he or she is exempt therefrom and the basis for the alleged exemplion. Any violation of Section 7031.5 try any applicant for a permit subjects the applicant to a evil penally of not more than five hundred dollars TMD. ❑ I, as owner of the property or my employees with wages as their We compensation, will do on work. and the structure is not intended or offered for sok (Section 7044. Business and Professions Code: The CaMradaro Licata" Law does not appy to an owner of property who builds or improves thereon, and wdo does such wort himself a herself or Ovo gh his or ler own employees, provided then such improvemem are not inlended or offered for sale. t. however. Ih" building or improvement is sold within are year of oomplookm. the owner -builder vAn have tha burden d proving he or she did not build at improve for the purpose of mkt. ❑ I, as owner of the properly, am exclusively eomradig with "- Ie ed contractors to om»uuet the project (Section 7344, Business and Professions Cade: The (,Wractas License Law does not apply 10 an owner of property who brdlds or 'snprovas Iherew and who contracts fa such projects with a contractor(s) licensed pursuant to the Owdradors License Law). ❑ I am exempt under Section: B. A P.C.. for this reason: Date: Owner: I do hereby centity that I am aware of and understand the requirements of California Health and Safely Code Sections 25505, 25533, and 25574, and that I or any (inure building occupant win ! will rat joirels one) need to comply with said state codes and the requirements for a permit for construction a modification from the Al t anagemaq Qi%lnci Re�ident camafrudion eppicst era exempt from d+ssa proviabm. Date: Applicart: WORKER'S COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one d the following dadaretional ❑ I have end wit maintain is eertifiede d orient to safftnsura kr workers' compensation, as provided for by Section 3700 of the Lauver Code. for the perfonnmmoe of the work for which this permit is Issuetl. I he" and will maintain workers' oompensation insurance, as required by Section 3700 of to Lebo Code, forth a performance d the work fm which this perrnh is issued. My workers' EMiC insubar are: Carry: 1oreaMmEXPIRES Pollen Number: MOM 6A 04/01/98 . This section need naw be oor Wk&d 7 the permit is tar are hundred doWrs t J or Is=.) ❑ 1 certify that in the performance of the work Far which this penny is' Iohm nor any any manner oro es to become subject to the workers' comparaation mew. of California, neeLIhd it fto the wodom, tnmpe ion 'siom of Section 3700 of the Labor Code, I shall foci co those 's�i Date: i '"r AppflraM: ling: Fallure to secure worksro' compansatton coverage Is unlawful, and sfsll sub t an "rployer to crt Ural pertain" and clvfl tinea up to one hundred thousertd dotlons ($1001000), In &WIffon to the cost of rorrpensadon, deny pas as prodded for In Secdon 3706 of the tabor Coda, lntataat, and attorneys fees. CONSTRUCTION LENDING AGENCY: I hereby affirm under pandty of perjiuy that there is a construction trading agency for the performance of the work for which this perm[ is issued (S"dion 3097. Civ. C►. LENDER'S NAME: LENDER'S ADDRESS: I certify that I read this application and state that the above infonhation is caned. l agree to campy with all city mond county ordins nose end elate k re ng to building construction and hereby authorize mpresertlatives of this city to "Mar upon the above-mentioned property for inspection ar. . DUSTY WAT N Dale: Signatu d OwnedAgantl rector (5151.45.WP) What -Building 6 Safely, Grsen­Rla; Canary-Appkant: 1`4041evenue; Goldenrod-Aeseseo CITY OF COSTA MESA - BUILDING PERMIT PERM NO: B 08381 PERMIT NO: B 083813 PLAN CHECK NO: 02654-97 A GOVT: N SUPP: N CONSTRUCTION TYPE: I FR PERMIT TYPE: STR PURPOSE: ALT JOB DESCRIPTION EXPAND OFFICE 70SF INTO EXSIT COURT AREA SQ FT: 30,000 CLAIM VALUE: 3,000.00 CALC-VALUE: 30,000.00 GROUP OCC: B / COMMENTS: MISC ALT TO SOUTH COAST PLAZA MANAGER'S OFFICE Z 0 N I N G R E Q U I R E M E N T S S E T B A C K S ------------ MAIN BUILDING ---------- --------- ACCESSORY BUILDING--------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN PARKING REQ: PROV: PARCEL: 41250107 ZNE: C1 -S REF NO: PLANNING NOTES> INTERIOR ALTERATION FOR THE PLAZA ADMINISTRATIVE OFFICES. �M;t!#E*��iEdEdEit*iE1E*iF9tif�FM;iUfiFiF*�EiEiEiE:1Eit*fik�F����4iE�**'1F9E�***ifiE�it*act*****�dEiE**�FiF*iFitftFiFiFiklE**9E��t•** D E V E L O P.M E NST S E RGt V I C E S R E Q U I R E M E 'N' T S/ 1 0111 - ZONING APPROVED BY Inj �I� DATE: -y''- -1 /z4127 BUILDING APPROVED BY' rtSPA DATE: -7/7-447 APPLICATION ISSUED'BY: 1' DATE: :f7 2% LEGALIZATION:N F E E S U M M A R Y STRUCTURAL~SEGMENT:Y BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT 394.75 SMIP/NON-RES PLAN 64.15 6.30 ISSUE FEE BUILDING -DIV-> PERMIT ISSUE PLAN -CHECK TOTAL PAID DUE TOTALS----> 401.05 0.00 64.15 465.20 465.20 .00 REVENUE DIVISION TOTALS—> COLLECTED: 401.05 OVER/SHORT: 00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN -CHECK 394.75 6.30 dEdEAE*i6�1lifdf�ldEdF'IEiE**�;ItililjF#�k�[•�FiE*ilkiF'1Ffrt�Eilk**AE��l�iE�*iE*�!*�9t�tIH*iFitiE�E'1F �l•�EiE�F9l•iF*i!•***'>i")1'if9E*dEdEdE*?.t9F IND I V I D U A L FEE BREA�IgrTDOWN TYPE QTY D E S C R I P T I O N _`519 1T COST TOTAL COST SFC 30000 T.I. OFFICE BY VALUE ;I a G9- 1.00',. 30,000.00 END OF FEED & � C, �s e�am . Ib\� a a. 67-21-1997/83:87 PNA401.03 �L5)1 PERMIT:10838I3 CONSTRUCTION AND PLANNING: FQO' 'PA i Date Inspector Date Inspector !#TROVALS Permit # APPROVALS Permit # I, Temporary Electrical Service or Pole 52. Pool & Equipment Location 2. .5oil Pipe-Undrgrnd. 53. Steel Reinforcement tit :Electrica�Co* lt_lEJ Iity Undrgrnd. 54. Forms 4�'Electrica l -Cg uit�l r�drgrnd. 55. Electrical Bonding ,.154 _6t 1 Reinforcement 56. Rough Plumbing & Pressure Test X - w +�6:lectrica}fliE�ir rrid. 57. APPROVAL•TO COVER-GUNITE -F, `;" 58. Electrical Conduit'-Undrgrnd: 8. Foundations 7I> 59. Gas Pipe, 0 tindrgrnd., Test §5water Pipe-UndArnd...t 60. Backwash Lines, P -Trap, O Undrgrnd. 10. Structural Floor -System 61, APPROVAL TO•DECK 11. Property Sewer Line & House�,Connection 62. Backwash & Re6eptor•Final- 12. Sewer Cap - 63; Heater & Vent -Final �]3. Roof Drains - 64. Plumbing System - Final L4, Rough Plum g --s 65. Electrical -Final t 1i5. Rough Electrical -Conduit "66., Solar SYsterrt Fti,naO U - W • -7 - �6. Rough &"ectric`1'4ltliring, •67. Fencing & Acm"s Approval. it7. Rough Wiring Sign " 68. APPROVED FAR'PLASTERING. `. t "98, Rough Electric�,t+•T Bar Ceiling69. POOL/SPA SYS MS -FINAL 19: Rough Heating & Air ConditioningFIRE DEPT. REQUIREMENT' 7 ti rrti r., rn M w zr -0n,1y'- tw 1. C 1J 20, RoQh F�cto�r+ R,�eface ` S cam' £ `�' APPA01 Ai -JP a PTtrnit 21.�bur c, in$truGturv.r: ! riS 7 "* 70.�Undergl�eu d I dro k 22. Dui , 1lenti�tin 'k I f3 A 'KS +: ' r - E * 71. Product`-Piping`roij3as Oil -j w . .e. .•. ,- 23. Gas ipe_Roagh &fest s I wt .' ir± -j; O it 72. Underg?dund Fkaht, 24.'Ro6l Fr�trting' t-4' `'`" `" � "*73� Undergr6d'StgYj3Tank El Gas 0.0il .L% r i M P. L, Sv. 3 7 w 25. RooLS4pthing r_ �r V i r� .• � > CU.i. 7.4•.aOvel:head Hydf3~ r: 26.-T•B517 Ceiling (Ste"ural) &Vmoat `_ r ro ^k t.: s O >: t 1 -p �qT ca f F,,. • i 27.�Framead Flashiflgx.�� 'z 76. r 4taa_! M tr Dry Siper-• i� 28. Lot ng&Siding�t a•�" 7Z. FIXEDtFSTEjVjFIN�L� .� CJ 29. Insulatlgy•t �D 1, S t:IY 7$. FIRE PREY. FINAL -'' > 30. DrywallSgailrng,U�#ALT€1 DEPT,-REIJUlMENT ' 1 rTi :tet * ! '_T? �k I�_ ' , +X 1 •.. r fi L� _ 31. Plaster8rawn40oat;• s ! -rtr x f. # 7T F I NA L if,6PECTAO N E 32.rEIectriW;PorWer fleeter•=Fipa1 r N I + 80 FOOD CERTIF Oa TE � ED 33.1in k ElUtriB. r3 y r1 i W "� Dotes: -� M I_ ' atin-At+Cordiionie Cf'34.,Finat Heri ; a ..,VIA j! ^ ;..ti .• i) a i' ^ -i ` F-' y •Y 35 "1z in 1 Gas. Pi �a Fp•Tes�tr S X`_f*. 36. Hood t7r�Ca noPY� v r n .� :� tT- d t'," k• 1 C' M R• e"1 � hi ti "' � � fK ,h 37.`�inW.Fa�y�ory Firep e --'r�� ri a + , i Y is -7:, 38.cFinB�Plumbing � " u -� t• " 1 i �. �~ 13 39.,Water S?ry ices•'Fina1� I s-¢ * ; `` .I 40.'bsService-F_Inain * rrs c;^r=' W r { f; Or+ 41.-Sotar 06*est c-Fpol 42. ackflo,rPrevenLer:i -i y ru _1 43. Backflo4IrrLgationfi :44. Landscape Irrigation Systertr*: m.I -T, 4 e , � -r t< E-4 7 5L,Sound Aitteritfatior� i- t*s ;- -t � -- :r � H: %46.'Handicap.8egulatiops .J x ` r s AAZFINAL STRUCTURE & BUITIDING ^ {� Iti y- a. 1 [ ! 4$_ FINAL PLANNING: - :�: t� t E r :-i C ,• O e k n , t : 49i'ElecOic Release to Edison {� ' Y =50. •Gas�cfleluse to Southern California Gas Co r x it. r+ D .a: S 14 5V CePiTlFICATE OF.�000UPANC .c r rJ !T; s ra No. Date is AttnnsocMum- 3333 BRISTOL ST mNV:;tNwEiFIDm--C 3 SEGERSTROM awns: 3315 FAIRVIEW R92626 COSTA MESA,CA 7 435-2019 APDL. NAILING AtfMM: UM: ADM I N FLOOD: AO -38 AIICHiTECT OR E NEER: DAVID OL S ON luC. No: C 1 9 4 2 4 ARCM OR ENG'S ADI)OM 6 MORGAN ST UNIT: 100 IRVINE CA 92716 CONTRACTOR'S11MM ROBERTS ELECTRICAL CONTRA (714)894-8741 CONTRACTOR'S YAIUM 12 SAND POINTE m,m. LAGUNA NIGUEL CA �Ng., 380116 92677 UW; LICENSED CONTRACTORS DECLARATION: I hereby affirm under perety of parpay that I @m ioansed under provsiom of Chapter 9 {mmmencng with Sedion 7000) d Diobion 3 d the Business end Prdania Cods, and my hoarse is in to faros and affect. CITY uc. NNO.: 0-2713 8 4 4LIC. CLASS: C 10 LIC. No.: 3 16 E 7 Data: convanar. OWNER fr BUILDER DECLARATION: I hereby a m undernd paty perjury than i am exempt from the Contractors LioWnse Law for the lodovhV raeaon (Section 703iS Musics std Prdesaioro Gods: Any cty a county which requmpermit sa a per to construe[, after, krorove, drndsh. or repair any Structwe, prior to b 'asu a ce, also requires the app6am for such permit to Tie a signed stmei mw *0 he or she n licensed pursuam to the provisions of the Contractors License Law Law [Chapfs 9 (oonmrucuq with Section 7000) dv Dsd lan 3 the 3tsiness axed profess ions Code] or that he or she is exempt therdmm and the bass for do alleged erurnption. Any violation of Section 7031.5 by any applicant for a permm subjects the appliiam to a ars penalty of not more than rove hundred dollars [5500]). - p I, aW owner of the prapemy or my employsWs with wallas as their sole mmprsmion, will do the wok and the gn wkwe is nal irtemded . or offered for sale (Section 70", Business and Professions Code: The Contractor License Law does not apply to an owner of properly, who builds a improve* thereon. and who does such waft!a i or herself or through lin or har awn employees. Provided that WAIN •. Improvements are not kaeruded or offered for sale. 1, howe -ar. the building or impwwwnens is sold with m are yew of oorplation, the . ownerbui ler wig have the burden d povitq he or she did not hold or improve for the prapoae of wale).' �] 1, m owner d the property. am axrhsirey oorrracfrq wbh fioensed eararaclose to nonstrw Ihe project (Section 7041, Busman and Professions Code: The Cordroctors Lieerue Law doss +Nat apply to an owner of property who bends or imposes thereon and who •, contracts for such Projects with a oar' ods) Warned pusurm to the Cowactors Lloerse Law). ' Yr ❑ I am exempt oder Section: B. & P.C.. la this renon: Date: Owner: . I do hereby termly [hal I am aware of and understand the requmemerts of California FbeRh and Solely Code Sections 2551M. 25533, and 25531, and that I or any here Isaldwug 000 mm wal l wra mol (circle ore) need to cw" high Wail surds codes end the nuquirem@rrs for a penia to mmmmuon at modocoion tram rte Airy emepanmt DaM. PAodsiW oomnaon appivastiaro an exampl horn theca prarisipre, Dale: AppGrams: WORKER'S COMPENSATION DECLARATION: I hereby affwm under prehy d Perjury ere of ft following declarations: 0 1 have and wil mantai, a osmdurate of aaeera to sel;nsue lot workers' oonNpeN+anlon, as provided la by Section 3700 of the labor Code, for the pedammerve d do wok for which this perms is issued. ❑ 1 hers and wtl maird= workers' own ion ieuanc e, as required by Sertian 3700 d the labor Code, lar the prformanw d the work for whidh this pens is issued. My workers' compensation hneaer,ee wrist rhe parity number are: Carrier: Policy Number. (71his sedion need not be compyered i Ow permR is for me hundred dAn JIM] or Aus.J I ceruy tum in the performance at the Walt for which this perms is ism cf, I shelf employ eery any so n to ii become subject to the workers' ownparemion law@ of CeLdoms, sal i I WlNadd '/[lis worker' mrhpe saiion Provisions of Section 3700 of the labor Code, I shall torch with Data: 1 Appfiart: Wamin : Adfum to serws vorkr@' contowsadon eov y p. is AnkwfK and shall suejacf an wW4yer to erfrdrel poaddss and ctwo Ong tF to aha huhdmd diousand dolbra (S104000A Am addition to the cost of corrWarANUM denWas a provided for In Sargon 3706 of etre Labor Code, kms saL and aRamey's fma CONSTRUCTION LENDING AGENCY: I hereby affmn ods penalty of perjury UW then is a construction isrAft agency for Oo perfomante of the work for which this permit s saued (Section 3097. Civ. C). LENDER'S NAME: LENDER'S ADDRESS: I cerufy thm I have rad dNs appk4mm and sues Iha< the above WorrWion is oared. lag to aompy with M dh end ooNasY ordshanaoas and store laws relating to hrddiNg mestruaboh and hereby author¢e haprssrrtativu of this city to enter upon the above-owdio ned property for inspection purposes. STEVE ROBERTS i Dom: of (5151d8.WP) Whit&4RAft d Safety; Green -We: Canary-Appicaq; Prole-Ravenue: Goldenrod-Assomor CITY OF COSTA MESA - BUILDING PERMIT PERM NO: E 083664 PERMIT NO: E 083864 PLAN CHECK NO: N GOVT: N SUPP: N CONSTRUCTION TYPE: I FR PERMIT TYPE: ELE PURPOSE: ALT JOB DESCRIPTION : EXPAND OFFICE 70SF INTO EXSIT COURT AREA SQ FT: CLAIM VALUE: CALC-VALUE: GROUP OCC: B / COMMENTS: MISC ALT TO SOUTH COAST PLAZA MANAGER'S OFFICE, RE:B83813 Z O N I N G R E Q U I R E M E N T S S E T B A C K S ------------ MAIN BUILDING ---------- ---------- ACCESSORY BUILDING--------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN PARKING REQ: PROV: PARCEL: 41250107 ZNE: REF NO: PLANNING NOTES> > ? �. )F1tlt*ititit�lt�t�tlt�itit***it*moitit*dE�*�dE�***its*it�t,7F9t9F9f it i4*lt�t;ytirriFatdf•lt*dE*•lt,ytdE�*;rt 9t�t•Ir'�t�t•IF9FaE*iF*****9f �F# D E V E L O P M E N T S E_R V I C E S R E Q U I R E M E N T S ZONING APPROVED BY DATE: BUILDING APPROVED BY , DATE: APPLICATION ISSUED BY: DATE: •lt �! *?fE ?IE * * * * it !t irk * �t * �t 1t >tit * *,tit it �t * * �t � 9t 9t ,yt it,yt �t •Il• LEGALIZATION:N F E,E S U M M A R Y STRUCTURAL SEGMENT:N BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT 28.00 ( 50t SMIP/NON-RES PLAN ISSUE FEE 22.00 BUILDING -DIV-> PERMIT ISSUE PLAN -CHECK TOTAL PAID DUE TOTALS ---- > 28.00 22.00 0.00 50,00 50.00 .00 REVENUE DIVISION TOTALS—> COLLECTED: 50.00 OVER/SHORT: -00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN -CHECK 50.00 * it it * it }t ,7t •1t 3E * 9t it �t it it it 14 � ?ft �t'1F'1t'lt it it zW * * � itit i7t it * * ?IE i!')t * * iyt � art ,7! alt dF 9t int !t dE it * * >7t iht �!• •IE alt dt'lF � i't �t >tit it it •It •It •It iF 'It •It �[• !F �t it >It iF ,tit it I N D I V I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST ELE 10 FIXTURES, LIGHTING 1 ST 20 EA. 1,00 10.00 ELE 18 RECEPT/OUTLET 1 ST 20 EA. 1.00 18.00 END OF FEES The work authorized by this permit shall comply with all applicable handicap access requirements under Calffoml statutes and relented ►egulagons. 17-24-1997/18:48 PAA52.89 (Ord. No. $2.20, § t, 12-21-$2 RCPTa:01-0229599 1 PERMIT : 083864 i h ti POOL SPA CONSTRUCTION AND PLANNING APPROVALS Permit # Date Inspector APPROVALS Permit Date Inspector 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location �f s 2. Soil Pipe-Undrgrnd. ,' 53. Steel Reinforcement r �:-Electrical: CordUit UfiIity-Undrgrnd. 54. Forms 4.; Electrical Cor�dOit-I. drgrnd, 55. Electrical Bonding -� 5y :Steel Reinforcei�ep� 56. Rough Plumbing & Pressure Test " x6. Sectric0)1FFER jRpd. 57. APPROVAL TO COVER•GUNITE `:�, •Footings rm 58. Electrical-Conduit-Undrgrnd. y8. Foundation) �L', y Z> 59. Gas Pipe, Q Undrgrnd., Test " 9, "Water Pipe-Undrqrnd. 60, Backwash Lines, P -Trap, Q Undrgrnd. 14. Structural Floor System 61'• APPROVAL. TO DECK ' 11. Property SewerJLine,& HousF'Connection62. Backwash & Receptor -Final I 12. Sewer Cap X ' •. 63. Heater & Vent-Finai „1,3. Roof Drains `: 64. Plumbing System - Final X14. Rough Plumbing; -• 65. Electrical -Final '15. Rough Electrical -Conduit 66 iar Systen-Final Hifi. Rough EiectriclNiritig `• _ 'r, Fencing & Access Approval 77. Rough Wirtng Sign - ` APPROVED FOR PLASTERING T8. Rough ElectricAT Bar Ceiling -6- POO USPA SYSTEMS FINAL 19. Rough Heating & r Air Conditioning ? i' FIRE,�EPT iEQUIREMENT JT a+ W 'R, APP(,-tOV1 C Pgmit # 20. 'Rough F cto4y F enlace �' iT 21.-0uats, ir:Stracture-t. :1 = K ' 70.`'Unde2rrsu,-fid I�.ydro t. Yin 22.-DuG, VRntil ing �S .-+ �" - 71. Prods Pi 17�as p 9 Oil ,t < H .P 23.'Gas;PipeAou>3h & hest C1S ►: (TI 1 d Gf• - 72, Underg�5u'hd F iUsh F~• _ , , ' Z �. 24.'Ro6f• Frgnin4' ""' '" ~ D =" Ir 7� Under rfid. St e Tank• *'D Gas Obit? 3l 9 r -r w - �= 4Ci3 25. RogLSheathing ` . 11: v f.t i ria 7.41 Overhead Hydr# 26.-�-Ba? Ceiling (Structural) & �1VidVboat �• 7W. Dry Chgmical �. • ,�. r- :D „ -+•r 27.' Frame and FlashiRgIr .r x . .e: rx >a W* 76. Dry StaVl ipeF • .,M y 28. LatNng &Siding, 77: FIXED gST6¢i�-FINA�,., 4 1 29. Insulatiop _ S *- �t 79, FIRE PREY. FfI`qr�%L 30. Drywall Mailing ^_ `4 ".A & A L TI,9EP4t."REdU1 1 E N T .e. 31. Plaster Browrr)Coei �; r -+ , t { ;i, u 79. F INA L I'NSPECT:tOiN r " 32."_ lectrical%Power Meter'•F�ipal 33. Tinal- Electrig> � .s �+ w '3 :� *' I ' ' � { �Y 0 0 D CE RTIF�CW_TE 1$S Ep otes• •-A--j 11M :=. v •S 7.z S 3 34.: Final.Heating-& A1r•--Con2fition*54T '1 35.-Fin£I'Ga"s-Pl e•Tesst'` 3 36. koadi or"Canopy - y 37. finar.FaGiory Fire- ce :;: i -r'r v .! j ' .;. �i� _� •� _. �� �, _ .7 38. Finat Plumbing '+ v 1 } x >- {V ' 39. Water Service-Firrai ! 40• Gas Service -Final i:i . , tt-,I rr* x rr) b,:> 41, Solar Domestic -Final - % tr. D " a �. _, ^1 G C W is 42.'BackflowCPrevenfe11; ;t: t Y I �tt: '� F V C '+ ;Wn c f-:. E4 n 43. 8ackfloW-1rr{fati8p_;' > CJ o •Q4, Landscafre Irrigation' SYstem""'.-.+ _z: :U tU v f r y C 45i.'_Sound Atterittati • `, z`� T _ t" `" IF ` - 46.-Handicat Regulations -. C * tx 5 rn_�r }- t 47�.'FINAL -DING 41 t• STR(JVTUP[£ & BUI 48. FINi L PLANNING+ s i3 tt [r1 I r 49'. Elecfi'ic Release to �dison- 50. -Gas Release to Southern California•Gas Co t I + S -n i •.51 CERTIFICATE OF OCCUPANCY T. No., _� Date v- .DDRESSOFSWLDING: 3333 BRISTOL ST DNT.. ADMIN '""Erts•'"MEIFIaowR"C , SEGERSTROM FLOOD: AO -38 ' 1 ADpftEss' 3 315 FA I R V I EW RD }_.AlCOSTA MESA,CA 92626 APPL. MAILING ►DDRES& 435-2019 ARCHITECT OR ENGINEER: LIC. NO.: ARCIL OR ENG.'S ADDRESS: 6 DAVID OL S ON C� 9 4 2 4 6 MORGAN ST 100 coNTRACTDIrs "E"IRVINE CA 92716 THERMALAIR INCORPORATED (818)442-3341 CCNTRACTOR'SMAILING 1140 N RED GUM ST AfIDm' ANAHEIM CA "NO-: 102216 92806 UNIT: LICE CON! RACTORS DECLARATION: I hereby affirm under penalty d perjury that I am licensed under provisions d Chapter 0 ( end with Section 7000) d Division 3 d the Business and Profeasions Code, and my Ikarus is in fun farce and affect. IC. N .: D 6 0 b uc. "ASS: C 20 uc. ND.; 16 �P : 0/ are: Conlrador: deli OWNER B ILDE DECLAR IDN: I hereby affirm under penalty of that I ..am the odors LioenasQ I ion 708 .5 Gusi lass and Professions Code: Any which rsquhr m a permlt n orshoet, m or repair arty structure, prior to its issuance. also requires flee applidmt for such permit to file a Sig sutement that sed Pursuant to the provisions d the Contractors License Law [Chapter a (commencing with Sed' 70DO) d Division 3 of the usiress and Protessiom Cadet or that he or she is exempt theraho n and the basis for the alleged wamptiah. Any violation of Section 1031.5 by any applicant for a permit subjects the applicant to a dyif penalty d nit more than I" hundred dollars ($5001). ❑ I. as owner of the properyor my employees with wages as their soh compensation. wi ldo the work and de shunts ism intended or offered for sale (Section 7014, Business end Prdessiona Code: The Contractors License Law doss not appy to an owner of property who buiids ar improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvemams are nit intended or offered for sale. 1. however, the budding or improvement's sold within one yam of completion, the owner-0uiMm win have the burden d proving he or she did not build or improve for the purpose of sets). ❑ I. as owner of the properly, am exclusively, contracting with licensed wnhadore m Construct the Project (Section 7014. Business and Prdesaicna Coda: The contractors Licerse law does not apply to an owner of property who builds or improves; Uhsreoa and who oontracs for with protects with a comrador(s) licensed pursuant to the Contract" License Lao. ❑ I am exempt under Section: B. A P.C.. for this reason: Date- Owner: I do hereby cerdy that I am aware d and understand the requirements d California Health and Safety Code Sections 25505. 25533. and 25534, and dear I or arty future buildirq oowpam reit ! wdl rat (circle anaj need to comply with said state codes and the requirements for a Permit for arshuuion or moddirafion from the Ai t arhapemert Ostrinl. Residents) cont Klion appimtias am mumpt from these P"N" ons. Date: Applicant: WORKER'S COMPENSATION DECLARATION: I hereby affnm under penalty of perjury ars of the following dodmatiors: `] I have and" mairaw a cerificste d orsent to setdmum tar workers' Compensation, as Provided forby Ssdj)n 3700 d the Labor Code, for the pedonmmhce d the work for which this permit is issued. ❑ I have and w0 maintain wodwm' compensation irmmance. as required by Section 3700 of the Labor Code. for the parfamance d the X work for which the pem* is issued. My worked compensation insurance carrier and pdiry number ere: Carrier. 111— 1Gn GeTTnT Iry EXPIRES Policy Number. 03/31/98 Rus section reed nit be ca pkW I the parmir is nor ma 100 err lass J nerdy that in the performance of the work for which this permit is issued. I *lent not employ any perm in any manner so as to sub[ d to the workers' compensation laws of California, and agree that I I shad become subied to the wodws' Pen/s'e]tio provsi F Sedicn 3700 d the Labor Code, I hilly nee rovisiane. Dat / Applicant: hv.. Felt fo utero' comparsatfon carer o I hnvftA shrll sub loyw to almitiraf and clvll 9rras up m ons hundred fhowarrd dollars (S100% 000), fn a cwt o! Comprrrsa hialnagsa u pi= lorin Section 3706 of the Labor Cads, Interest and attot, oy s loss. CONSTRUCTION LENDING AGENCY: I hereby affirm under penalty of penury that them is a o"ntdhon lending apmtty for the performance of the work for which this permit s scored (Sedion 3097, Civ. C). LENDER'S NAME: LENDER'S ADDRESS: I certify that i have read this eppIketion and state that the aboas irdon. ion 6 Correct. I agree to oompty with ad dry and ovary ordinances and state Laws relating to building construction and hereby authorize reprssentatives of this city to enter upon the above-merltionsd Property for imspedhon Purposes PUENTE JR (5151.46.WP) While -Building d Dare: Pink -Revenue: Goldenrod -Assessor CITY OF COSTA MESA — BUILDING PERMIT PERM NO: M 08394 PERMIT NO: M 083944 PLAN CHECK NO: N GOVT: N SUPP: N CONSTRUCTION TYPE: I FR PERMIT TYPE: MEC PURPOSE: ALT JOB DESCRIPTION : EXPAND OFFICE 70SF INTO EXSIT COURT AREA SQ FT: CLAIM VALUE: CALC—VALUE: GROUP OCC: B / COMMENTS: MISC ALT TO SOUTH COAST PLAZA MANAGER'S OFFICE REF:B-83813 fkiF�4jF1F*�titif•��*�**��*�FiF**��*��*��*****��**�**�*****�;f�**�****��**��*�*��**�***�*:tom Z O N I N G R E Q U I R E M E N T S S E T B A C K S -------------- MAIN BUILDING ----------- --------- ACCESSORY BUILDING ----------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN PARKING REQ: PROV: PARCEL: 41250107 ZNE: REF NO: PLANNING NOTES>•s > '!! i! * iF �F ?'E irk !f * �4 � �! irk i! � d! �! �i'1[' lE iE 9E �f 3E irk if'1(' iF �E �! ? E ?✓E �E * 9F � * ilNk *;fF �E dE ?+E * � it * dE'1f � �I.9E �E'1E � �F i4 �E !E �t is 91' * * 9E 1F il' � 9t �i 94 � dE'IE * * * frt D E V E L O P M E N T S E R.V I C E S R E Q U I R E M E N T S ZONING APPROVED BY DATE: BUILDING APPROVED BY DATE: APPLICATION ISSUED BY: DATE: NE**i4�iE*iEdE�*>W*!M>'kdt'1!•9Firk�EiFi6�iEdE�**it*9t•dE '1F* LEGALIZATION:N F E E S M A R Y STRUCTURAL SEGM£NT:N BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT 24.50 25% SMIP/NON—RES PLAN ISSUE FEE 22.00 BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE TOTALS ---- > 24.50 22.00 0.00 46.50 46.50 .00 REVENUE DIVISION TOTALS--> COLLECTED: 46.50 OVER/SHORT: •00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK 46,50 � * 1! i! iE 9E 9E * 94 iE � it_`'1! iF # cit'1F iE * * 9E i! if:'1!• it �F * iE �E iE * 9k if if• if iE ?+F * d4 irk i4 if �t � iE it iE * � it it• iE � 1E it• * * * �E iE �F iF lE iF iF i4 i[• iE 1E i(iE i4 �E iF iF iF # it• dE I N D I V I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST MEC 2 REPAIR/ALT COOLING UNIT/SYS W/CNTLS 12.25 24.50 END OF FEES 07-29-1997/09:49 AN/$46.50 RCPT0:01-6009533 PERMIT:083944 CONSTRUCTION AND PLANNING , POO;PA-• #rte' APS+ROYALS Permit pate I nspector APPROVALS Permit# Date Inspector ,.•Temporary Electrical Service or Pole 52. Pool & Equipment Location• 2. Soil Pipe-Undrgrnd. :� . 53. Steel Reinforcement r' ; 1 4 r 3.. Eiectrical.Conduit Utility Undrgrnd, 54• Forms - 4! E€ectrical'Cond6if-Un 3rgrnd, ~ 55. Electrical Bonding , S�Stee1 ReintofceiZ-ieent _ - 56, Rough Plumbing & Pressure Test Y -=6•�ectrical_l1FER^fnd. + 57. APPROVAL TO COVER-GUNITE ` -7-Footings 58. Electrical Conduit•Uncirgrnd. �s Foundationoi =ti 59: Gas Pipe, G Undrgrnd., Test , �� t� �• 9.-Water Pipe-Undrgrnd. "� 60. Backwash Lines-P•Trap, ID U'ndrgrrid. 10. Structural Floor.System 61. APPROVAL TOIDE,CK ' 11. Property Sewer Line _& House'Connection 62. Backwash & Receptor-Fin- 12, Sewer Cap Y �' f 63. Heater &Vent E'rnai 1.3. Roof Drains 64. Plumbing System • Final Rough Plumbing 65• Electrical-Final t �, 15. Rough Electricalf-Condu'it ' 66. Solar System Final 7' 1.6. Rough Egctric Wiririg; -' ' { 67. Fencing& Access.Apprpval F t . s. =;17. Rough Wiring Sign y - i > 68: APPROVED FOR-PLASTERING Z18. Rough ElectricallfT• Bar CeitingY 69, POOL/SPA SYS31 M5'FINAL ' 19: Rough Heating & Air-conditioning _ FIRE DEPT. REQUIREMENT •APPROVALSF Pern'tit i` rl 20. FjjDug_h Factor Fir2p;.lace ' ] �; j• r _� 21, putts; in Stru�ture7 +5 S C r • 70. Underr_r'(j n� Hydro 22. Putts Ve'ritila�ing-'4 r iJ� ,� . S k r,rr 71. ProductlPi,ping Gas JO11 23, Gas I pe-!'oug- & fast ti rt i' -+ 72. Undeeground Flush r - ,© 24. Roof-Framing `" ` " ~' 73� Undergrr3,• Storac} Tank❑ Gas Oil �,i }• 25, Ro4She3thing 1 } :y v r v vi -C 74:` Overhead Hydro? 26. Z-Bar=Ceilin Strs d'tyral) & Mono oat g { G }' -' 75. Dry Chemical ?: J' r + t-0 _ 7. 27. Frame and Flashir�L * , � Az r+ LLI *ter f 76" Dry Standpipe ,i- X28. LatHM g &Siding 77„ FIXEDSINAI: +' ✓ 29. Insulation* ^., < ..r 78:. FIRE PREY, 1=1tVflt_ � w j 30. Drywall Nailing J ' _ + ~HE'ALTWDEP-l'.'REQUIREMENT 31. Plaster $ro,wri:Coaj' i ,:: ' 79�:' FINAL 1NSP,EMON 0 -'32. E;ectrical-•Povier Mehr=Final { ��-ti$OYIFOOD CERT3FiLATI E 51 ED r 7-33. Einar' eGtric i' No es: ? 34. Finat•Heating & Air:Conditionirtg I�L 43 L_ j :+t. =� '�:� = �x _ 51 35. Onai'Gas,fte;Test * � _� r •c _ 36. Hood>or Canopy -: t' a -07, Final Factory Fire)" cep 5 �. t� r"`T� t� � j i .38. Final-Plumbing-- r'39. Water Service•Final -''° -D W :, 40. Gas Service-Final r~ 41. Solar Dorrsestic-Fir<af* 42. Backflow;Preventer I. 43. Sackflowlrri iitio " 44. Landscape' IrrigationrSyster•n rz r . ,�S ,� .--I �+'.+:. .,.r ,r :r err•- .�. _ -, _ 45, Sound A.l;enuatiao 4s. HandicapAeguiations =, 4. t-• , a 'r 7 �• 47, RNAyL STRUCTURE & BUILDING 48,. FJN,4L' PLANNING - i t 1 e 491., ElectHc Release to Edison • `. } 5.0. Gas Release to Southern California-Gas Co -- t: _ CERTIFICATE OF OCCUPANCY A .5t ' k- No. _- _ __ - Date 0 ADDRESS of 801mal 3 .3 JJ BRISTOL S T ALJ 01,,,Nw,,,117m*. C• J SEGERSTROM FLOM: AO - 3315 COSTAFAIRVIEW MESA,CA 892626 435-2019 "ft. tiAIUM ✓VDDRESS: l l 0, me,. DAVID OLSON UC.tfD, C19424 AM OR EM'SADORESS: 6 MORGAN ST UNT: 100 IRVINE CA 92716 CONMACTOITSNWE ALERT FIRE PROTECTION INC (714)993-2822 CONTRACTOR'SUNLINi 5200 E HUNTER AV ADDREss: ANAHEIM CA LIC. No: 316324 92807 B UNIT: LICENSED CONTRACTTOOR�SS D¢iECCLARATION: I herebbyjtafffir�mpunder penalty Of perjury tthhdas III am lioenaed uynpdJerrprprovisions Of Chapter 9 Division 3 of the CITY u Owitn tS 1 LT ! LIC C. CLASS: l• ! t "rot signs cl1 J L '! is m f� 1C Y V 3/ 9 8 Date: Contractor: OWNER BUILDER DECLARATION: I hereby affirm under penalty of perjury that 1 am exempt from the Ca ora License Law for the following reason (Section 7031.5 Business and Professions Code: Any city or county which requires a permit to conduct. ager, improve, demolish, or repair any structure, polar to its esuamme, also requires the applicant for such permit to fib a signed statement that he or she is ticensed punruant to the provisions Of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Cada] or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applkwrt to a civil penalty d not more than five hundred dollars [$500jj. 1, as owner of the property or my employees with wages as their sole oompanamion, will do the work, and the structure is not intended or offered for sola (Section 7044. Business and Professions Cods; The Contractors License Lawdoee not apply to an owner Of property who builds or improves thereon, and who does much work himself or herself or through his or her own employees, provided that such improvemams are not intended or Offered for sob. 11, however. the building or improvement is sold within one year (A completion, the owner -builder will have the burden of proving he or she did not build or improve for the purpose of sale). I, as owner d the property. am exclusively contracting with I'm Re oonha ton Io 11re project (Section 7044, Busies and Professions Code: The Contraaore License Law does red apply to an owner of property who builds or improves thereon and who contracts lor much projects with a oontrador(s) licensed pursuant to the Contractors License Law). I am exempt under Section: B. d P.C., for this reason: Data: Owner: I do hereby certify that I am aware d and understand the requirements of California Health and Safety Code Sections 25505, 25583, and 25534, and that I or any future building occupant will I will not (circle one) need to comply with said state codes and the requirements for a permit forconstruction or modification from the A'r u ty anagemenl District. Roaidentid oonslnrction appicationears exempt from these pry. Date: Applicant: WORKER'S COMPENSATION DECLARATION: I hereby affirm under penalty of perjury One of /fit k4owkg declarations: 0 I have and will maintain a cerffirate of consent to ss94rsure for worlran' comparmaion, as provided for by Semon 3700 of the Labor Code, for the performance d thio work for which this permit is issued. ® I hew and wig maintain waken' mmoensaf ion insurarm. as required by Section 3700 of the Labor Code. for thio pedormance d the work for which this permit is issued. Aly workers' goayp{aslioMaaurarseeyGI'�Vi ��V policy number en: EXPIRES carrier: Polity Number. mic- 3 2 3 4 10/01/97 (This soman need nd be completed I The pert a for one hundred doflam j$1001 or less.} I certify that in the performance of the work for which this peri is issued. I shad not employ arty person in any manner so as to became o the workers' oompensstion laws of Cafdornia, mrd that ' I should become subject 10 the waken' p' tom d Section 3700 d the Labor Cods, I shad f aogh - tlnoae Date: -/ Appfram: Wamhng: Fallurs to secure workers' compensstlon covenpe Is untalrnd, and shill subject an enrployrr to red penslgas and civil !!nu up to one hundred thousand dollars ($104000), In addldon b flee cost of conpon"tlon, dernape as provldsd for In Section 37os of thio Labor Cods, Interook and sttomey's foe. CONSTRUCTION LENDING AGENCY: I hereby affirm under penalty of perjury that there is a construction larding agency for the performance of the work for which the peri is issued (Section 3097, Civ. C). LENDER'S NAME: LENDER'S ADDRESS: I certify that I haw read this application and state that the above informalion is correct, l agree to comply with all city and county crdrnsthose and state Laws relating to building owdruc ion and hereby authorize representatives of this city to enter upon the above-meetiored property for inspection ptrpoaea. SHEILA LOONEY � Prem N Date: (515145.WP) White-Buildmg 6 Safety; Green -File; Canary -Applicant; Pink -Revenue; Goldenrod -Assessor CITY OF COSTA MESA — BUILDING PERMIT PERMIT NO: F 084062 PLAN CHECK NO: 02970-97 L PERM NO: F 08406 GOVT: CONSTRUCTION TYPE: I FR PERMIT TYPE: FIR PURPOSE: ALT JOB DESCRIPTION ; EXPAND OFFICE 70SF INTO EXSIT COURT AREA SQ FT: CLAIM VALUE: 300.00 CALC—VALUE: GROUP OCC: B / COMMENTS: MISC ALT TO MANAGER'S OFFICE, RE:B83813, SPRINKLER SYSTEM ALT Z O N I N G R E Q U I R E M E N T S S E T B A C K S ------------ MAIN BUILDING ---------- --------- ACCESSORY BUILDING--------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RIGHT: FT IN LEFT: FT IN RGHT: FT IN PARKINGGRNOIES> PROV: PARCEL: 41250107 ZNEt REF NO: > D E V E L O P M E N T S E R V I C E S R E Q U I R E M E N T S WNINU AV?AOV90 VY f DATE: BUILDING APPROVED BY DATE: APPLICATION ISSUED BY: L C DATE: 5 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * WW *W W LEGALIZATION:N F E E S U M M A R Y STRUCTURAL SEGMENT:N BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT 21.00 65t SMIP/NON—RES PLAN 13.65 ISSUE FEE BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE TOTALS ---- > 21.00 0,00 13.65 34.65 34.65 .00 REVENUE DIVISION TOTALS--> COLLECTED: 21.00 OVER/SHORT: .00 BLDG PMT'PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK 21.00 i�JEiF1f)F�E1Ei(•iFiFiFiEiF**9I-dF*iEiE3E1EiFiF***�I-**iEiEiF**#*?F1EiFiEiEiE*�EiEi(�EiEiE�E9t�4�4�E�ti(-ilif**iE***********9E�E3f*ikriE I N D I V I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST FIR 21 FIRE EQUIP FEE (FROM BLDG VAL TABLE) 1.00 21.00 END OF FEES 88-65-1997/12:25 PMA21.68 RCPT#:81-8816257 PERMIT : 084062 r I� I iCONSTRUCTION AND PLANNING'._POOL APPROVALS Permit 7D�teInspector - SPA APPROVALS Permit # Date Inspector 2. Temporary Electrical Service or Pole 52. Pool & Equipment Location r s 2-. Soil Pipe-Undrgrnd. 53: Steel Reinforcement 3: Electrical' Conddit Utility-Undrgrnd. 54. Forms ; 4. ElectricaLCondu d. 55. Electrical Bonding 5. Steel Reinforcement; 56, Rough Plumbing & Pressure Test ,*6." 57. APPROVAL TO COVER-GUNITE - 7. Footings' 58. Electrical Conduit-Undrgrnd. 8. 'Foundation T; :, .� 59. Gas Pipe, ©Undrgrnd., Test 9: Water Pipe Undigtnd:� 64. Backwash Lines,'P•Trap, ❑ Undrgrnd. 10. Structural Floor System ` 61. APPROVAL TO DECK s' 11. Property Sewer. Line & House Connection 62. Backwash &' Redeptor-Final , 12. Sewer Cap .63. Heater & Vent-Final 13. Roof Drains"-, 64. Plumbing System . Final ' 14. Rough Ptumbing _ - 65: Electrical Final •15. Rough Electrical-Conduit 66. Solar System Final 16. Rough Electric-Wiring, t F 67. Fencing & Access Approval -17. Rough Wiring Sign " ' , 68. APPROVED FOR PLASTERING "18. Rough Electrica.1-T Bar Ceiling a 69• POOL/SPA SYSTEMS FINAL 19, Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS-- Permit- ,�� .- 20.. Rough Factory Fireplace • .s 'Y •,+ .t. :`h � .�. 21 � Dusts, in•StructLire - _ °: r _ ; , , r, 70.- Underground Hydro 22K Ducts, Ventilating } 71. Prod trpt Piping•©Gas ❑Qil 23'-.Gas-Pipe''- Rough & Test t�-'� �• :+ �" ,.� _,-� I _ 72. Underr ground F-lush 24.- Roof Framing 73. Undergrnd. Storage Tank ©Gas 10 Oil 7. 25. Roof Sheathing ;;. _ T,4. Overhead 1i.r^_, r $�� �(� 1'-47, 26--aT-Bar Ceiling {Structurall &.Monocoat 1 ':' -' T;+ 75. Dry Chemical Frame and Flashing 27:--Frame76. ` n . 'J Dr y Standpipe J 28. Lathing-& Siding x `" _ w + 77. FIXED7SYSTEM FINAL ���a 29. Insulation " r � •' � i _ - �� 8. FERE PREY. FINAL W,�T7 30. DrywallNailing r, i + HEALTH DEPT:-REQUIREMENT r 31. Plaster Biiown Coat' _ # k +; T 79. FINAL.N8PECTION - T 32. Electrical Power Meter,-Final r ., I I µ r, 80. FOOD CE RT IFICATE'ISSUEDi 33; FiQl Elgctric34.-,Final H,eatirig`& Air Cbnditioning; 35.-:Final Gas Pipe-Tesst- 36. Hood or Canapy j Y 37, Final Factory Fireplace 38.-Final Plumbing t ,-, = v • W + Y 39:: Nater Service-Finaw 40.�'Gas Service-Final 41. Solar Domestic-Final-. 42._Backilow Preventer' 43. Backflow' Irrigation" a' S 44. Landscape 1r.-Egation System-, 4�.tSound Attenuation 46.-Handicao Regulatldns 471.7FWN L STRUCTURE & BUILDING I d- ' • - 48._FIOAL PLANNINGr • tS � ' i - . Z;49.,-Electric Release to Edison j" ,• _ n ; 50. -Gas Release to Southern California Gas Co r - 51. CERTIFICATE O 'OCCUPANCY No. Date a" - tity;of Costa Mesa - Development Services, Division of Building and Safety 4 CERTIFICATE- OF OCCUPANCY a 1 lam..}� This certificate is.Iissued pursuant to�the requirements of the. Uniform Building Code, Section 308 adopted by,the Cit} of Costa Mesa certifies that.,at- the_ tine of its issuance the building structure herein below described was inspected and,approvedfor�occit pancyas:foltows:� Building Address 3333 Brisigo Adafnkstration Office N Use Misc. alteration toAxSoutheCoa"st .1'1aza;Manager.I of Group B Type Construction IFR Fir6�Zo Owner of Building C 3.�SeReretrom --Tenant Address 3315 Fairview U. -Costa Mesa, CK, 02626 By �~ J BUILDING OFFICIAL -tong (t -T ,��6 23aca F REQUIRED TO BE Permit No. B-083813 ►` �-�1I Use Zone -CI-S ONSPICOUS PLACE Date' REQUIRED TO BE Permit No. B-083813 ►` �-�1I Use Zone -CI-S ONSPICOUS PLACE _; �: N. �,.. . ..� � w-�....�.R � ... � r ,ti � 1.. r �ti :. h � ��.n .� ti ` ' t r ♦ 'ter. -';r- ', c.'N^.t'rt. -f . - CI--Y 0E--COSTA MF -: Development Services, Division of Building and Safety CERTIFICATE OF OCCUPANCY This certificate is issued pursuant to the requirements of the Uniform Building Code, Section 308 adopted by the City of Costa Mesa certifies thatak the time of its issuance the building structure herein below described was inspected and approved for occupancy as follows: Building Address 3333 Bristol St.` Sp 1243 Bldg.PermitNumber B06-00132 Use Clothing ; (3.471 sf) ` Group M �- Type of Construction 1=FR '. . e ,jam Use Zone PDC South Coast Plana' TED BAKER Owner of Building r '"_•�Tehant Address 3315 Fairview Rd, Costa Me.sa', CA 92626 By ��BUILDING OFFICIAL-Khanh Q. Nguyen,. C.B.C. . Date 11/02/06 REQUIRED TO BE POSTED IN A CONSPICOUS PLACE 1=1 (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesaDING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Suite: 1243 Vicinity: STE 1243 TED BAKER LONDON Primary Occ: M Display/Sale Merchandise Parcel Number: 41250107 Applicant: LAUGER, BARRY Address: Status: ISSUED Applied: 01/26/2006 Issued: 0311412006 Type of Construction: I -FR Zoning: PDC Phone: 512-294-3749 CELL ISSUED BY: Zip: Owner: SOUTH COAST PLAZA Address COSTA MESA CA Phone: 3315 FAIRVIEW ROAD Zip: 92626 Contractor: FOUR.CORNERS CONSTRUCTION LP Address: 110 WILD BASIN RD" STE 23o., Phone: 512-336-2279 AUSTIN, -TX Zip: 78746 License: 855866 Arch : Eng: Address: Address: Phone: Phone: Zip: License: License: SCOPE OF PERMIT INTERIOR STORE 71 FOR 'TED BAKER" IN SUITE 1243. REF: B05-00131 FEE SUMMARY Plan Check: $184.24 Calc Valuation: $125,000.00 Permit: $1,133.75 Claim Valuation: $125,000.00 SMIP Res: $0.00 SMIP Cam: $26.25 Other: $0.00 - - -- - - - Inspection: $0.00 Total: $1,344.24 PLANNING & ZONING SETBACKS MAIN STRUCTURE. Front 0-0 Rear 0-0 Left 0-0 Right 0-0 ACCESSORY, Front 0-0 Rear 0-0 Left 0-0 Right 0-0 PARKING 0 Required: 0 Proposed: 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspe� or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 WORKERS' COMPENSATION DECLARATION: hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 at the Labor Code, for the performance of the ,-,work for which this permit is issued. ❑_Lhave and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. �My worare'-compensation Ir�sura carrier and policy number are: Carrier: _ / A, 0 S f 024 Policy 'Number -_ ; � (rh�ls section need not be completed i���"'the pe it va at ne undred dollars ($100) or less.) tr �- ❑ I certify that in the pe r ance of the for ch this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws f lifo it I should become subject to the workers' compensation provisions of Section 3700 at the Labor Code, I shall forthwith oomply_with t vi Applicant Signet e: Date: _�� WARNING: FAILUR E E EN ON COV GE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOL LARE (5 00,000), IN D T OF CO PENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that.I a licensed er prgvisions f Ch er 9 (commencing with Section 7000) of Division 3 at the_BusinesA and Professions Code, and my license is in full force and effect.. LtC # Class Contractors Slgnatur Data: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Data: OWNER-BUILDER DECLARA71ONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. 11, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under see. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the I)Msion of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future bullding occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be tiled with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure), - ----•.............................. .......................................................................................................... ...................................................................................................................... - ........... .................................... 1.111....1.111.......................... 2 Does or will the applicant Or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the Celdornla Health and Safety Code, with same exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feat of compressed gas at standard temperature and pressure). ....................... t'h"..................-...'0'r*.......S-6i..............'t'u.'r'9'...........rig...................................................ria,.........................................................--.....n'd-_._............................................._......-e-f -h-'............_-, -----............__....... 3 Does or wi11 the applicant or present or future building occupant need to prepare an RMPP (Aisk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. _..............................................................................................................................- _........................... .-....... ............. ......... 11-.............................. -...................................................... _........... -.............. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No ...................................................................................................................................................................................................................................................................................................................................................................................... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application a enmit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). .. - ....................... .................................................................... ._....................................................................................................................................................._.............................................----............................... 6 Will any part of the facility to be constructed under this permit be within 1000 feel from the outer boundaries of a school? ❑ Yes ❑ No (If yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 1111.....-- : ...-•.................................................................................... _........................................................................ -. - - -1111................................-........................................................................... 7 If a permit from the South Coast Air Quality Management District Or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No -................... .................I'll ..... ............................................................ ......................................................................... ­---...11.............................................................. .................................................. _ ........................... 8 pf yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE ANDA ORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. f agree to Comply with aI1 state I s try ordinances relating to building construction, and authorize representatives of the City of Costa Mesa t0 enter upon the above-described property for inspection ores. agree not t0 occupy or allow occupancy of any building authorized by this permit until final inspection. r(s) I -Ad/ nz cant Late _ PAM INTITIALS CODE. INSPEMON TYPE QA1E IHTiiiALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final BuildinglOccupancy �r9 vv (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 MECHANICAL PERMIT .lob Address: 3333 BRISTOL ST Suite No 1243 Vicinity: TED BAKER Parcel Number: 41250107 ISSUED BY: Applicant: BILL SANDARS Address: 1140 RED GUM ST Phone: 714-630-3200 ANAHEIM, CA Zip: 92806 owner: SOUTH COAST PLAZA Address: COSTA MESA CA Phone: 3315 FAIRVIEW ROAD Zip: 92626 Contractor: THERMALAIR INC Address: 1140 RED GUM ST Phone: 714-630-3200 ANAHEIM, CA Zip: 92806 License: 102216 Status: ISSUED Applied: 03/16/2006 Issued: 03116/2006 SCOPE OF PERMIT MECHANICAL PERMIT FOR INTERIOR STORE TI FOR 'TED BAKER" IN SUITE 1243. REF#: B06-00132 WORK TO INCLUDE: 1 REPAIR/ALT COOLING/HEAT, 4 VAV BOX AND 1 VENT FANISINGLE DUCT. FEE SUMMARY �T Quantity Quantity ISSUE FEE $23.50 Repair/ Alt Absorbtion Unit $0.00 0 Inst FAU <100 k BTU $0.00 0 Repair/Alt Refrigeration Unit $0.00 0 Inst FAU >100 k BTU $0.00 0 = - Ventillation System $0.00 0 Repair / Alt Cooling/Heat $13.70 1 Evaporative Cooler $0.00 0 Inst / Rep. Recess Wall Htr $0.00 0 Commercial Incinerator $0.00 0 Refrig Sys X100 k PTU $0.00 0 Domestic Incinerator $0.00 0 Refrig Sys >100 k PTU $0.00 0 Compressors / Absorption Systems Gas Piping $0.00 0 Up to 3 hp / 100 k BTU $0.00 0 Factory Fireplace $0.00 0 3 To 15 hp/500k BTU $0.00 0 Hood wJMech Exhdust 50.00 0 15 To 30 hp 11,000 k BTU $0.00 0 VAV Box $42.60 4 30 To 50 hp / 1,750 k BTU $0.00 0 Vent Fan 1 Single Duct $7.25 1 Over 50 hp / Over 1,750 BTU $0.00 0 Appliance $0.00 0 Boilers Fire Dampers $0.00 0 Up to 3 hp $0.00 0 Smoke Dampers $0.00 0 3 To 15 hp $0.00 0 Inst or Relocate Appl Vent $0.00 0 15 to 30 hp $0.00 0 Air Handlers < 10000cfm $0.00 0 30 to 50 hp $0.00 0 Air Handlers > 10000efm $0.00 0 Over 50 hp $0.00 0 Floor Furnace $0.00 0 Other Mechanical Fee Floor or Suspend Heater $0A0 0 Investigation Fee $0.00 Plan Check Fee $0.00 Reinspection Fee $0.00 TOTAL CALCULATED FEES $87.05 COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit Shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord, No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. -1 INSPECTIONS: INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with ay opp"livable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the dkpiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 en 0 o {orwl WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 37DO of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My_workem' corn ensation Insurance carrier and policy number are: Carrier: ,S �,r-t R 7 �J�'� Poll y,lmlumber: hIS'8ectlon need not be completed if the permit is valued at one hundred dollars ($100) or less.) ❑ 1 certify that In the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that i should became subject to the workers' compensation provisions of Section 3700 of the tabor Code, I shall forthwith comply with thes Ions. f� Applicant -Signature:, Q _Dale: - WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TOONE HUNDRED THOUSAND DOLLARE (Si00,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license Is in full force and effect: Lic. M Z nt- Class a C?_n, C_--Ir,, Contractor's 5lgnature: Date: CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is Issued. (Sec. 3097, Civil Code), Lender's Name: Lender's Address: Slgnature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to Its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the properly, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Cade: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project wish a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made In connection with work authorized by this permit, and that no bullding structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2. AR 2, Sec. 341, Title 8. Califomia Adminfstrative Code). ❑ As owner-bullder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to lila and cenity a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the Celitomia Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds. or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to filo a registration larm for acutely hazardous materials? _3Y_ *a*' ❑ No (Section 25533 of the Cellfomia Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feat of compressed gas at standard temperature and pressure). ._ ..... .. _ ................_................. _............... ........................................................................................_....... _.......... ---............. — ....... ..---_.... _._....----- __............. 3 Does or will the appliant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ N Section 25534 of the Califomia Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes [E]No- .... -- -— .............—.._._.._ ... - .......... ....__._._... _.................... ........__._.._.................................................................. ..... - -_. ............_ ...... .._ ... _ _.__ �... 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this a plication appffrm'tt for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? N Yes LJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Wi11 any part of She facility to be cronsiructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ....._........................ _ _......... _............................................ __....................................._.._....... ........._...._.......—..._^_ _ _ 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ............................................ ---.......... _................. _............... -_................... 8 (If yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy Of any building authorized by this permit until final inspection. t Sig azure L alOwner(s) Date trs -�� An Or Authorized Applicant Date CODE Y. INSPECTION TYPE QdH WTITIA CODE a INSPECTION TYPE 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 206 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 PLUMBING PERMIT .lob Address: 3333 BRISTOL ST Suite No 1243 Vicinity: Parcel Nunmber: 41250107 Applicant: TOMAS EAGAN Address: 5 VIA AMISTOSA SUITE D Phone: 714-615-1961 RANCHO SANTA MARGARITA, CA Zip: 92688 Owner: SOUTH COAST PLAZA Address COSTA MESA CA Phone: 3315 FAIRVIEW ROAD Zip: 92626 Contractor: COMMERCIAL MECHANICAL CONTRACTORS Address: 5 VIA AMISTOSA SUITE D Phone: 714-615-1961 RANCHO SANTA MARGARITA, CA Zip: 92688 License: 845066 SCOPE OF PERMIT INTERIOR STORE TI FOR'TED BAKER" IN SUITE 1243. REF: B05-00132 Status: ISSUED Applied: 03/29/2006 Issued: 03/29/2006 ISSUED BY: e5� PLUMBING TO INCLUDE: 1 FLOOR DRAIN, 1 WASH BASIN, 1 DRINKING FOUNTAIN AND 1 WATER CLOSET. FEE SUMMARY AMT QTY ISSUE FEE $23.50 Landscape Irrigation Backflow irrigation $0.00 0 Backflow Preventer $0.00 0 Bathtub $0.00 0 Clarifier System $0.00 0 Connect (Ice,Soda,etc) $0.00 0 Dental Units $0.00 0 Dishwasher $0.00 0 Drain, Floor $9.80 1 Drain, Rainwater $0.00 0 Drain, Roof $0.00 0 Drinking Fountain $9.80 1 Expansion Tank, $0.00 ` ,0 Gas Earthquake Valve $0.00 0' Gas (1-4 outlets) $0.00 0 Gas (Over 4 outlets) $0.00 0 Gas Repipe $0.00 0 Gas Service $0.00 0 Interceptors (Grease, oil) $0.00 0 Interceptors (Sand Auto ) $0.00 '0 FEE SUMMARY AMT LaundryTub /Washer,, $0.00 Landscape Irrigation $0.00 P -Trap $0.00 Pressure Regulator $0.00 Process Piping (per 10 ft) $0.00 Receptors $0.00 Septic Tank $0.00 Sewer Cap for Demo - $0.00 Sewer Connect $0.00 Sewer Private Line $0.00 Shower $0.00 Sink, bar $0.00 Sink, commercial $0.00 Sink, Floor $0.00 Sink, kitchen $0.00 'Sink, servicelmop $0.00 Spa (private) $0.00 Spa (public) $0.00 QTY AMT QTY 0 Sump Pump $0.00 0 0- Swimming Pool $0.00 0 0 Trap Primer $0.00 0 0 Urinal $0.00 0 0 Vacuum Brkr Bkflow(1-4) $0.00 0 0 Vacuum Mr Bkflow(5+) $0.00 0 0 Wash Basin $9.80 1 0 Wash Basin Set $0.00 0 0 Waste and Vent System $0.00 0 0 Water Closet (Toilet) $9.80 1 0 Water Heater / vent $0.00 0 0 Water Piping (Inst or Rep.) $0.00 0 0 Water Re -pipe $0.00 0 0 Water Service $0.00 0 0 Water Softener $0.00 0 0 OTHER $0.00 0 VIOLATION $0.00 0 PLAN CHECK $0.00 REINSPECTION $0.00 0 COMMENTS 1 SPECIAL CONDITIONS TOTAL CALCULATED FEES: $62.70 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord, No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void it work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration -6f permit. FOR INSPECTIONS CALL: (714) 754-5626 Y WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance o1 the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed if the permit is valued of one hundred dollars {$100} or less.) I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' rompensation laws of Califomia, and rea that if I should become subject to the workers' compensation provisions of S ction 370 of the Labor Code, I shall forthwith comply with these prow ions. Appfiban Signature: Data x WARN rFAILURE TQ URE WORKERS' C.OMPENSATI COVERAGE IS UNLAWFUL. AND SHALL SUBJECT AN EMP OYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that.l.arfl-Ilcensed.und rvisions of Chapter 9 (commencing with Section 7000) of Division 3 of ihe,Busitless and Professions Code, and my license is in full _force`and effect. Lic. # _ ,.-Class # LV t- _�tractor's'Sig re: Date: rt CONSTRUCTION LENDING AGENCY: ❑ i hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason {Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high, (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature; Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of $00 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ............................................................................................................................................................................................................................................................................................................................................................................................ 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ..... .............. ................................................................................................................................................................................................................................................................................ I................... -­­----........................................................... 3 Does or will the applicant or present or future building occupant need to prepare an RM PP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ......................................................................................................................................................................................................................................................................................................................................................................... 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No ................................................................................................................................................................................................................................................................................................................. 5 Does or will the applicant or present or future building occupant require for the work which is the subject of fts application aggermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes L] No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). .................................................................................c-o--s--t----- .............rd.....................r............w-i'.-h-in,....0-0-........................................................d..iia........................................................................................................................................... 6 Will any part of the facilityto be .c-o- under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes ❑ No (If 'yes", the facility must moot the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ................................................................................................................................................................................................................................................................................................................................................... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ....................................-............................................................................................................................................................--------.....---•------------------.--.............................,......,...,........................,........................ (If yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with a!I state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Sign r Of galOwner(s) Dat S1 AndlOr Authorized, pliarit� 1 COt7E_L INSPECTION TYPE DATE INTFIALs COOS / LNSP�CTIVN LYPE DATE 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 5-4 -d G B of 200 Final Re-Roof 210 Final Electrical 201 Final BlocklRefaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Status: ISSUED Suite: 1243 Applied: 02/2812006 Vicinity: Issued: 03/24/2006 Parcel Nunmber: 41250107 Zoning: PDC PDC ISSUED BY; Applicant: LOONEY, SHEILA Address: 5200 E HUNTER AV Phone: 714-993-2822 ANAHEIM, CA Zip: 92807 Owner: SOUTH COAST PLAZA Address COSTA MESA CA Phone: 3315 FAIRVIEW ROAD Zip: 92626 Contractor: ALERT FIRE PROTECTION INC Address: 5200 E HUNTER AV SUITE 8 . Phone: 714-993-2822 ANAHEIM, CA Zip: 92807 License: 316324 SCOPE OF PERMIT ADD 11 NEW OVERHEAD FIRE SPRINKLERS AND 43 LOCATE 44 FOR 'TED BAKER" IN SPACE B06-00132 FEE SUMMARY Plan Check: $99.61 Calc Valuation: $7,800.00 Permit: $153.25 Claimed Valuation: $7,800.00 Other: $0.00 Total: $252.86 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or it work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 :440.90 kofw) WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of ft following declarations: ❑ I have and will maintain a certificate at consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workerscompensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 1 `^My wbrkers' ca s lnsur a carrier and policy number are: (/ / -Garner - PolicyNumbor:_.s C(7hi� Dion need not be completed it the pe it is valued at one hundred dollars ($100) or less.) ❑ I certify that in the performance the work far which this permit is issued, I shell not employ any person in any manner so as to became subject to the workers' compensation laws of Calif omi a ag at if I should ecome subject to the workers' compensation provisions of Section 3700 of the Labor Coda, I shall forthwith rcomply--with these provisions �Q Applicant Signature: Data: WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UN FL1L AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE (5100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commenciith Section 7000) of Division 3 ot� Business end Prof�SSions Code, and my license is in full force.and.effect. Lic. q tai Cfa a_I/ % Contractor's SignaWre:� Dat�� CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code), Lender's Name: Lenders Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions O1 the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (5500),): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her awn employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a cantractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e.. property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet In depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, wt$l be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Ari 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety a5 noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ...................................................................................................................................__-_ ...... ........_.................................................. _............. ----.................... --- .......... ---._..__....._. ...... Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 o1 the Callfomia Health and Safety Code. with some exceptions, requires registration with the Costs Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of SS gallons, or 200 cubic feet of compressed gas at standard temperature and pressure), 3 Does or will the appficant or present or future building Occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safely Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Firs Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. .......... ...................... .................................................. ................ .................. .._.................................................................................................................................... 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this a plication a ermil for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). __. M .._................— ...............-..-..................--........................................._.—_.................._._.................................-•------•-•---•............................._........................._...................._._................_............_..........._ 6 Will any part of the facility to be constructed undar this permit be within 1000 feet from the outer boundaries of a school? [:)Yes ❑ No (If yes", the facility must meet the requirement o1 Sections 25534 and 42303 of the California Health and Safety Code). _...............--- ........... -- .....................- _..........._ -_._...._..........----.................._......_.._............._..................----.._......_-----._.._._._._—.............. -........... ......................................... .. 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by Califomia Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (If yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. ` S' a ure Of Legal wner(s) �/ rasa Arrd/OrAuth - Applicant1 lei /�-�J g.QDE T. INSPECTIONTYPE ¢rte IMIEFALS CODE. INSPECTIONTY QeFE INTITAL 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention f•� 30" G 202 Final Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4855 • www.ci.costa-mesa.13MLDING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 .lob Address: 3333 BRISTOL ST Status: ISSUED Suite: 1243 Applied: 01/26/2006 Vicinity: STE 1243 TED BAKER LONDON Issued: 01262006 Primary Occ: M Display/Sale Merchandise Type of Construction: I -FR Parcel Number: 41250107 Zoning: PDC Applicant: -LAUGER, BARRY Address: Owner: SOUTH COAST PLAZA Address COSTA MESA CA 3315 FAIRVIEW ROAD, Contractor: ,FOUR %.1 CONSTRUCTION LP Address:, 110 WILD BASIN RD STE 230' Phone: 512-336-2279 AUSTIN,.TX Zip: 78746' License: 855866 Arch Eng: Address: Address: Phone: Phone: 512-294-3749 CELL ISSUED BY: Zip: 11`�7 Phone: Zip: 92626 Zip: License: 'Phone: License: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21.92) EXPIRATION: This permit shalt automatically expire and become void If work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained, Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754.5626 00646 (6m) SCOPE OF PERMIT INTERIOR STORE DEMOLITION IN PREP FOR FUTURE TI FOR "TED BAKER" IN SUITE 1243. FEE SUMMARY Plan Check: $136.01 Calc Valuation: $12,000.00 Permit: $209.25 Claim Valuation: $12,000.00 SMIP Res: $0.00 SMIP Com: $2.52 Other: , $0.00 - -' Inspection: $0.00 Total: , $347.78 -PLANNING & ZONING SETBACKS MAIN STRUCTURE Front . , 0- 0 Rear 0-0 Left 0-0 Right 0-0 ACCESSORY Front 0-0 Rear 0-0 Left 0-0 Right 0-0 PARKING' ' Existing: 0 Required: 0 Proposed: 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21.92) EXPIRATION: This permit shalt automatically expire and become void If work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained, Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754.5626 00646 (6m) WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to sail-Insure for workers' compensation, as provided for by section 3700 of the tabor Code, for the performance of thin work for which this permit is Issued. ❑ 1 have and will maintain workers' compensation insurance, as required by section 3700 of the labor Code, for the performance of the work for which this permit Is issued. My workers' compensation Insurance carder and policy number are: Carder. Policy Number. (This s on need not be completed if the permit is valued one dollars ($100) or less.) I certify that in the perio n of the work for which i sued, I shall not employ any person In any manner so as to become subject to the workers' compensation laws of a' la, and agree that i ecome s jest to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these pr ision . �� Applicant Signature: 'Date: WARNING: FAILURE T SE R O RS' TI D SHALL SUBJECT AN EMPLOYER TO CR1MI PENALTIES AND CIVIL FINES UP TOONE HUNDRED THOUSAND DOLLARE , IN AD IFION T F 01 COMP NS�IEMGES AS PROVIDED FOR IN SECTION 3705 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I alp Ilcen u�derpro�ionot Chapter 9 mmencing with Section 7000) of Division 3 of.lhe Business afQProfessions Code, and my license Is In full force and effect. Llc. q Class i 4 Contractor's Sigrmature: oats:7! CONSTRUCTION LENDING AG6W-' ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW fof the following reason (Sec. 7031.5, Business and Professions Code: Any city or County which requires a permit to Construct, alter, improve, demolish, or repair any structure, prior to Its Issuance, also requires the applicant for such penult to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than live hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation. WILL 00 THE WORK, and the structure is not intended or offered for safe (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or Improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). - © 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or Improves thereon, and who Contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Deme: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type o1 document, i.e. - property tax bill or deod): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet In depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title e, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I Will the applicant or present or future building occupant need to Zile and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 o1 the California Health and Safety Code requires, with some exceptions, that a Business Plan be filod with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet o1 compressed gas at standard temperature and pressure). ........ ...... ............... ............................................................................................................................... ...................................................................................................................................................................................................... ... ..... 2 Does or wit! the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code. with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of Compressed gas at standard temperature and pressure). — .............. .................................................................. _... _..... _................................................................................. _.......................................................................................................................................... _........ — ................ —....... 3 Does or will theappplicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? El Yes 11No (Section 25534 of the Califomia Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Departmont of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP Is presently required, has Section 25534 of the California Health end Safety Code been tuliy oompliad with? ❑ Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plicatlon a_ermil for such construction or modification from the South Coast Air Ouatity Management District or from any other air pollution control district or agency? Yes U No (Section 65850.2 of the California Goverment Code requires that the requested information be furnished on applications for non-residential building permits). ... _........... .................II:.... ....... .................—.--�_........................................ ....--•---__.—....... _.............................. ......................................_.........................................................................._ .._. 6 Will any part of the facility to be constructed under this permit be within 1000 foot from the outer boundaries of a school? ❑ Yes ❑ No (I1 'res', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). -................................ _........ _ _....•-•.................. ...... ........ ......................................................................... .................. _........................................................................ ....._.................... —_....... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No _...........__..........._...._......._.............................••....-....................................................... .....__................................................................................... ....._.......................................................................... _..................... ... 8 (li yes', attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above Is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the Informatkan given is correct. I agree to comply with all tate sand city ordinances rotating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-des d property for insp ti pu osas. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Date n O pllcant (— ata- ±<441`t QEIE INTRIACODE tI INSPE ONTfPE' 1?dIE INTITIAU 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 224 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final BuildinglOccupancy, (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT Job Address: 3333 BRISTOL ST Suite No 1243 Vicinity: Parcel Nunmber: 41250107 Applicant: RUSH, CHON JEREOMY Address: 9 ORCHARD SUITE 104 Phone: 949-600-6070 LAKE FOREST, CA Zip 92630 Owner: SOUTH COAST PLAZA Address COSTA MESA CA Phone: 3315 FAIRVIEW ROAD Zip: 92626 Contractor: ELECTRICALRUSH Address: 9 ORCHARD SUITE 104 Phone: 949-600-6070 LAKE FOREST, CA Zip: 92630 License: 798761 SCOPE OF PERMIT INTERIOR STORE TI FOR "TED BAKER" IN SUITE 1243. REF.: B06-00132 ISSUED BY: ELECTRICAL TO INCLUDE: 100 LIGHT FIXTURES, 15 OUTLETS, 6 SWITCHES AND 2 SIGN CIRCUITS. Quantity ISSUE FEE $23.50 Busway /100 ft Temp service test $0.00 $0.00 0 Res. a/c package $0.00 Transformers up to 1 kva/kw New Res (1-2 units) $0.00 0 New Res (3+units) $0.00 0 Pool / Spa 50.00 0 Lighting Fixts $80.40 100 Recept Outlets $16.50 15 Switches 56.60 6 Non Res Appl $0.00 0 Res Appl $0.00 0 Service to 200a 50.00 0 Service to 1000a $0.00 0 Service over 1000a $0.00 0 Motors to 1hp $0.00 0 Motors to 10hp $0.00 0 Motors to 50hp $0.00 0 Motors to 100hp $0.00 0 Motors over 1 00h $0.00 0 Communication drops $0.00 0 Sub panel to 200a $0.00 0 Pole Light Pkg $0.00 0 Sign Circuits $49.20 2 Temp Pwr Pole $0.00 0 Intermed Pole $0.00 0 FEE SUMMARY Status: ISSUED Applied: 03/14/2006 Issued: 03/14/2006 Quantity Temp Dist System / Lighting $0.00 0 Busway /100 ft $0.00 0 Standing Section $0.00 0 Misc Electrical Equipment $0.00 0 Transformers up to 1 kva/kw $0.00 0 ................up to 10 kva/kw $0.00 0 .................up to 50 kva/kw $0.00 0 .................up to 100 kva/kw $0.00 0 ..................over 100 kva/kw $0.00 0 Low Voltage Equipment $0.00 0 Low Volt Wiring System / Ckt $0.00 0 Misc. Conduit $0.00 0 Misc. Conductor $0.00 0 Circus ( gen or ride) $0.00 0 Circus (mech ride or lights) $0.00 0 Christmas Tree Stand $0.00 0 Fireworks Stand $0.00 0 Other Electrical Fee $0.00 Investigation Fee $0.00 Plan Check Fee $0.00 Reinspection Fee $0.00 TOTAL CALCULATED FEES $176.20 COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21.92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all aocabta•Cood se , and all required inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result in the expr` ratlan.ol this permit. FOR INSPECTIONS CALL: (714) 754-5626 cw.-IWWI WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: © i have and will maintain a certificate of consent to sell-Insuro for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the orkfor which this permit Is issued. I .a and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. y_workers' compensation Insurance carrier and policy number are: cm*ST�Wrt� Fc� rJa Poltcy Numbec. 1-7 26 Y19 -77'his section need not be completed if the permit is valued at one hundred dollars ($100) or lass.) ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that it I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisi WIFAILURE TO SECURE WORKED^.' OOMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUaIECT AN EMPLOYER 7b CRMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED D DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby 8111CM.that1airrilicensed.under provisions of Chapter 9 (commencing with Section 7000) of Division 3 o1 the Business and Professions Code. and my license Is In full rce and effect. Llc..# Contractor's Slgnal re: ogle Y CONSTRUCTION LENDING AGENCY: — ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lenders Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation a1 Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (8500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property. am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to Construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification o1 Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation We (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certity a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater then a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ------._.._......_............................................—.....................................,..,.,,.....,.,.....,.......,........................................................................_.............................._............ 2 E)aes er will the applicant er present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with Some exceptions, requires registration with the Costa Mesa Fire Depariment by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight o1 500 pounds, or a volume o1 55 gallons, or 200 cubic test of compressed gas at standard temperature and pressure). ......................................................... _ ------...._........---.._._._............................... __..................................................................................................... _.............. _........... ---......... __........... —............. 3 Dass or will the appplicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No Section 25534 of the California Health and Safely Cade provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ...... ...._................... _..._....................................... ._.................... ..................... ................................................. ............._............................_..............._...........,.._........ 4 1f an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No _....................................._......................— _.... _.. _ — __..... ............................... .................................................................................._....................._.............................. ..................... _.......... ............... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application afermil for such construction or modification from the South Coast Air Quality Management District or from any ocher air pollution control district or agency? LJ Yes No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under ihis permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ........................................................................................................................................................................................................................................................................................................................._........................................... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all o1 the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No _................. ............................... ..._...__.................._..........................._.....— ........... ......................... ..................... ....................................... __--------- —......... —_.... _..--- 8 {If "yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all slate laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. ignati. f Le al s) /Data CODE P. INSPECTIONIYPE 4DiE €!{ $ CODES INSPECTION TYPE Qfy1). INT{MLS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical J 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy CITY OF COSTA MESA BUILDING DIVISION i 77 FAIR DRIVE, COSTA MESA, CA 92626 - (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us r FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BC10-00227 PERMIT TYPE: B_COMBO STATUS: ISSUED Sub Type: COM—ALT DATE ISSUED: 07/14/2010 ISSUED BY: RMD JOB ADDRESS: 3333 1243 BRISTOL ST CM Suite/Unit: 1243 APN: 41250107 Zoning:PDC, , Vicinity: SPACE 1243 Primary Occ: Const Type: I -A SQ. FT: 2822 Valuation: $100,000.00 SCOPE OF WORK: 2,822 SF INTERIOR TI FOR "TED BAKER", SPACE 1243. WORK TO INCLUDE RELOCATION OF EXISTING RESTROOM, FITTING ROOMS, MANAGERS OFFICE, REAR EXIT, NEW CEILING, FINISHES; ALTER/REPAIR COOLING/HEAT, 1 VENT FAN; ADD/RELOCATE'28 LIGHT FIXTS, 8 OUTLETS, 3 SWITCHES, 3 COMM DROPS,' 1 SUB PANEL; 1 FLOOR DRAIN, 1 DRINKING FOUNTAIN, 1 INT SEWER CONN, 1 TRAP PRIPER, 1 WASH BASIN, 1 WASTE AND VENT, 1 WATER CLOSET. OWNER: SOUTH COAST PLAZA, Phone: APPLICANT: TSCHIDA, DAN Phone: 512-659-2251 Address: 3315 FAIRVIEW RD City/State/Zip:. COSTA MESA, CA Address: City/State/zZip: CONTRACTOR: FOUR CORNERS CONSTRUCT16N LP License No. 855866 Phone: 512-336-227.9 Address: 12201 ROXIE DRIVEUnit: Celt: City/State: AUSTIN, TX ARCHITECT: KENNETH L BUTTS ENGINEER: COMBINATION PERMIT FEE SUMMARY Building Plan Check: Building Fees: Electrical Fees: Mechanical Fees: Plumbing Fees: SMIP Residential: SMIP Commercial: Bldg Std Admin Fund TOTAL FEES: License No.04071 License No. $161.49 $993.75 $97.24 $44.45 $106.95 $0.04 $2i.00- $4.00 21.00"$4.00 $1,428.88 Unit: Unit: UNIT B ZipCode 91307 PHONE: 818-999-4272 PHONE: `Refer to fee receipts for all fees paid for project HOURS FOR CONSTRUCTION ACTIVITY: EFFECTIVE 3/18/2010 - PER CMMC Sec. 13-279 Monday thru Friday - 7:00 am thru 7:00 pm. Saturdays- 9:00 am thru 6:60 pm. Prohibited all hours - Sundays and the following Federal holidays: New Years Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day and Christmas Day NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE 9 INSPECTION TYPE DATE INTITIALS CODE Ir INSPECTION TYPE 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final BuildinglOccupency DATE INTITIALS .X 9�OCBrv) by �- 1 WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' ��][ provided for by section 3700 of the Labor Code, for the work for which this permit is issued. maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued, My woers' co pen tioh Insuran a carrier and policy number are: � 11 !!� � c m l,[1,7eX15. (This section nerd not ne oDmpleled rf the perm[ is valuudat one hundred dollars (3100) orless ) P C�y�MNuu be E) I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code,1,0aUJqrthwith comply ' these provisions. 7-- / V -id Api (tow * gnature R3 WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect, t. Ctinlraclor's Signature CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature pale OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that l am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Cade: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Sgction 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractors) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature pate 3D57-46(3!07) Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty -sic (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, Califomia Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Division of Industrial Safety Permit Number: Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department, 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Goverment Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If `yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If `yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: 1 certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Sig re IL 11) (s) Dale fid--- . �� Arfd*FAWPdrrzed:Appkcart LeIP� CITY OF COSTA MESA BUILDING DMSION f77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 - Fax (714) 754-4856 - www.ci.costa-mesa.ca.us FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BC08-00032 PERMIT TYPE: B_COMBO STATUS: ISSUED Sub Type: COM—ALT DATE ISSUED: 03/20/2008 ISSUED BY: JOB ADDRESS: 3333 1243 BRISTOL ST CM Suite/Unit: 1243 APN: 41250107 Zoning:PDC, , Vicinity: SUITE 1243 TED BAKER Primary Occ: M Const Type: I -A SO. FT: 0 Valuation: $52,800.00 SCOPE OF WORK: INTERIOR STORE FOR ""TED BAKER" IN SUITE 1243. WORK INCLUDES REMOVAL OF EXTERIOR DOOR AND REPLACE WITH SWING DOOR. ELEC: ADD 42 LIGHTS FIXTURES. + OWNER: SOUTH COAST PLAZA Address: 3315 FAIRVIEW RD Unit: Phone: CitylState/Zip: COSTA MESA, CA ' APPLICANT: DAN TSCHIDA Address: Unit: , Phone: 512-659-2251 City/StatelzZip: CONTRACTOR: FOUR CORNERS CONSTRUCTION LP - _ - License No. 855866 Phone: 512-336-2279 Address: i 10 WILD BASIN'RDUnit: STE 230 Cell: City/State: AUSTIN, TX ZipCode 78746 ARCHITECT: KEN BUTTS AIA License No.C4071 PHONE:8i8-999-4272 ENGINEER: License No. PHONE: COMBINTATION PERMIT FEE SUMMARY = Building Plan Check: $108.02 Building Fees: $664.75 :_' Electrical Fees- $61.56 Mechanical Fees: $0.00 r Plumbing Fees: $0.00 ' ;L -)OR SMIP Residential: $0.00 SMIP Commercial: $11.09 TOTAL FEES: . $845.42 "Refer to tee receipts for all fees paid for project NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE 1, INSPECTION TYPE DATE INTMAL5 CODE F IN5PECTION TYPE DATE iNTMAL5 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing C 200 Final Re -Roof 210 Final Electrical P/A 201 Final BlocklRetaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy WORKERS' COMPENSATION DECLARATION. I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compen stion, as provided for by section 3700 of the Labor Code, for the perf ance of the work for which this permit is issued. have and will maintain workers' compensation insurance, as required by -section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy 1� -number are: � Carrier. (This swian need nal be awtptered tf rhe pWO a valYred at one hu>drad dollars ($ too) or less.) Colicy Number. ! _, ICertify that in the performance of the work for which this permit is Issued, I shall not employ any person in any manner so as to become subject to the workers' cbmpensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of LborCode, t shall forthwith comply wi these provisions. Applicant's signature v Date WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. 'Contractor's Signature Date CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code), Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of periury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, 8nd the structure is not intended or offered for sale (Sec. 7044, Business anq Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not appy to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License taws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature 3057-46(3107) Date Owner ID verified by dri%. , lice,._~. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Division of Industrial Safety Permit Number: Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions. requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If -yes-, the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If "yes", attach certificate of compliance from the appropriate air pollution control officer), CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. �Sign of/ Le al er(s) Date � 4 r 3-zo-o8' Cl— Antlror Authorized Applicant Date (714) 754-5273 + Fax (714) 754-4856 • www.ci.costa-mesa.0p1LDING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Phone: Suite: 1243 License: Vicinity: License: Primary Occ: M Display/Sale Merchandise Type of Construction: I -FR Parcel Number: 41250107 Zoning: PDC Applicant: STEVE HONDA 'TED BAKER" SPACE 1243 Address: 308 S CROCKER ST Phone: 213-680-3500 FEE SUMMARY LOS ANGELES, CA Zip: 90013 Owner: SOUTH COAST PLAZA Calc Valuation: $1,100.00 Permit: Address Claim Valuation: $1,100.00 SMTP Res: COSTA MESA CA Phone: 3315 FAIRVIEW ROAD Zip: 92626 Contractor: FOUR CORNERS CONSTRUCTION LP Other: Address: 110 WILD BASIN RD - -�_- Inspection: STE 230 Phone: 512-336-2279 ' AUSTIN, TX $69.47 Zip: 78746. License: 855866 Arch Eng: Address: Address: Status: ISSUED Applied: 05/23/2006 Issued: 05/23/2006 i NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the worts authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 !446-0 (sroo) Phone: Phone: Zip: License: License: SCOPE OF PERMIT INSTALL 1 9" X 7'6.5 " NON -ILLUMINATED SIGN FOR 'TED BAKER" SPACE 1243 FEE SUMMARY Plan Check: $27.17 Calc Valuation: $1,100.00 Permit: $41.80 Claim Valuation: $1,100.00 SMTP Res: $0.00 SMIP Com: $0.50 Other: $0.00 - -�_- Inspection: $0.00 ' Total: $69.47 PLANNING & ZONING SETBACKS MAIN STRUCTURE , Front 0'00 Rear 0-0- Left 0-0 Right 0- 0 ; 1N ACCESSORY Front r 0-0 Rear 0-0 Left 0-0 Right 0-0 PARKING Existing:.. 0 Re wired: D "' Proposed: 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the worts authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 !446-0 (sroo) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self-,Insure for workers,compensatlon, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is Issued. `- �( 1 have and will maintain workers' compensation Insurance, as required by section 3700 o1 the Labor Code, for the performance of the work for which this permit is Issued. My workers' compensation Insurance carrier and policy number are: Carrier: 10//0 y CbN k,&Y 7 �ne14L,,2 4_ z Y' Co Policy Number: 1coo f t- C4,2 00 (This section need nor be completed if the permit is valued at one hundred dollars ($100) or fess.) ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' Compensation laws of California, and agree that If I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisions. ,l+ Applicant Signature: - �2y �` _ _ Date: SZ O 6 WARNING: FAILURE TO SECURE W ERS' EM$ATION COVERAGE IS UNLAWFUL AND SHALL S1113JECT AN EMPLOYER TO CRIMINAL PENALTIES AND GVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,006j, IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEI^S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 o1 the Business and Professions Code, and my license Is in full force and effect. Lac. q RS Class 4 Contractor's Signature:- Date: CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Data: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself Cr through his or her awn employees, provided that such improvements are not Intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). [] C. as owner of (he property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to Construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason; Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ NO Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demofition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-buitdor, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: T _ Date: Division of lndustrial Safety Permit Number. HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to Tile and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _._..._.......—........... - _........ �--- ..................---� ._........_.......... _...........- _ .........................._......---.............—...............---..�._................................ 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 o1 the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume o1 55 gallons, or 200 cubic feet of compressed gas at standard temperature anti pressure). 6..: ...................................._^_.......................---.....................-.......................................... - ........................... -------................. -... .._....................................... ...... ... ....................... .....-.. 3 Does or will theappplicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes 1:1No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the l=ire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. _..................._............_........................................................................................._............................................................................................................................ ............................................................. ........................................................... 4 If an RMPP is presently required, has Section 25534 o1 the California Health and Safety Code been fully comptied with? ❑ Yes G] No -._............... -................................................ .-.................................. --......................... -................... _-.............................................................. .............. ................r-- ......................... _.. 5 Ooes or will the applicant or present or future building 000upant require for the work which is the subject of this application aermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes 6 No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). _................................................................................................................... 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries o1 a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ............................................................................. ................................................................................... ,.......-.............................. ....................................................... 7 It a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which Is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (If yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for Inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Sign cur Of Legal ner(s) Date 5-23 --06 A r Authori ed Applicant Date LODE I• INSPECTION TYPINTITIALS D 1 INSPEC110NTYPE INTnmt 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final _ 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval , 203 Final Sign 222 Final Site 204 Final Demolition _ 250 Final Building/Occupancy s.,CITY OF COSTA MESA BUILDIMG DIVISION F77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 - Fax (714) 754-4856 www.ci.costa mn us ? FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: E08-00392 PERMIT TYPE ELEC STATUS: ISSUED APN: 41250107 DATE ISSUED: 10/1512008 ISSUED BY: BJK JOB ADDRESS: 3333 1236 BRISTOL ST CM Suite/Unit'" � 1236 Vicinity: STE 1236 BURBERRY SCOPE OF WORK: INTERIOR T.I.•FOR "BURBERRY" IN SPACE 1236. ELEC: 24 LIGHT FIXT_ URES OWNER: SOUTH COAST PLAZA Address: 3315 FAIRVIEW RD Unit: PHONE: - -City/State/Zip: COSTA MESA, CA . APPLICANT: DAVIS, KELLY Address: 2010 INDUSTRIAL BLVD - Unit:UNIT 605 PHONE: 817-658-7568 CitylState/zZip: ROCKWALL; TX' CONTRACTOR: JOHN M DONAHOE' License No. 913799 Address: 2010 INDUSTRIAL BLVDUnit: UNIT 605 PHONE: 617-658-7568 City/State: ROCKWALL, TX ZipCode: 75087 CELL: ELECTRICAL PERMIT FEES Electrical Plan Check Fee: $0.00 Electrical Permit Fee: $48.42 Reinspection Fee $0.00 TOTAL FEES $48.42 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS., In order for the work authorized under this permit to be Considered legal, such work must comply with all applicable codes, and all required inspections and Final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE I• INSPECTION TYPEApAT INTMAL5 CODER INSPELli0N TYPE DATE INIMAL 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy WORKERS' COMPENSATION DECLARATION. I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for woi kers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain workers' compensation insurance, as required by. section 3700 of the labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier. (This section need not be campk0d I the pemzf is vakred of orte htmdred dollars (S100) or less.) Policy Number: d,r �,, cert I^y hal -Tnet a pe o� ��sf the to fo u is this perm,11 Is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forth comply with these provisions. r a /"rc,��b� SApplic awe Oale ] v WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Liv, Clan ContrJUw's Srgrwlare Date j CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: i Lender's Address: Signature Hate OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that i am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit t0 construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees wish wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). , ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature 3057-46 (3107) Date 1 Owner ID verified by drive. _ .,cense. ❑ Yes ❑ No 2 Driver's License No. - Expires: .;r:40 . Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ` ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Tille 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit t0 do such work from the division. Applicant's Signature Dale Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be riled with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 85850,2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. It a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 6. (If "yes", attach certiricate'of compliance from the appropriate air pollution control officer). I ` CERTIFICATE OF COMPLIANCE: I certify that under penalty -of perjury the information given above is correct. I agree to comply with all state.laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF -COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. sign galOwner(s) Date _harized Apphcant_S Da -- (714) 754-5273 - Fax (714) 754-4856 - www.ci.costa-mit"KUPRESSION PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Suite: 1236 Vicinity: Parcel Number: 41250107 Zoning: PDC PDC Applicant: SHEILA LOONEY Address: Phone: 714-993-2822 Zip: Owner: SOUTH COAST PLAZA Address COSTA MESA CA Phone: 3315 FAIRVIEW ROAD Zip: 92626 Status: ISSUED Applied: 12/29/2004 Issued: 01/25/20 5 ISSUED BY: Contractor: ALERT FIRE PROTECTION INC Address: 5200 E HUNTER AV Phone: (714)993-2822 ANAHEIM, CA Zip: 92807 License: 316324 SCOPE OF PERMIT CHANGE 52 EXISTING DROPS AND RELOCATE 49 EXISTING SPRINKLERS FOR "BARNEY'S" STORE TI. REF: B04-01849. FEE SUMMARY Plan Check: $172.41 Calc Valuation: $15,500.00 Permit: $265.25 Claimed Valuation: $15,500.00 Other: $0.00 Total: $437.66 f'4 -o3 6);#s - /r,4, hudA - ast.4 / hd� �hdc mf`5 v�►i��s 4r f NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result In the expiration of this permit. FOR INSPECTIONS CALL: V1 4) 7545626 244646 (6101)) DECLARATIONS WORKERS' COMPENSATION DECLARATION: tt hereby affirm under penalty of perjury one of the foll.114 declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Coda, for the perlormance of the work for which this permit is issued. G 1 have and will mai tain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this perm t is Issued. My workers' com an Insurjdce carrier and policy number are: Carrier: Policy Number: e � j�~d (This section need not be complafad it the p&rrVt is valued at one hundred d6lars ($100) or lass.) ❑ I certity that in the performance of the work for which this permit Is Issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agr at if hould becomesu bject to the workers' Compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisions. .,! �� Applicant Signature: Date: Lfa- WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWJVL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE (S100,0W), IN ADDITION TO THE OOST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. t LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am Ilcansed under provision of Chapter 9 (commencing with Section 7000) of Division 3 of the Business an Prof ions Code, and my license Is in full force and effect. LIc. a Class a (�S Contractors Signature: Ii z Date: d CONSTRUCTION LENDING AGENCY: ❑' 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is Issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to Its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or Improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or Improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). . ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feel in depth Into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet o1 compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight o1 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ......................................... ................ ...................................................... ......_........ ......... ........... ....... .......... ................................... ........................................................................................... _................. ................... ................ - ...... _. 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. _................... __. __... ............ _............�..............—...............—_............................................................................. ......................... ..---....—.— ....... 4 If an RMPP is presently required, has Section 25534 o1 the California Health and Safety Code been fully compiled with? O Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this epplicatlon aPPermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes L� No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). YA ty 8 Wilt an art of the facill to be constructed under this permit be within 1000 feat from the outer boundaries of a school? ❑Yes ❑ No (If 'fres", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ... _........... _._.—_............. —................ _.................................................................................. .................................................... —.................................. ............................ 7 if a permit from the South Coast Air Eu city Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (if "yes", attach certificate of compliance from the appropriate air pollution Control oHlcer}. CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction. and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Sid1liature Ot al Owner(s) Date And/Or KtWzod Applic yJ Date CODE f. SECTION TYPE i INTMAL$ CODE 0 it(SPECTION TYPE WMALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retalnl all 212 Final Fire Prevention 202 Final Factory Fire ace 220 Final Planning Approval 203 Final Sign 222 Final Sita 204 —Final Demolition 250 Final Building/Occupancy Job Address: 3333 BRISTOL ST Status: ISSUED Suite: 1231 Applied: 06/15/2006 Vicinity: SPACE 1231, TORY BURCH Issued: 06/20/2006 Parcel Nunmber: 41250107 Zoning: PDC PDC ISSUED BY: Applicant: LOONEY, MARK _ Address: 5200 E HUNTER AV SUITE f'�J Phone: - 714-993-2822 ANAHEIM, CAr� �I -- Zip: j 92807 Owner: SOUTH COAST PLAZA Address j COSTA MESA CA Phbne: tJ 3315 FAIRVIEW.ROAO- Zip: 92626` Contractor: ALERT-,FIRE,,PROTECTION INC \,A Address: 5200. E HUNTER'i.."AV_. X/ SUITE B Phone: 714-993-2822 \ i o ANAHEIM, A Zip: f , 92807 , <� Licen ea ` 316324 Til --i SCOPE OF'PERMIT PWG 2, ADD 4 AND RELOCATE,18 OVERHEAD'SPRIN0ER HEADS FOR -TORY-BURCH". SPACE• 1231.. ` REF.: 806-04480 FEE SUMMARY PIan,Checkr f $63.21 Calc Vaivatiori:, , $3,200.00 P_ ermit, $97.25 ----_ --- --_ _ _ _ _ � Claimed Valuation-, $3,200.00; f Other:,. - '$0.00 r�-: a �`'l.1 y Q�1C _!1 T)[H R 7&3_ Total ' $16 0.46 An lA 6ll \ ✓ \ \ i. _== p�F-��rll-i✓ �� to d NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS:. In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2448.46 (6=) r a WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ 1 have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of -the work for which this permit is issued. My workers' compensation insurance carrier and policy number are: Vv_wl - p Carrier: Policy Num�be r:�i S O 1 f? - % OO( (ThIs section need not be completed it the permit Is valued at one hundred dollars ($ f 00) or less.) ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that If I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, 1 shall forthwith comply with these provisions. Applicant Signature: Date: WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUEUECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THiOUSAND DOLLARE ($100,000), IN ADDfFION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions o1 Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Profs Ions Code, and my license is in full force and effect. Uc. q Class k ' C_ - / Contractors Signature: Date: - CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lenders Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, after, improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions o1 the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation o1 Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty o1 not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. 11, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license, ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, I,e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more lest in depth Into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Gode). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industria! Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Data: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _ ......................._.............__._...__.........._.....-----............. —............... ......................................................................... _._.__.._ ...... .._ 2 floes ar will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ............ a ................. _..... .... ... ............. ...................................................._....................................................................................................................................----......_........ , ............_ ..... 3-r1Doea or will,the a icant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? � ❑ Ye9 '❑,N ' (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ....................................................._.............................................................._......................................................... ......................................................,...,,............................................................. _.................. -................ __.............. 4 It an RMPP is presentiy required, has Section 25534 of the California Health and Safety Coda been fully complied with? ❑ Yes ❑ No ........... .................... - ......... ...... -. _ - _ ___._ . -._........................---......................... _.... 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this application a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes f No (Section 65850.2 of the California Government Cade requires that the requested information be furnished on applications for non-residential building permits). -_...._....-..._— - ....... ........... _ _...... - - -- 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (!f yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality. Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by Califomia Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (If yes", attach oertificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: t certify that under penalty of perfury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that i have read this application and state that the Information given is correct. I agree to comply with all slate laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for Inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Of Legal Owner(s)Date~ Z r Autito Applicant L—Date CODE I INSPECTION TYPE RM INTMAL$ g_Q,DE INSPECTION TYPE >?AI>: INMLS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention p 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 260 Final BuitdinglOocupancy (714) 754-5273 • Fax (714) 754-4856 • www.cl.costa-mesa.SW;LDING PERMIT ,lob Address: 3333 BRISTOL ST Suite: 1231 Vicinity: Phone: Primary Occ: M Display/Sale Merchandise Type of Construction: I -FR Parcel Number: 41250107 Zoning: PDC Applicant: IMBRIALE; PATRICK Address: SANTA ANA, CA Phone: 714-957-8250 'License: 748446 Zip: 77 FAIR DRIVE, COSTA MESA, CA 92626 ISSUED BY: s Status: ISSUED Applied: 03t29I2006 Issued: 06/01/2006 Owner: SOUTH COAST PLAZA Address COSTA MESA CA Phone: 3315 FAIRVIEW ROAD Zip: 92626 Contractor: DEVELOPMENT SUPPORT SERVICES INC Address: 1515 W ALTON AV Phone: 714-957-8250 SANTA ANA, CA Zip: - 92704 'License: 748446 Arch : DAVID UDKOW Eng: Address: 9750 N 96TH ST STE 219 Address: Phone: 480-614-3385 Phone: SCOTTSDALE,AZ Zip: 85258 License: C8912 License: SCOPE OF PERMIT 1,762 S.F. INTERIOR TENANT IMPROVEMENT FOR 'TORY BURCH" SPACE 1231 FEE SUMMARY Plan Check: $206.99 Calc Valuation: $150.000.00 Permit: $1,273.75 Claim Valuation: $150,000.00 SMIP Res: $0.00 SMIP Com: $31.50 Other: $0.00 Inspection: $0.00 Total: $1,512,24 PLANNING & ZONING SETBACKS MAIN STRUCTURE, Front '0- 0, 0-0 Left 0-0 Right 0-0, i_ ^Rear ACCESSORY '. Front -0-0 ,��• Rear '0-0 Left-' 0-0 Right -% 0-0 , PARKING _Existin '0' i Rea ired: 0 Proposed: 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced wiihin 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result In the expiration of this permit. FOR INSPECTIONS CALL: (714) 754.5626 2446-46 (6=) DECLARATIONS WORKERS' COMPENSATION DECLARATION: ' I hereby affirm under penalty of perjury one of the following declarations: ❑ 11 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. -❑--A..I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Cade, for the performance of the work for which this permit is issued. ":—My workers' compensap'on Insurance carrier and policy number are: `Cagier: ' CIA/f!Hb,c,/ ,PalicgNumber:_d.�ii��•�42 •�i `?l y (This'section need not be completed if the permit is valued at one hundred dollars ($100) or fess.) ❑ 1 certify that in the performance of the work for which this permit is issued, I shalt not employ any person in any manner so as to become subject to the workers' compensation laws of Califomia, rid agree t t If I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply_with these pr io / ApplicantSignafure t� WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUEVECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed der revisions of Chapter 9 (commencing with Section 7000) of Division 3 of the.Businy and Professions Code, and my license is in full w .Class a I/Yfl ,force and effect. Lic. q � �1� y � _ COntractor's-Signature: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lenders Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit to file it signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more then five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License taw does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building of improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property. am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License taws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID veriilod by drivers license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, Le. - property tax bill or dead): i DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .................................................................................................................................................................................................................................................................................................................................................................... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). �, ..._._......__................._....._......----.....-............................_................._.._...............---.._.............__._..................._._............................................._...._..........._......................—._..................- .... ......... 3 Does or will theapplicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, cartification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ INo ..._............................................... _-_......-_.................................... ................ ..............._........................ ...................... ---........................ ..._._................. ... __.........._......-r. ................................. ................... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of thisa plication a ffrmit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Byes L3 No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ..................... :......................................... __............ ....................,............................... ................................ .......................... ..................................................,..................... ...................................................................................................................... 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If "yes", the facility must meet the requirement o1 Sections 25534 and 42303 of the California Health and Safety Code). ..........................................................................................................................:...............................................................................:.................................--.................................................................................................----.. 7 If appermit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this applicatlon, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes j] No _ ....................................._ __.__.................................__._........... .......... ---._..................... .......................................................... -... _.................... .................................._._.._.........................._............... _...... .... ... a (if'yee, attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state taws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. I i tura Legal ne s) � 4ateO Ind AuthorizadApplicant ,;`Data CODU INSFECTIONTYPE tiBIE 1NTlYlALCODE INSPECTIONTYPE 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Relaining Wall 212 Final Fire Prevention 202 Fjnal Factory Fire Place 220 Final Planning'Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy ^� (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.9WiLDING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 .lob Address: 3333 BRISTOL -W Status: ISSUED Suite: 1231 Applied: 04/26/2006 Vicinity: issued: 06/01/2006 Primary Occ: M Display/Sale Merchandise Type of Construction: I -FR Parcel Number: 41250107 Zoning: PDC Applicant: IMBRIALE, PATRICK ` Address: Phone: 714-957-8250 ISSUED BY: Zip: Owner: SOUTH COAST, PLAZA Address COSTA MESA CA Phone: 3315 FAIRVIEW ROAD'" Zip: 92626 Contractor: DEVELOPMENT SUPPORT SERVICES INC Address: 1515 W ALTON AV ' Phone: 714-957-8250 SANTA ANA, CA Zip: 92704— License: 748446 Arch Eng: Address: Address: Phone: Phone: Zip: License: License: SCOPE OF PERMIT INSTALL 9', HIGH MOBILE, STORAGE SHELVING FOR'TORY BURCH" IN SPACE 1231 FEE SUMMARY Plan Check: $136.01 Calc Valuation: $12,000.00 Permit: $209.25 Claim Valuation: $12,000.00 SMIP Res: $0.00 SMIP Com: $2.52 Other: $0.00 Inspection:. $0.00 Total: $347.78 PLANNING & ZONING SETBACKS MAIN STRUCTURE Front 0-0 Rear - 0-0 Left 0-0 y . Right 0-,0 ACCESSORY— Front, 0- 0 Rear 0-0 Left 0-0 Right. 0- 0, PARKING Existing: 0'' - Required. 0 Proposed: 0 - NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 244646 (6100) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I 1 have and will maintain a certificate at consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the ____�work for which this permit is Issued. ❑ t.have=rind will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. My workers' oompensatio%Insurance carrier and policy number are: `Corner ��r�/L'i[e�B�i -Policy Number: 0-?& ,�/�� 3l (This•seclion need not be completed if the permit is valued at ons hundred dollars ($100) or less.)`- ❑ I I certify that in the performance o1 the work for which this permit is issued, I shall not employ any parson In any manner so as to become subject to the workers' 'compensation laws of California, and agree that If I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith ;comply with these p Io s. ,ApplicantSlgnalure: - L.1.1L r"Date: WAANWG* FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPCOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED -THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 37D6 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby.affirm that ham I'' ci�rj� o . ions of Chapter 9 (commencing with Section 7000) of Division 3 of the Busine and Professions Code, and my license is in full f cro a and.effecl..Lic. if /-. T 7Q� e n Ciera N_ R ` onlractors'Slgnature: ' S. 6n... s _Date:] •' "O r i CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lenders Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty o1 perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any City or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than live hundred dollars ($500).): ❑ -1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors license Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or improvement is sold within one year of Completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of safe.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Ownei ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth Into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has e permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of Compressed gas at standard temperature and pressure). 2 Does or wilt the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑Yes ❑ No (Section 25533 of the California Health and Safety Code, with soma exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .........................................11--1........................................................................................................ _.............................. ................................ ....................... ................................................................................................................ 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ....................... ... .......................... ....................... ........................................................................,.,.,.,,..,............................................................................................................................... ......................................................................... 4 if an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No .:........... .............I ......... ........................ ..........................-.................................................................................... ..................................................................... ............................................................................................................. 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a armit for such construction or modification from the South Coast Air Ouality Management District or from any other air pollution control district or agency? Yes a No (Section 65850.2 of the California Government Code requires that the requested information be fumished on applications for non-residential building permits). ...... .................. ._...._............. ........................... -... .......... 1- ••--------....... ... ............... .... ........._.......................... _..................... -................... _.._............................................................................................... ._...............---.................__-. 6 WIII any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if 'jres W. the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Solely Code). W........... _ ............. - ---..........._...---.........—_......_...._. _ _......._....._._--...._...—_._..................---- .... _.... ....... _ _.._......... .... ..... ....--- 7 if a permit from the South Coast Air Ouality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures proscribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ................................... _-----............................----.�_..........................._................. __....................... —................... __-.............................. ................. ........................_._................... -................. __........................ 8 (If 'yes ,attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Si etur f Legal Owner(s) Date __ - AncllOr AuthorizedApplicant�- CODE 1, i INSPECTION TYPE INTMALS �Q.RE-! INS?gCJION TYPE RAM Iffliva 1$16 ! Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wali 212 Final Fire Prevention 202 i Final Factory Fire Place 220 Final Planning Approvat 203 Final Sign 222 Final Sita 5 204 Final Demolition 250 Final Building/Occupancy I1 (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 PLUMBING PERMIT .lob Address: 3333 BRISTOL ST , Status: ISSUED Suite No 1231 Applied: 07!1112006 Issued: 07/11/2006 Vicinity: Parcel Nunmber: 41250107 ' Applicant: JOHNSON, DARRYL ISSUED BY: Address: 12262 GeORGIAN ST Phone: 714-799-1907 = 1 GARDEN GROVE; C4 s t " i Zip: • 92814 Owner: SOUTH COAST,PLAZA; Address/% •COSTA MESA CA-/ �� �� � -Phone: %3315 FAIRVIEW.ROAD. Zip: 92626 .Contractor: JOHNSONS DISCOUNT PLUMBING 1 � ,,,Address. 12262�GEORGIANST Phone: �. GARDEN GROVE, CA Zip: ( 92814 u'Licensr :% 724339-,, J t ' \�• "_. SCOPE OF PERMIT 1 762/S.F: INTERIOR TENANT IMPROVEMENT FOR 'TORY BURCH" SPACE 1231 i L PLUMBING TO INCLUDE: f WASH'BASIN'AND 1'WATER CLOSET. /" 1 "_FEE SUMMARY AMT QTY _ AMT CITY i' _ AMT ' E QTY ISSUE'FEE _ ��_ $23.50 Laundry Tub /Washer $,0.00 10' i Sump Pump 1 J ' � $0,00 � 0 Backflow irrigation, , i;, $0.00 0 c J - Landscape Irrigation �� ` ;$0.00 `..0,1 ' A! Swimming Pool ri,' ^$0.00 'A Backfiow.Preventer $0.00 0-"_"_'P=Trap "�" -, �`$O.00 i 0' Trap Primer •� 1so,00:0 0 Bathtub �" ,! ' ` $0.00 0 ; Pressure Regulator' ' - -$0.00 ;' 0' Urinal J' �f $0.00r�' 0 Clarifier System- $0.00 0 Process Piping (per 10 ft) $0.00 0 Vacuum Brkr Bkflow(1-4) $0.00;'' /0 Connect (Ice,Soda,etc)'1% $0.00 o") Receptors t<$0.00 0 Vacuum Brkr Bkflow(5+) ` : $0.00 ' ,` 0 Dental,Units ! �:�r"$0.00 0� Septic Tank -,.,,$0:00- i3O Wash Basin //�' / $9.80 ; 1 Dishwasher\_\ !1 \�� $0.00 04 Sewer Cap for Demo $0.00 0 Wash Basin'Set $0'bb 0 Drairi,.Floor $0.00 0 . Sewer Connect; . " $0.00 0 Waste and,Vent Systema $0.00 0 Drain, Rainwater $0.00 01 Sewer Private'Line $0.00 D Water Closet (Toilet) ,$9.$0 1 Drain, Roof . - $0.00 0, Showier $0.00•.1- 0 Water. Heater I vent $0.00 0 Drinking Fountain <, ' $0.00;��\ 01 • . Sink,'bai $0.00 •y -O..; - : _ Water. Piping (lns(or Rep.) •i$0.00 0 Expansion Tank $0.00 .�` ' D �•' �= t f�Sink, commercial $0.00' "O:i,. Water Re -pipe �, $0.00 0 Gas Earthquake Valve $0'.00 0\� Sink, Floof" i '- $0.00 0 Water Service ' x$0.00 0 Gas 1 4 outlets' ` / _ _ „ % f ( ) �.��, $0.00�� 0 \� cSink, kitchen $0.0D 0 �. Water�Softener ,� $0.00 0 �ti Gas (Over 4 outlets):` \. 50.00- 0 ,Sink, servicelmop $0.00 0 OTHER �%% $0.00 Gas Repipe $0.00, ' 0 -_ Spa (private) $0.00 0 rVIOLAT*N $0.00 Gas Service . \--$0.00, 0 f Spa (public);'= _ $0.00> 0 PLAN CHECK��/ $0.00 Interceptors (Grease, Oil) moo (O��fi� `� \'` REINSPECTION $0.00 0 Interceptors (Sand Auto) �$O.OD� 0- \� r /i r }; TOTAL CALCULATED FEES: $43.10 ` COMMENTS [SPECIAL' CONDITIONS,%` NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work Is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be oonsldered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 44"-" til DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ l I have and will maintain a certificate of consent to self -Insure for workers', compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. ❑ 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit Is Issued. My workers' compensation Insurance carrier and policy number are: Carrier. Policy Number: (This section need not be Wm efed if the permit is valued at are hundred dollars ($100) or lass.) 1 &er ify that in the performance r which this permit is Issued, I shall not employ any person in any manner so as to become subject to the workers' --compensation laws of Calito a, and agree th t If I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provi -Appiicant Signature: , ` - f ---Date:- Z' —r `WARNING: FAILURE T CURE OFHERS' TION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOlL4RE t$100,000), TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR W SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license Is in full force and,effect-lJc'tt"-"�- Class a �•< Contraetoi Dale: Z7 CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business end Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for safe (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or Improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or Improvement Is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or Improve for purpose of sale.J. ' ❑ j I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owi nor 1D verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. • property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation live (5) or more feet in depth Into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, tarp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ...........................•-or,----...-•--.........f'u...................-i'n............................................................is.'t.............*f*o"r..............'c.ut'e.'1..............'d"'..................................................._..........................,............................................ 2 ', Does or will the applicant or present or future building occupant need to file a registrefion form for acutely hazardous materials? ❑Yes ❑ Np (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materiels equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic foot of compressed gas at standard temperature and pressure). _..._.......................... _._............ ............_...—_._._...---....................................... ................................................. .-...... ................. ..._.......................... __........ ....... __.......... ............................... — ...... — 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. _.......................................—............................__..............................._.......................—_....................._.—........_..........__..... ................._......................_—............—_.....---- 4 [f an RMPP Is presently required, has Section 25534 of the California Health and Safety Code been fully compiled with? ❑ Yes ❑ No ............. .....................................................................................•------..............................................................._.........................................................................................................................................„.„ 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification from the South Coast Air Ouallty Management District or from any other air pollution control district or agency? Yes No (Section 65850.2 of the California Government Code requires that the requested Information be furnished on applications for non-residential building permits). 6 Will any paA of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'fres", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ...................................................................................................................................................................... ........................................................................... . .......................................................................................................... _........ 7 If apermit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ..................................................................................................................................................................................................................................................................................................._....................................... .,.,,................................... 8 'attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state taws and city ordinances rotating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. i Date A ihonzed Applicant _ . -Date PQR.F�L INSPECTION TYPE gAFE INTITALS CODE# INSPECTION TYPNTMALl 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pod Spa Final 208 Final Plumbing R -d -o b 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 . Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250' Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.cLoosta-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 MECHANICAL PERMIT Job Address: 3333 BRISTOL ST Suite No 1231 Vicinity: SPACE 1231, TORY BURCH Parcel Number: 41250107 Applicant: DONE, DAWN Address: 316 E DEYER RD ISSUED BY: Status: ISSUED Applied: 0612012006 Issued: 06!2012006 SANTA ANA'CA Zip: U 92707 ` = Owner: SOUTW'COAST PLAZA} Address: �1�f � STA'MESA CA J Phone: A 3315 FAIRVIEW,ROADS Zip: 92626 Contractor: ALLIANCE,HEATING AND AIR CONDITIONING INC. Address: 2144S WRIGHT ST ���� Phone:�714-436-1652 /t1 / S NT 'ANA, CA Zip: . X92705 License:.840838��li�� ✓ SCOPE OF PERMIT N MECHANICAL PERMIT FOR~A,1,762'S:F.•INTERIORIENANT IMPROVEMENT FOR'TORY BURCH" �+ REF#: -B06-00480 J i - WORK TO INCLUDE: 1/AV BOX AND 1 VENT FAN/SINGLE DUCT. ,. C�.lf FEE SUAR MMY, j 1 r � 2 .Z U - - ---._ A11tYJ�' , (-Quantity! ISSUE,FEE---j ,1�1� ! $23.50 Repair IAlt AbsorbtionUnit' J f$0.0 ,0 i Inst FAU 5100 k BTU!,' $0.00- O r� �Repai(!.Alt Refrigeration Unit$0 00 '0 insi FAU >100 k BTU Uj $0.00 p4 Ventiflation System_, f /$0.00 0 Repair /-Alt Cooling/Heat $0.00 ' 0 _ Evaporative Cooler ? x$0.00 0: n InstlRep..Recess Wall'Htr $0.00 0 -' __Cor)mercial Incinerator) �! $0.001-0 i Refrig'Sy`s X100 k BTU\ ' $0.00 0 Domestic Incinerator $O:o4 J4 4x' Refrig Sys >100 k BTU �`, ` $0.00 0 Compressors I Absorption Systems I1.>> Ga 'Piping �l r�it $0,00 0 Up4o,3.hp 000 k BTU j �$o.00w 0 Faso -Fireplace \, $0;00 0 3 To 15 hp 1500 k BTU { -J$O.00j d I M. '`'"'' rte° x;15 To 30 hp 11,000 k BTU 11 J Hood'wlMecFi Exhaust $0.00 0 s» x$0.00 /oj VAV Boz ��t 1, $21.30 2 �,�5 i"�,U " 30 To,50 hp 11,750 k BTU $0.04 "10,/ Vent Fan ! Single Duct-\- `� $7.25 1 ; s � o � , ° r. OVer 50 hp'/ Over 1,750 BTU � $4.40 �0 Appliances ��`�$0.00 0 ;� n� ( ai Boiler's r�`° d ,•w )7� /� c/ l Fire Dampers / �,a � G 'G� p �\ $4.00 0 Up to 3 hp" v- $4:00/ 0 Smoke Dampers_. r $0.00,-0 �' r ��f3 To,.15 hp , ��� $4.00 0 Inst or Relocate Appl Vent ' - $0.00 0 �� �) ��` . , ; , �15 to30'hp `� $0 00 0 Air Handlers < 10000cfm �' ° / $4.00\0�. r'„ X30 to 50 hp $0.00 0 Air Handlers > 100006fm / $6.00 0 v Over-6Q.hp ;v $0.00 0 Floor Furnace0 $0.00, - V � �-� `'-�.�Other- Meehanicai Fee( Floor or Suspend Heater$0.00 0 / _ Investigation.F.ee \ \ � $0.00 �> �fl ) -_.Plan Check Fee1� ; 1 $0.00 i Reinspection Fee $0.00 �1 i ' ✓ , . TOTALGA_ICULATED FEES $52.05 COMM ENTS.I-SPECiAL''CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia'statutes and related regulations. (Ord. No. 92-28, § 1, 12-21.92) EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days, or if wo'K is' -suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply�ith all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 244646 (6=) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a Certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I haioa and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the.performance of the work for which this permit is issued. My work@rS' compensation Insurance carrier and policy number are:° '" r rrfe • _ CGE%if1�%D �PolicyNumber: r"3"�""��'� "� l/ secfron need not be completed if the permit fs valued at ane hundred dollars ($100) ar fess.) ❑ ,' I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Califomia, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply-wifh.ihese F�� y . AppllCant.Slgrteture: _ ate: WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVE AND SHALL SUBJECT AN EMPLOYE O CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby-affiun.ihat.l.arn licens u r o 514Ds of Chapter 9 (commencing with Section 7000) of Division 3 af.the-8usin ss Rn Pr fessions Code, and my license is in full -tOrce�and gffacE-Cic: #� tJ ass # �F -Con6ctor's•Signatr . : Data: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction fending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lenders Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended Or offered for sale (Seo. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) i license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ ` I hereby certify that no excavation five (5) or more feel In depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, ialsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title B, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division, Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 I Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ....................................................................................................................................................._................................................................................ i, Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ NO (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). :.................................................................._...............................................................................................................................................................................................................................................-�-............................................................ 3 Does or will the appplicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑Yes ❑rc (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ........................ .. .. ................ ................................................................................................................................................................................................................................................................................................................ 4 It an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No ..................•-,.,.................................................................--......... ...........................................................................................................................................................................................-.................---�- ............ ............... 5' Does Or will the applicant or present or future building occupant require for the work which Is the subject of this a plication aggermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes LJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-resEdential building permits). ............................................................................................................................................... .................. ............................................................................... ........................................................................................... 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No l (I1 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). .......................................................... ..................................................... ........................................................................................................................................ ..................... ........................................ .................. 7' If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this i application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 boon made? ❑ Yes ❑ NO .................................................................................................................... .............................. ............................................................................................................... I ............. I.... .......................... ................ attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances i regarding Hazardous Materials and Emissions. i Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of penury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. I - Si Dale 'And/Or.Aidhorlied'Applicant cX ipate�� D i INSPECTION TYPE - >wLE INTRIALS CODE N INSPECTION TYPE fA 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site i 204 Final Demolition 250 Final Building/Occupancy CITY OF COSTA MESA BUILDING DIVISION -'�• } 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 7544856 • www.cLoosta-mesa.ca.us °. FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER:- BC08-00500 PERMIT TYPE: B_COMBO STATUS: ISSUED Sub Type: COM -ALT DATE ISSUED: 10/15/2008 ISSUED BY: CAC JOB ADDRESS: 3333 1231 BRISTOL ST.CM ' Suite/Unit:; -1231 APN: 41250107 Zoning:PDC, , Vicinity: 1231PrimaryOcc_: M,, _ Const Type: I -A SQ. FT: 0 Valuation:. $34,000.00 SCOPE OF WORK: REMOVE;FAKE FIREPLACE . REMOPIE SILK PANELS FROM BAY WALLS AND INSTALL. NEW LACQUER PANELS IN ALL WALL BAYS -INSTALL MIRROR PANELING IN FITTING ROOMS AND INSTALL NEW HOOKS IN THE FITTING . ROOMS. 4. . OWNER: SOUTH COAST PLAZA , H'. r -- Address-Unit:.3315 FAIRVIEW RD ' Phone: CitylStatelZip: COSTA MESA, -CA APPLICANT: TOM P ENDLETON Address: 155 W MAIN STREET �� Unit: Phone: 4804610777, a° ",d,CitylStatelzZip: MESA AZ CONTRACTOR: FIWI BUILDERS License No. 816987 Phone: 480-948-9451 Address: 155,W MAW STREETUnit: Cell: ;" ,'City/State: MESA AZ _ , : ZipCode 85201 ; ARCHITECT: License No. PHONE:'. ENGINEER: License No. 'PHONE: COMBINATION PERMIT FEE SUMMARY Building Plan Check: ''$313.72 Building Fees: $482.65 Electrical Fees: $0,00• Mechanical Fees: $0,00 Plumbing Fees: $0.00. SMIP Residential: $0:00c SMIP Commercial: $0.00 TOTAL FEES: $796.37 "Refer to fee receipts for all fees paid for project i 'INN NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. Na. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTiON. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. 99090, INVEcnoN TYPE LAN INTMALi CODE 1 INSPE01,9N IN AL 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Finat Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building10ccupancy0TL WORKERS' COMPENSATION DECLARATION: , I hereby affirm under penaity.of.pMury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-tnsure for workers' compensation, as provided for, by .section. 3700 of the Labor Code, for the _ performance of the work for which this permit is issued. ' I have and will maintain workers' compensation insurance, as required by sechon 3700 of the Labor Code, for the performance of the work for which this permit is issued. My rkers' compensation Insurance carrier and policy numb rriC<L) F P, J&D'.., —PW/. C&6y n not be ownoetearfif the permd valued ai one Aundred do,7ars (5 roo) or less) Po' umber: ❑ I certify that in the performance of the work for which [his permit is issued, 1 shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become s ect to the workers' compensation provisions of Section 3700 of the Lab ode, I fodlrith co p1 ith these provisions. N i� Ap Signature D e 1 WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS ' UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force de e �e j Lic. s # / i��. [ __ C s gnature to CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: Hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or .improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.).. . ❑ I, as owner of the piroperty, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors license. Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: I Signature 305746 (3107) 1 Date Owner ID verified by driveiense. Yes Driver's License No. E: sires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Division of Industrial Safety Permit Number: Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be tiled with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (if -yes-, attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury. the information given above is correct. I agree to comply with all state.taw_s and city ordinances regarding Hazardous Materials and Emissions. Signature ' Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. ature of Lep er(s) 1 _ Date _ — An or Authonze pphrant '11� date (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT Job Address: 3333 BRISTOL ST status: ISSUED Suite No 1231 Applied: 06/20/2006 Vicinity: SUITE 1231 TORY BURCH Issued: 06/20/2006 Parcel Nunmber: 41250107 Applicant: THOMAS, STEVE Address: 16321 GOTHARD ST ISSUED BY: STE A Phone: 714-861-4060 HUNTINGTON BEACH CA Zip - 92647- Owner: Address Contractor: Address: SOUTH COAST -PLAZA COSTA MESA CA, 3315 FAIRVIEW,ROAD HARBOUR ELECTRIC 16321 GOTHARD ST STE A HUNTINGTON BEACH CA Phone: Zip: 92626 Phone: 714-861-4060 Zip: 92647 License: 707899 - =� `. ' SCOPE OF PERMIT 1,762 S.F. INTERIOR TENANT IMPROVEMENT FOR'7ORY BURCH" IN SPACE 1231. REF: 806-00480 90 LIGHT FIXTURES, 26 OUTLETS, 16 SWITCHES FEE SUMMARY Quantity `' Quantity ISSUE FEE $23.50 Temp Dist System 1 Lighting $0.00 0 Temp service test $0.00 Busway 1100 R - $0.00 0 Res. a/c package $0.00 Standing Section $0.00 0 New Res (1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0 New Res (3+units) $0,00 0 Transformers up to .1 kvalkw $0.00 0 Pool / Spa $0.00 0 ....:...........up to 10 kva/kw $0.00 0 Lighting Fixts $73.10 90 .......... —...up to 50 kva/kw $0.00 0 Recept Outlets $26.38 26 ...........:.:..:up 10 100 kva/kw $0.00 0, Switches $17.60 16 ..................over 100 kva/kw $0.00 0 Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0 ' Res Appl $0.00 0 Low Volt Wiring System / Ckt $0.00 0 Service to 200a $0.00 0 Misc. Conduit 1$0.00 0 Service to 1000a $0.00 0 Misc, Conductor $0,00 0 Service over .1000a $0.00 0 Circus (gen or ride)• $0.00 0 Motors to 1 hp so -60- 0 Circus (meth ride or�lights) '$0.0o, 0 Motors to 10hp $0.00 0 Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 0 -Fireworks Stand $0.00' 0 Motors to 100hp $0.00 0.1 Other Electrical Fee$0.00 Motors over 100hp $0.00 0 .- " Communication drops $0.00 0 Investigation Fee ' ' $0.00 . Sub panel to 200a $0.00. 0 Plan Check Fee- -$0A0 , /! Pole Light Pkg $0.00 0 Reinspection Fee ~ $0.00 Sign Circuits $0.00 0 " Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES ;140.58" Intermed Pole $0.00 0 COMMENTS I SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Catitomia statutes and related regulations. (Ord. No. 92-28, § 1. 12-21-92) EXPIRATION: This permit shat! automatically expire and become void it work Is nog commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must compty with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 24048 (M) DECLARArIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a cer0cate of consent to self -Insure for workors' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensafion Insurance, as required by section 3700 of the tabor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Ca ambar: 00 21 IQ(Q6 (This section need not be completed it the permit Is valued at one hundred dollars ($ 100) or less.) ❑ 1 certify that in the performance of the work for which this permit is issued. I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Califomia, a agree that If f should become subject to the workers' compensation provisions of Section 3700 of the E ober Coda. I shalt forthwith comply with these pro WARNING: FAILURE TO SECUR RS' COMPEN TION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE (S100,000), IN ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST. AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 8 (commencing with Section 7000) o1 Division 3 of the Business and Professions Code, and my license Is in full force and effect.# p in CorfeClots:Signa` tur� Date,,7 6-so—a7 CONSTRUCTION - 0• - CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation. WILL 00 THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License taw does not apply to an owner of property who builds or Improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or Improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of tloCumeTIt, Le. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet In depth Into which a person Is required to descend, will be made in connection with work authorized by this I permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high, (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 W III the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be tiled with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ........................_..............__.................._..................._ _ ....._..._. _..�.._ ............................ ........-.......................... — 2 Does or w the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 5(0 pounds, or a volume of 55 gallons, or 200 cubic foot of compressed gas at standard temperature and pressure). .................-..... ........ -----. _.......................... _... —..................................................................... _... ..._......... .._...-- 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No DSection 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire epartment of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ................ ....._._._................. _....................__.............................................................................................................................................. ............-..................................................._.--•---...._. 4 If en RMPP Is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No ........................... . ......._...._...---..._..................................-...............................,,._..................................................................-.........._.-._..---............._............._._............__......._.. 5 Does or will the applicant or present or future building occupant require For the work which is the subject of this a plication a ermll for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Ll Yes M No (Section 65850.2 of the Califomia Govemment Code requires that the requested Information be furnished on applications for non-residential building permits). •....................................................................................................----..................................................... ............................. .............................................................................................................. ........................................._ 6 Will any part of the facility 10 be tonstructed under this permit be within 1000 feet from the outer boundaries of a school? [:]Yes ❑ No (If -yes-, the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ........ .._-.-........................ I ......... _._.__.._........_.._................................._._.................................................................... 7 if a permit from the South Coat Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No _ ..... __. e fro _....__ _...................................._.........--- _ 6 (it yes', attach Certificate of compliancm the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. elute egal er(s) Date .3no[CW&ftrtzsd Applicant CODE .. WSPECnO TYPE FdI INTMA CODE ! INSPECnON TYPE pM WTMA 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Root 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Bulidinglpccupancy (714) 754-5273 - Fax (714) 754-4856 - www.ci.costa-mesa.ce"ILDING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Status: ISSUED Suite: 1231 Applied: 07/19/2006 Vicinity: Issued: 07/19/2006 Primary Occ: M Display/Sale Merchandise Type of Construction: 1 -FR Parcel Number: 41250107 Zoning: PDC Applicant: BEAKS_TROM, REBECCA Address: FOVELL ENTERPRISES INC �— CORONA, CA Phone: 909-734-6275 ISSUED BY: 1540 COMMERCE ST ,Zip: 92880 UNIT owner. SOUTH COAST PLAZA Address COSTA MESA'CA Phone: 3315 FAIRVIEW ROAD. �� _ Zip: 92626, \ Contractor: SOUTHWEST SIGN CO. - _ �� _ �� \ •;�;\ Address: , ,FOVELL ENTERPRISESINC CORONA; CA,,- '+i Phone: 909-734-6275' / 1540'COMMERCE ST Zip: 92880 �,�'''i� License: 724929 'Arcti r Eng: .;� / �.. A �• �, Address: t Address: Phone: Phone: Zip: License: - License: SCOPE OF PERMIT 1.66 S.F. ILLUMINATED SIGN FOR 'TORY BURCH" IN SPACE 1231 FEE SUMMARY Plan'Check:' _ -' $33.12 Calc Valuation: $1,370.00 Permit: $50.95 _ ' _ ;� _'/ .'v,,Claim Valuation: `' $1,370:00 SMIP Res: $0.00 _ - SMIP Com: $0.50 Other: .� $0.00 Inspection: $0.00 . _Total: $84.57 PLANNING & ZONING SETBACKS- MAIN ETBACKS MAIN STRUCTURE Front 0- 0 Rear X0.0Left 0-0 Right 0- 0'�� ACCESSORY ✓ Front 0 0, •,; , �- Rear ` 0-0 Lefl 0-0 Right `0=0` ; PARKING Existing:,. 0 Reduired: 0 Proposed: 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work is not commenced wlthln 180 days, or If work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 2ags-4s ts+ool DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to salt-Insure for workers' oompensaflon, as provided for by section 3700 of the Labor Code, for the performance Ithe. work for which this permit is Issued. jK" I Have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit Is Issued. ---My workers' pensation InsW#n rd r and policy number are: ---��0 p O V /� p �b .Carter. r V FicRcjlhlumbor — sectlon need not be completed if the permit Is valued at one hundred dollars ($ loaf or less.) ❑ I I'Certlfy that Im the pe rrlanCe of the work } r which this permit is issued, I shall not employ any person In any manner a0 a3 to become subject to the workers' compensation taws Ilfomia, and agr at kf I s Id become subject to the workers' compensation provisions of 3700 the Labor Code, I shall forthwith cormply with th l Applicant Sig r Date:- • �/ WAI�AIitJfe: FAILURE O SECURE WORKERS' C PENSATICXV COVERAGE I5 UNLAWFUL AND SHALL SUBJECT AN EMPIAYERfiD CRI P TIES AND CAVIL FINES UP TO ONE HUNDRED THOUSAND (5100,000), IN ADDITION T THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby.afffrm that I am licensed rid provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Bushg� fessions Code, and my Iloense is in full f rof ro Ce and,affect..Lic: N• - Clara o ctor's.Signal Date: m4 CONSTRUCTI N LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is issued. (Sec. 3097, Civil Code). Lander's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to Its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for safe (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not Intended or offered for sale. If, however, the building or Improvement Is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of safe.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors Ucensa Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a conlractor(s) license pursuant to the Contractors Lloonse Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, I.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more loot In depth Into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, TIIle 8, California Administrative Code), ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Dale: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and Certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 hoes or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Masa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). �..©'Yds - ......13 o._........................................................................_._.................. __.._...._.............. ....................................................... _._..._.__...... ---..�.............................................. 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? (Sectlon 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certifinaflon and filing with the Fire Department of an RMPP by businesses which are required to register acutety hazardous materials with the Fire Department. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied wilh7 ❑Yes ❑ No ............................. .................................. _... ........ .......�.......................... ...........__..—_......_...__......-----�� _......... W................................ 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this application a aermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes U No (Section 65850.2 of the California Government Code requires that the requested information be tumkshed on applicatkxu for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes No (If yes', the facility must meet the requirement of Sections 25534 and 42303 of the Califomia Health and Safety Code). 7 If armit from the South Coast Air Quality. Management District or other air pollution control district or agency is requlmd for the work which is the subject of this appypetion, have all of the disclosures prescribed by Calitomia Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (If -les', attach certificate pikance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given Is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Masa to enter upon the above-desc properly for inspection urposas. I agree not to occupy or allow occupancy of any building authorized by this permit until final Inspection. Sig re Of naris) ' / Date r uthorized Applicant (�� Date CODE m, MPECMNTYPE NTnIALS fit MSPE02MM fr'ATE HIM 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1256 Pod Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final BlockfAstaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250. Final BulldinglOccupancy (714) 754-5273 • Fax (714) 754-4856 • www.cl.costa-mesa.lftCTRICAL PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Suite No 1231 Vicinity: Parcel Nunmber: 41250107 Applicant: BEAKSTROM, REBECCA Address: FOVELL ENTERPRISES INC ISSUED BY: CORONA, CA Phone: 909-734-6275 1540 COMMERCE ST - 'Zip '92880' ' UNIT G Owner: SOUTH COAST PLAZA Address „'% ` '; r Af /COSTAMESACA,"-. _ - Phone: --_ i 3315 -92 FAIRVIEW ROAD-" Zip: - 626 V , _ ! Contractor: l SOUTHWEST. CO Address: FOVELL-ENTERPRISES INC CORONA, CA Phone:,,909-734-6275 1540 COMMERCE ST Zip: x,.92880 UNIT G r License: 724929 SCOPE OF PERMIT 1.66 S.F. ii-LUMINATED SIGN FOR "TORY BURCM" IN SPACE 1231_ FEE SUMMARY - Quantity \ Quantity ISSUE FEE ; $23.50 Temp Dist System! Lighting $4.00 0 Temp service test $0.00 �' r Busway_/100 ft -; J $0.00 01 Res. alt package $0.00 Standing Section ;l $0.00 0 I, New Res (1-2 units) $0.00 ` 0 Misc Electrical Equipment $0.00 0 .New Res (3+units) $0.00 `, 0 Transformers up to' 1'kva/kw $0.00 0 r Pool / Spa _ $0.00 0 ,'................ .... up to 10 kva/kw $0.00 0 Lighting Fixts $0.00 _ _ 0 ' r' .......:......:.up to 50 kva/kw .� $0.00 0 Recept Outlets $0.00 0 - -- - - - ...........,:.-._.up to'100 kva/kw' $0.00 0 Switches $0.00 "0 0 ..............;-over.700 kva/kw $0.00 ; Non Res'Appl. $0.00 0 Low Voltage Equipment $0.00 D Res'Appl ` $0.00 0 Low Volt Wiring System / Ckt $0.00 0;",/ ` Service to 200a $0.00 0 Misc..Conduit $0.00 :0 j ��' r Service to 1060a $0.00 D Misc. Conductor S0.00 %0 Service over 1000a $0.00 D "Circus (gen or ride) $0.00 ✓ '0 ; Motors to 1hp' - $0.00 0 Circus (meth ride or lights) $0.00 0 Motors to 10hp $0.00 0 Christmas Tree,Stand $0.00 "i 0 Motors to 50hp c, 0 Fireworks Stand $0,06 i 0 Motors to 100hp $0.00, ,f. = 0, -Other Electrical Feel-` Motors over 100hp i; $0.00, �.' , 0 Communication drops $0.00 ; , 0 Investigation Fee$0.00/;- Sub pane! to 200a $0.00 �0, - .Plan Check Fee Pole Light Pkg ; $0.00, 0 Reinspection Fee $0.00 ` ' Sign Circuits \`' g ��, $24.60 n 1 Temp Pwr Pole \ \; $0.00 ; ,0-11 y- = TOTAL CALCULATED FEES ti\,$48.10 �$0.0d 0 Intermed Pole �, �f � COMMENTS 1 SPECIAL CONDITIONS Status: ISSUED Applied: 07/19/2006 Issued: 07/19/2006 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permlt shall automatically expire and become void if work Is not commenced within 180 days, or If work Is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result In the expiration of this permit. FOR INSPECTIONS CALL: (714) 75456213 2"646 (ems) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: - ❑ I have and will maintain a cartifiicate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the _ work for which this permit Is Issued. �f fmave and will maintain workers' compensation Insurance, as required by section 3700 of the labor Code, for the performance of the work for ~ Oils permit is Issued. _Myr work e compoInsurance Carrier and policy number are: _ �/� � Carrier:' ��1� j fyumber._. x,000 /, Ave 4,_GINS section need not be completed if the permit is valued alone hundred dollars ($100) or less.) ❑ 1 certify that in mho performance of the work for which this permit is Issued, I shall not employ any person in any manner so as to become subject to the workers' compensatl.o laws apfomla, and a e that it I should become subject to the workers' compensation provisions o1 Section 3700 of the Labor Code, I shall forthwith oompty with ties tuts. / g/ ApptlCant Slgnatuie: Date:. o G __ WARNING^FAILURE 0 SECURE WORSE COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SU91ECf AN EMPLOYER Tp CRI NAL TIES AND CML FINES UP TO ONE HUNDRED THOUSAND E (Slt>o.000J, IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3709 OF THE LABOR CODE INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed undgtyrgvis of Chapter 9 (commencing with Section 7000) of Division 3 of.the.Busirrss d Professions Cade, and my license Is in full forts and effect. tic, M [L�f ��-- ,Class,a- [- -Cont lic— 8 Slgnattire: �er - O CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance o1 the work for which this permit Is Issued. (Sec. 3097, Civil Code). Landaes Name: _ Landar s Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under`penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason {Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter. Improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (Commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he bi she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a ohril penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Profgssions Code: The Contractors License Law does not apply to an owner of property who builds Cr Improves thereon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not Intended or offered for sale. It, however, the building or Improvement Is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or Improve for purpose of sale.). ' ❑ I, as owner of the property am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 70, Business and Professions Code: The contractors Lice44 nse Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 em exempt under sec.. Business and Professions Coda for this reason: Signature: Data: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more fest In depth Into which a person is required to descend, will be made In connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, See. 341, Title 8, California Administrative Code). ❑ As owner -builder, 1 will not employ anyone to do work which would require a permit from the Division Of industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number- HAZARDOUS umberHAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant Or presant or future building occupant need to file and certify a Business Plan for emergency response to release Or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be flied with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity o1 hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet o1 compressed gas at• standard temperature and pressure). 2 Does or will the applicant yr present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 D ser will the applicant Or present or future building occupant Head to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? t5ectlon 25534 foVf the California Health and Safety Cade provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP 4y businesses which are required to regisler acutely hazardous materials with the Fire Department. 4 If an RMPP is presently raqulred, has Section 25534 Of the California Health and Safety Code been fully complied with? f Yes ❑ No ------------------ 5 Does or will the applicant or present or future building Occupant require for the work which is the subject of this a plication armit lot such construction or motilflcation from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes LJ �aNo (Section 65850.2 of the CeIlfomia Government Code requires that the requested information be fumished on applications for non-resldentlai buUding permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If yes', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). _.......- ----. — — .....•. ......... ........................................... _................. 7 If a permit from the South Coast Air Quality. Management District or other air pollution control district or agency is required for the work which Is the subject of this sc application, have all of the disclosures pranbed by California Health and Safety Code Section 42303 been made? ❑ Y ❑ No ..................................................rIif1.........................................'iro............a e' a'-........11ut....n con..........._.......r........................................................................................___ — ._......... _ ._....... 8 {If "yes', attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I Certify that under penalty of perjury the Information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. SignOfAcler(s) /� O D A _ thodzod Appt cant ( Data CODE 0CODE111 INSPECTION TYPE gds, m� 1616 Fixed System Final Fire Provenilon 206 Final Mechanical 1268 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Slock/Rotalning Walt 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 . Final Demolition 250 Final Buliding/Qccupancy CITY OF COSTA MESA BUILDING DIVISION e 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 - Fax (714) 754-4856 • www.ci.costa-mesa.ca.us �. FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BC09-00425 PERMIT TYPE: B_COMBO Sub Type: COM_AL,T STATUS:, ISSUED DATE ISSUED: 11/06/2009 ISSUED BY: RMD JOB ADDRESS: 3333 1231 BRISTOL ST CM Suite/Unit: 1231 APN: 41250107 Zoning:PDC, Vicinity: SUITE 1231 TORY BURCH Primary Occ: Const Type: SO, FT.: 0 Valuation: $5,000.00 SCOPE OF WORK: INSTALLATION OF AN ACRYLIC SCREEN WITH BLOCKING AND ELECTRICAL FOR 'TORY BURCH" IN SUITE 1231. ELEC: 24 LIGHT PIXTS, OWNER: SOUTH COAST PLAZA Address: 3315 FAIRVIEW RD Unit: Phone: APPLICANT: PENDLETON, TOM Phone: 214-675-9906 i CONTRACTOR: PWI BUILDERS Phone: 480-461-0777 Cell: ARCHITECT: ENGINEER: COMBINATION PERMIT. FEE SUMMARY Building Plan Check: Building Fees: Electrical Fees: Mechanical Fees: Plumbing Fees: SMIP Residential: SMIP Commercial: Bldg Std Admin Fund TOTAL FEES, **Refer to fee receipts for all fees paid for project City/State/Zip: COSTA MESA, CA Address: Unit: City/StatetzZip: License No. 816987 Address: 155 W MAIN STREET,Unit: City/State: MESA, AZ . • ' ZipCode 85201 License No. License No. $72.31 $111.25 $48.42 $0.00 $0.00 $0.00 $1.05 $1.00 $234.03 PHONE: PHONE: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12.21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit, CODE #. INSPECTION TYPE DATE INTITIALS CODE # INSPECTION TYPE DATE INTITIAL 1616 Fixed System Final Fire Prevent{on 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final BIG&IRetaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final BuildinglOccupancy f/ i WORKERS' COMPI~NSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ � I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ ! I have and will maintain workers' compensation insurance, as required by section 3700 of the Ivabor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: - i (This section ne no bei-m+mpleled it the Permit is valued at one/undyed dolrars ($100) or less,} Policy. Number ❑I I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should becomes lett to the workers' compensation provisions of Section 3700 of the LabXAode J s I fo hwiA comply with these provisions. Appiicall 5 Signatures / fat WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is full force and effect. ,� r �J fnl �� Class # 11,1, # Contractor's Signature Aate CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors iLicense Law (Chapter 9 (commencing with Section 7000) of Division 3 of the I Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sect. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature 3057-46 (3107) Date Owner ID verified by drivers license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Division of Industrial Safety Permit Number: Dale HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. 1f an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or presenter future building occupant require for (he work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be fumished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Sig We or Y7P14Z to / Andlor Authonzed Applicant r; Dat CI Y OF COSTA ML-.jA Development Services, Division of Building and Safety CERTIFICATE ,0F OCCUPANCY This certificate is issuedpursuant to the requirements'of the Uniform Building.Code, Section 308 adopted by the City of Costa Mesa certifies that at the time of its issuance the building structure herein below described was inspected and approved for occupancy as follows: 3333 Bristol St. Ste 1237 B07-00608 Building Address Bldg: Permit Number Retail (3,502 s.f.) Use p Type Grou � T e of Construction 1- r R Fire Zone XXXXXX- Use Zone PDC OwnerofBuilding South, Coast Plaza Tenant MICHAEL KOPS Address 3315 Fairview ­Rd., Costa -Mesa, ,CA 926.2;6 By- BUILDING y.BUILDING OFFICIAL-Khanh Q. Nguyen, C.B.O. Date.. 11/a7 REQUIRED TO BE POSTED IN A CONSPICUOUS PLACE Mr 'ff ER (714) 754-5273 • Fax (714) 754-4856 • www.cl.cosla-mesa.®W#LDING PERMIT Job Address: 3333 BRISTOL ST Suite: 1237 Vicinity; 1237 Primary Occ: M Display/Sale Merchandise Type of Construction: I -FR Parcel Number: 41250107 Zoning: PDC Applicant: GRONACHON, BILE_ Address: ' Phone: 650-575-7878 Zip: 77 FAIR DRIVE, COSTA MESA, CA 92626 Status: ISSUED Applied: 05/07/2007 Issued: 07/20/2007 ISSUED BY: Owner: SOUTH COAST PLAZA $358-96 Permit: Address SMIP Res: $0.00 COSTA MESA CA Phone: Other: 3315 FAIRVIEW ROAD Zip: 92626 Contractor, JAMES AGRESTA CARPENTRY INC $2,634.48 Address: 795 TABOR DR' Phone: 201-838-7903 \ SCOTTS VALLEY, CA Zip: 95066 License: 865289 Arch : KEN BUTTS AIA Eng: Address: 124 STAGECOACH RD Address: Phone: 818-999-4272 Phone: 19ELL CANYON, CA I _ _ ` Zip: 91307 License: C4071 License: SCOPE OF PERMIT 3,501 SF INTERIOR T.I. FOR "MICHAEL KORS", SPACE 1237. Plan Check: $358-96 Permit: $2,208.95 SMIP Res: $0.00 SMIP Com: $66.57 Other: $0.00 Inspection: $0.00 Total: $2,634.48 FEE SUMMARY -Calc Valuation: Claim Valuation PLANNING & ZONING SETBACKS MAIN STRUCTURE Front 0-0 Rear 0- 0 Left 0-0- Right 0-0 ACCESSORY Front 0-"0 Rear 0-0 Left 0-0 Right 0=, 0 PARKING Existing: 0 Required: 0 Proposed: 0 . $317,000.00 . $317,000.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia statutes and,re ated regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or I� uspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must-ca4 rmpfy with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspectlons and final approval will result In the expiration of this permit, FOR INSPECTIONS CALL: (714) 754-5626 '-aas-ae (ama) DECLARAVONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is Issued. ❑ 1 have and will maintain workers' Compensation insurance, as required by secilon 3700 of the Labor Code, for the performance of the work for which this permit Is Issued. My workers' ompensatfc Insurance carrier and policy number are: D - µr19 �p�-oj'-ar Carrier: l L1'� ( Po11c Ny�umbar (This section need not be completed if the permit Is valued at one hundred dollars ($100) or less.) ❑ I certify that in the performance of the ork for whjo this permit is Issued, I shall not employ any person In any manner so as to become subject to the workers' compensation laws of Callfomia n roe should be a subject to the workers' compensation provisions of Section 3700 of the tabor Code, 1 shall forthwith comply with these provision . _Applicant Signature:% Daie r f" 1 o - 7 _WARNING: FAILURE TO SECURE WORKERS'COMP6AI&OCIVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LAEIOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: hereby affirm that I am licensed tindeyprov s of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license Is in full tgrce and effect-Lic: #Class #. -- Contractor's Signature—' : ' t� �� _ CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is Issued. (Sec. 3097, Civil Code), Londer's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, atter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 8 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation. WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not Intended or offered for sale. If, however, the building of improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify, that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more then thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title B, Califomia Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 WIII the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the Califomia Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity o1 hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _..._.............---....._..._._�W _..................._ _ ......._..�.............................................................. . .._...... ........ ...................—_............._.—...... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the Califomla Health and Safety Code, with some exceptions, requires regtsiration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .................................................. _........................................................................................ ........ ..................... •........... __............... .............................. ............... ..._....... _.............. ...._................ ...._.................... ..._ ........ 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Sectlon 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4.......If an RMPP is presently required, has Saction, 25534 of the Califomia Health and Safety Code been fully complied wiih?' ❑'Yes.... .......... ❑ No............. _—..._._._........__...__.............................._... ..... ... ............................... ......................_._............................ __................... --._.................. --....... �5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this a plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? I[I Yes No (Section 65850.2 of the California Govemment Code requires that the requested Information be lumished On applications for non-residential building permits). __ ......................_............................ .........................._.._......... ................... _......................... _...................... ............................ _._._.__.._..._........�..... .......................... ...... ..— ............. 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes*, the facility must meet the requirement of Sections 25534 and 42303 o1 the California Health and Safety Code). — ............. _ _._................._.._......................... __._................... _—.._............... --•--•----..�........_............._...__�_......._.....---•--.................. ._........ --- 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by Califomla Health and Safety Coda Section 42303 been made? E] Yes [I No .................. ................_......................................................................................... —........................ __..................... ................ ..............._..................................._..........................._...................... _ ....................._ .. 8 {If "yes attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORC A71ON OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. / Si re Of Legab er(s) f 20 Ole v ) o f uthorizad'Applicant .Dale CODE 1. INSPECTION TYPE 2AU INTITACODE fF IN5PEUON TYPE pig, INTMAL$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250- Final Building/Occupancy. CITY OF COSTA MESA BUILDING DIVISION } 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 - Fax (714) 754-4856 - www.ci.00sta-mesa.ca. �.� FOR INSPECTIONS CALL: (714) 754-5626 1407-00238 FIRE SUPRESSION PERMIT .lob Address: 3333 BRISTOL ST Status: ISSUED Suite: 1237 Applied: 07/26/2007 Vicinity: MICHAEL KORS '. Issued: 08/14/2007 Parcel Nunmber: 41250107 ,, , '' .Zoning: PDC` PDC , Applicant: LOONEY, SHEILA Address: Phone: .714-993-2822 Zip: Owner: SOUTH COAST PLAZA - Address COSTA MESA'CA Phone: 3315 FAIRVIEW ROAD Zip: 92626, Contractor: ALERT FIRE PROTECTION INC Address: 5200 E HUNTER AV SUITE B Phone: 714-993-2822 ANAHEIM, CA Zip: 92807. License: 316324° SCOPE OF PERMIT FIRE SUPPRESSION PERMIT TO REWORK THE EXISTING FIRE SPRINKLER SYSTEM (38 HEADS) FOR A 3,501 SF INTERIOR T.I. FOR "MICHAEL KORS", SPACE 1237. FEE SUMMARY Plan Check: $117.81 - Calc Valuation: $10,000.00 Permit: $181.25 Claimed Valuation: 51o,000.00 Other: $0.00 Total: $299.06 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No, 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, -such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE II. INSPECVgN TYPE DAT INTITIALS CODE >t INSPECTION TYPE DATE INTMAL 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention rD',r3 O 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222. Final Site -k 204 Final Demolition 250 Final Building/occupancy WORKERS' COMPENSATION DECLARATION: 1 hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' Compensation, as provided for by section 3700 of the Labor Code, for.the orrnance of the work for which this permit is issued. C> I have and will maintain workers' compensation insurance. --as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy er are: /f a rri _ j�Gvtiv (T need rro! be rorrrptet d rhe 4 is valued at one hundred dollars (S 100) or less -J Poli N ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I shou)d become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forth comply with these provisions. Applicant's Sig ture Date WARNING: FAILURE TO SECURE WO ERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and m is se is in fu I[ force and effect. # -?/& CI s# �-- Con nature F to CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: I Lender's Address: Signature Date OWNER-81.IfLDER OECLARATIONS: I hereby affirm that under penalty of perjury that i am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, after, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder Will have the burden of proving that he or she did not build or improve for purpose of safe.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature 3057-46 (3107) Date Owner 10 verified by drive, .nse. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature Date Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes 0 No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department, 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. W)II any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yos ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code), 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If "yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Dote CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature of or Legalr(s) Date,/ 7 �- AnClOr Applica Dat CITY OF COSTA MESA BUILDING DIVISION 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 - Fax (714) 754-4856 • www.ci.costa-mesa.ca.us FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER;/M07-00437 PERMIT TYPE MECH STATUS: ISSUED _-DATE ISSUED: 0712612007 1`1 ---ISSUED BY: RMD JOB ADDRESS: 3333 1237 BRISTOL ST°CM;c 1SUtte/Unit:'`�.-'°1237 Vicinity: MICHAEL KORS SQ. FT: 0 �. ''• , ,. 's alk �.'�:�: y�'�'==-;".�: "__ _..,'`�-. SCOPE OF WORK: --MECHANICAL PERMITFOR A 3,501 SF INTERIOR T.I. FOR "MICHAEL•KORS' SPACE 1237 'f ¢ • - N ''"� ..OM1 :..., `h t. ., OWNER: SOUTH COAST PLAZA �',; .�� Address: Unit:COSTA:MESA CA PHONE:f z' �, CitylStatelZip: 3315 FAIRVIEW ROAD ` APPLICANT: SANDERS; BILL i _ _. -' = Address: C1672230'Unit , PHONE: 714-630-2300 CitylState/zZip: CONTRACTOR: THERMALAIR INC r '.License No 102216 Address: 1140 RED GUM St6r it: - PHONE. 714-630-3200 ," _`__ City/State: ANAHEIM,'.CA I,m- r ZipCode: 92806:.. - CELL: ' _ � , l F ESS UMMARY MECHANICAL PERMIT E U -, MEC1I ITEM FEE: 4 x$76.40 PLAT! CHECK FEE:, $0.00 INVESTIGATION FEE: REINSPECTION FEE: 0.0074 .z TOTAL FEES: $76.40 W NOTICE. The work authorized. by this permit shall comply with all applicable handicap access requirements under. California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and•fnal approval will result in the expiration of this permit. OE I INSPECTION TYPE DDT INTMALS CODER INSPECTION TYPE DATE +INTITIAL 1616 Fixed System Final Fire. Prevention - ' 206 Final Mechanical C) 1266 Pool Spa Final 200: Final Re -Roof 201 '. Final BlocklRetaining,Wall 202 Final Factory Fire Place 203 Final Sign 204 Final Demolition 208 Final Plumbing 210 Final Electrical 212 Final Fire Prevention 220 Final Planning Approval 222 Finai Site 250 Final Building/Occupancy WORKERS' COMPENSATION DECLARATION: Owner ID verified by driv, rise. ❑ Yes ❑ No I hereby affirm under penalty of perjury one of the following declarations: Driver's License No. Expires: ❑ I have and will maintain a certificate of consent to self -Insure for workers' Verification of Ownership by (type of document, i.e. property tax bill or deed): compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: permit is issued. My workers' compensation Insurance carrier and policy ❑ I hereby certify that no excavation five (5) or more feet in depth into which a number are: person is required to descend, will be made in connection with work authorized Ca r, ON C]A by this permit, and that no building structure, scaffolding, falsewc*. or demolition rrieor dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp (This secfiort need not be completed Alhe pelma is va at are hundred collars Woo) of less.) 2 Art 2 Sec. 341, Title 8, California Administrative Code). PcyNumber: E]—Irtce tfy that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the rkers'Ecomply nsation provisions of Section 3700 of the Lobar Cod half f withwith these provisions. Applicant's nature_-=' -Date- 1___ -Date`_ WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. �l ic. # Cfass ax �C ,C?-n._C M Con radar's ignalure Date J CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lenders Address: Signature Date OWNER -BUILDER DECLARATIONS: hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any City or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he of she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature 3057-46 (W) Date ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Division of Industrial Safety Permit Number: Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. if an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be fumished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No. 8. (If "yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE.OF COMPLIANCE: I certify that under penalty of perjury,the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit untiginal inspection. ksinatu of %gal D e (s) Date :7•z.( --V - [__XncTlor Authorized Applicant _ Date -- CITY OF COSTA MESA BUILDING DMS►ON } 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBE : P07-00516 -u=�F PERMIT TYPE PLUM STATUS: ISSUED ' J• DATE ISSUED: 09/1012007 - ISSUED BY: RMD .SOB ADDRESS: 3333 1237 BRISTOL ST CM' ','Suite/Unit: M -1237 Vicinity. MICHAEL KORS - SCOPE OF WORK: PLUMBING PERMIT FORA 3,501 SF INTERIOR T.I. FOR "MICHAEL KORS", SPACE 1237, WORK TO INCLUDE: 1 WATER CLOSET; 1 WASH BASIN, 1 MOP SINK, 1 WATER HEATER. REF#:.807-00608 OWNER: SOUTH COAST PLAZA Address: COSTA MESA CA PHONE: CitylState/Zip: '-3315 FAIRVIEW ROAD APPLICANT: GRONACHON; BILI_ Address: 795 TABOR DR - PHONE: 201-838-7903 CitylStatelzZip: SCOTTS VALLEY, CA CONTRACTOR: JAMES AGRESTA CARPENTRY INC License No. 865289 Address: 795 TABOR DR PHONE: 201-838-7903 City/State: SCOTTS VALLEY, CA ZipCode:_95066 CELL: PLUMBING PERMIT FEE SUMMARY ' PLAN CHECK FEE: $0.00 . PERMIT FEE: $65.20 TOTAL FEES: $65.20 ' NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia statutes and related regulations. (Ord. No. 92-28, § 1, 12-21.92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION, INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiratio�f ibis permit. OE 9 INSPECTION TYPE DATE INTMAL qODE 1 INSPECTION TYPE DI / INTMAL 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Ptumbing I a R - C 200 Final Re -Roof 210 Final Electrical r/ 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' Compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Ler: G m f7hrs section nmd not be c=#ereld d Ute/rm pe! uvaL99dd att o" nurKired dollars (S r00) or kSSJ Policy-Number:n09_ =01 1 r ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensaf of California, and agree that if I should become s bj a wompensat' provisions of Section 3700 of the tabu C all fortpty oil ese provisions. 2-/(9,_07_ A`pptt Cs s t , _pat WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing With Section 7000) of Division 3 of the Business and Professions Code, and my license is in full ford nd t, Lic..#_ C�la s #� 'Contractor's SfgrtaturDate s CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which INs permit is issued. (Sec. 3097, Civil Code). Lenders Name: Lender's Address: Signature nate OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): 0 I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sate.). ❑ 1; as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a c ontractor(s) license pursuant to the Contractors License Laws,). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature Date 3057.46 (3107) Owner ID verified by drive rse. ❑ Yes ❑ No Drivers License No, Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ i hereby certify that no excavation five (S) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, faisework, or demolition or dismantling thereof, will be more than thirty -sic (36) feet high. (Chap. 3.2, Grp 2, Art 2, Set-. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Date Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantify of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes Cl No (Section 65850.2 of the California Govemment Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'fres", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code), 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If 'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I Certify that under penalty of perjury the information given above is correct, I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to Comply with all stale laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Si to of t.ege mer(s) Z 10 7 Andra-Author pptimnt Oate PrA (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.6LgLDING PERMIT ,lob Address: • 3333 B_ R35TOL ST Suite: 1237 Vicinity: SPACE 1237 Primary Occ: M Display/Sale Merchandise Type of Construction: I -FR Parcel Number: 41250107 Zoning: PDC Applicant: GRONACHON, BILL Address: } ' Phone: 650-575-7878 Zip: 77 FAIR DRIVE, COSTA MESA, CA 92626 ISSUED BY: Status: ISSUED Applied: 05/07/2007 Issued: 07/20/2007 Owner: SOUTH COAST PLAZA Address COSTA MESA CA Phone: 3315 FAIRVIEW ROAD Zip: 92626 Contractor: JAMES AGRESTA CARPENTRY INC Address: 795 TABOR OR - s:. Phone: 201-838-7903 SCOTTS VALLEY, CA Zip: 95066 License: 865289 , Arch Eng: Address: Address: Phone: Phone: Zip: License: = License: SCOPE OF PERMIT 9' HIGH MOBLE AND FIXED STORAGE RACKS FOR "MICHAEL KORS", SPACE 1237. REF#: B07-00608 ' FEE SUMMARY ' Plan Check: $18.08 Calc Valuation: $5,000.00 Permit: $111.25 _ Claim Valuation: $5,000.00 SMIP Res: $0.50 SMIP Com: $0.00 Other: $0.00 Inspection: $0.00 Total: $129.83 PLANNING'& ZONING SETBACKS MAIN STRUCTURE Front "020 (Rear 0-0 Left 0-'0 ' Right ., '.0- 0" ACCESSORY ' Front 0-0 `. Rear 0-0 Left 0-0 Right 0-0 PARKING Existin ': 0", Required: 0 Proposed: 0 l NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or If work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5526 2446.46 (6/00) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 0—� I have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. �— My workers' co pensatlon Insurance carrier and policy number are: _ �� Carrier: �_ Policy Number: I!1- ) �(Thls section need no be completed It the permit is valued at one hundred dollars ($100) or less.) ❑ 1 certify that in the performance of the work for which this permit is Issued, I shall Znoleploy any arson In any manner so as 10 become subject to the workers' compensation laws of California, and agree that if I should become su c o hers' Com sation provisions o1 Section 3700 of the Labor Code, I shall forthwith comply with these provisions. Appl�nt Signature: Date:- '~ WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PINALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($1 00,00D), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: Ihereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full "Vice and effect. Uc. a Class 4 Contors Signature: , CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Data: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, atter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ' ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certHy that no excavation five (5) or more feet in depth into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Coda requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ................... _........... ............................................__...................... ........................... ................................................ - .... ........................................................................................................................... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume o1 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the appplicant or present or future building occupant need to prepare an R M P P (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes 13 ;T (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. -----........... _............................................_......................_......................_......................................................................... ........................................................------........__................... 4 If an RMPP Is presently required, has Section 25534 of the Celilomia Health and Safety Code been fully complied with? []Yes ❑ No .................................................... .............................. .............................................. ..................................................................... _..--..................... ................. 5 Does or will the applicant or prtisent or future building occupant require for the work which Is the Subject of this a plicatlon a ermit for such construction or modification I rom the South Coast Air Quality Management District or from any alher air pollution control district or agency? U Yes (�] No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). .......................................................................................................................................................................................................................................... .......... ............................................................ 6 WIII any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? Yes ❑ No (if 'yes , the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ....... .........................................._... ......----......-..................... ._............................... _..................... .................................. ..... ....._.................. ..............................................._._........................................................... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (it fires', attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Data: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. / ' ature O1 al Owners)�} Date 'v2() ^ 0 7 rid/Or Authorized Applicant Date CODE r'. INSPECDONTYPE RM INIMA QODE INSPECTIONTYPE INTITIA 1616 Fixed System Final Fire Prevention 246 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final SlocklRetaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy v I`7 (714) 754-5273 • Fax(714)754-4856 77 FAIR DRIVE, COSTA MESA, CA 92626 SIGN PERMIT .lob Address: 3333 BRISTOL ST Status: ISSUED Suite: NORD Applied: 07/19/1999 Vicinity: Issued: 07/19/1999 Parcel Nunmber: 41249108 _ Zoning: ISSUED BY: Applicant: NORDEN,KEN Address: Phone: Zip: Owner:/ -SOUTH -COAST PLAZA %NORDSTROM INC Address; PO BOX 2229 � r i \ Phone: •°•��•_ ;, �- ��� - � � , �SFJaTTLEINA Zip: 98111-2229 Contractor: ROMAINE'JOSEPH MACHAN JR /EtAddress - 10390.REGIS CT Phone: 909 948-7232 RANCHO CUCAMUNGA, CA Zip: 91730 1 License: 616633 ' Arch DEng Address: Phone: Zip: License: - .SCOPE OF PERMIT REPLACE 3 ILLUMINATED EXISTING BUILDING SIGNS TOTALLING 486 SF WITH 3 NEW , ` ILLUMINATED BUILDING SIGNS TOT. 337.5 SF AND ONE NON -ILLUMINATED WALL SIGN OTHER MISC SIGNS NOT VISIBLE TO STREET ALSO PROPOSED TO BE CHANGED. - ti FEE SUMMARY' . r � "Plan Check: , $4$.59 — - r Calc Valuation: ; =$2,500.00' ,! $0.00 Permit: " ' $74.75 =' -- ' - Claimed Valuation:: $2,500.90 SMIP Cam`: $0.53 A , Other: ` $0.00 .. � $0.00 Inspection: , `x$0:00 ���' , .,. ..•%%` �" :�� $0:00 //$0.00. Tot! _' $123.87 ��V 1 PLANNING & ZONING " NOTES: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void it work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 7have PENSATION DECLARATION: der penalty of perjury oneof the following declarations: wlll maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the i/work for which this permit is issued. I14 i have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My worker ' compensation Insuran a carrier and policy number are: 1 f Carrier: ,S Policy Number: ! �]/ I (This section need not be completed if the permit is valued at ane hundred dollars ($100) or less.) ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, f shall forthwith comply with these p ov' io -. p Applicant Signature: Date: Z`- WARNING: FAILURE TO SECURE ORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Prof ,ns Code, and my license is in full force and effect. Lic. N 3 Class # _ Contractor's Signature: �ro�s. `_� , , _ Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to Its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No, Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation live (5) or more feet in depth into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more then thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Data: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Pian be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity o1 hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is resent) re aired, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No or will the app is --- —p• --------- .,_,...-.., 9.occupant require for...,...-., - - - - ---'-,...,..... - l of ctio-_- ... modification hcant or resent or future buildin the work which is the subject of this a plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes f No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'fres', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (it yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: i certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the Information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described properly for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final Inspection. Si ure Of Legal wner(s) Date And Authorized Applicant Date CODE /• INSP9gJI0NJXP 2A11 INTITIAL CODE INSPECTIONTYPE ¢NTMAL 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 206 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy 244fi-46 f (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 .lob Address: 3333 BRISTOL ST Suite No NORD Vicinity: NOROSTROMS 3RD LEVEL Parcel Nunmber. 41249109 Applicant: HETTICK, RICK Address: 3705 LONE DOVE LN ENCINITAS, CA PLUMBING PERMIT Phone: (858)756-0197 Zip: 92024 Owner: SEARS, ROEBUCK & CO %NORDSTROM INC Address ATTN TAX DEPT SEATTLE, WA Phone: P 0 BOX 2229 Zip: Contractor: NON-STOP Address: 3705 LONE DOVE LN Arch / Eng : Address: ENCINITAS, CA Phone: -(858) 756-0197 Zip: 92024 License: 585146 Phone: Zip: License: ISSUED BY: Status: ISSUED Applied: 03/24/2003 Issued: 03/24/2003 SCOPE OF PERMIT INTERIOR 5330 SF REMODEL OF AN EXISTING CAFE ON 'NORDSTROM' 3RD LEVEL. WORK TO INCLUDE NEW FLOOR/WALL FINISHES, EQUIPMENT AND FURNISHINGS. RE:B02-01971. PLUMBING TO INCLUDE: 1 BACKFLOW PREVENTER, 1 GAS (1-4 OUTLETS). 4 FLOOR SINKS, 6 SINKS, 1 WASTE AND VENT SYSTEM, 1 WATER RE -PIPE. D QTY AMT FEE SUMMARY 0 AMT QTY 0 AMT ISSUE FEE $23.50 0 Laundry Tub / Washer $0.00 Backflow irrigation $0.00 1 Landscape Irrigation $0.00 Backflow Preventer, $9.80 0 P -Trap $0.00 Bathtub $0.00 0 Pressure Regulator $0.00 Clarifier System $0.00 0 Process Piping (per 10 ft) $0.00 Connect (Ice,Soda,etc) $0.00 0 Receptors $0.00 Dental Units $0.00 0 Septic Tank $0.00 Dishwasher $0.00 0 Sewer Cap for Demo $0.00 Drain, Floor $0.00 0 Sewer Connect $0.00 Drain, Rainwater $0.00 0 Sewer Private Line $0.00 Drain, Roof $0.00 0 'Shower $0.00 D QTY AMT QTY 0 Sump Pump $0.00 0 0 Swimming Pool $0.00 0 0 Trap Primer $0.00 0 0 Urinal $0.00 0 0 Vacuum Brkr Bkflow(1-4) $0.00 0 0 Vacuum Brkr Bkflow(5+) $0.00 0 0 Wash Basin $0.00 0 0 Wash Basin Set $0.00 0 0 Waste and Vent System $9.80 1 0 Water Closet (Toilet) $0.00 0 0 Water Heater / vent $0.00 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21.92) EXPIRATION: This permit shall automatically expire and become void It work is not commenced within 180 days, or If work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 2446-0 (6=) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the fallowing declarations: ❑ t have and will maintain a certificate of consent to self•Insuro for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. ave and will a works mpensatlon insurance, as required by section 3700 of the Labor Code, for the performance of the work for which thispen�i� is issued. My workers' C 5 1 r nce carrier and policy number are: — J / Carrier; I _ Policy Number; _ !TL \R/ (This settlor need not be Completed if the permit is valued at one hundred dollars ($ Ioo) or less.) ❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that it 1 s uld become subject to the workers' compensation provisions of S coon 3700 of the Labor Coda, I shall forthwith _ comply with these provisions. Applicant Signature: Date: WARNING: FAILURE TO SECUR RS' COMPENSATION RAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMSNAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE (SI OD,100), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under RasWnK-dMh-f%t ommoncing with Section 7000) of Division 3 of the Business and Professions Codeand n is in full force and affect. Lie. a D ✓ Class a ( Contractor's Signature; - Date: 14-2 CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lenders Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than No hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and professions Coda: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or improvement is sold within one year tlf completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). - ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractors) license pursuant to the Contractors License Laws.). ❑ i am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers license No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL- SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, An 2, Sec. 341, Title 6, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: _—__ _ _ _ _ Dale: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: t Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the Califomla Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet o1 compressed gas at standard temperature and pressure). ........................................................................................_ .................... .—............._....................................................................................,....................... ..I..............................�...............—............. . 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the Califomia Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ........ ^ ................--......._: -- --- -- — ^_....—_.._..—_............... .._.........................._..................................................................... 3 Does or will theapplicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ Na (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. .................1111....................... __..._......................_._—..............................................................,.............................................................................. .............................,......_........................... —_.._................ . 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes j� No ................. ............................................................................ _.............................. ... ................ ............................................................... ...........................--•---._...................------........... 5 Daes or will the applicant or present or future building occupant require for the work which Is the si,bloct of this a12piication agermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes LJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ........1..-11 ................... _............... _._................................................ ................................................. 1• ............11 ..........................- -...._...................._ ............._-- 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (I1 yes', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). --..._.............. .....—......... —.._.................. _.._.................................... _._.._................ ..—....._.................. __............ 7 If a permit from the South Coast Air Quality. Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? [I Yes ❑ No _$........�f.........�._.........1111---...........------11__11_ _1_111.._._— ......... —. ( W, attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I Certify that under penalty of perjury the information given above is Correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the Information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the abovo-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. 5' a] O agate Qr pIi v Date CODE- /. INSPECTION TYPE un Iffy CODE I INSPECTION TYPE 1616 Fixed System Final Fire Prevention 206 Final Mechanical a 1266 Pool Spa Final 208 Final Plumbing �-✓� 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retalnirlg Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 2173 Final Sign 222 Final Site 204 Final Demolltion 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT Job Address: 3333 BRISTOL ST Suite No NORD Vicinity: NORDSTROM CAFE Parcel Nunmber: 41249109 Applicant: BEREITER, BRAD Address: 20724 LOYALTON DR WALNUT, CA Phone: (909) 598-4045 Zip: 91789 Owner: SEARS, ROEBUCK & CO %NORDSTROM INC Address ATTN TAX DEPT SEATTLE, WA Phone: P O BOX 2229 Zip: Contractor: PREFERRED ELECTRICAL CONTRACTORS INC Address: 20724 LOYALTON DR Phone: (909)598-4045 WALNUT, CA Zip: 91789 License: 427052 ISSUED BY: status: ISSUED Applied: 03/19/2003 issued: 03/19/2003 SCOPE OF PERMIT PRELIMINARY ELEC PERMIT IN CONJUNCTION WITH THE INTERIOR 5330 SF REMODEL OF AN EXISTING CAFE ON "NORDSTROM" 3RD LEVEL. 24 OUTLETS, 12 SWITCHES REF:B02-01971. AMENDED T25p-�,: ADD 132 LIGHT FIXTURES, 23 ADDITIONAL OUTLETS, 10 NON -RES APPLIANCE=S, 4 MOTORS TO 1HP, 1 MOTOR TO 50 HP, 1 TRANSFORMER OVER 50 TO 100 KVAIKW. NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia statutes and related regulations. (Ord. No. 92.28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2448.46 (8100) FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 Temp Dist System 1 Lighting $0.00 0 Temp service test $0.00 Busway 1100 ft $0.00 0 Res. a/c package $0.00 Standing Section $0.00 0 New Res (1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0 New Res (3+units) $0.00 0 Transformers up to 1 kvalkw $0.00 0 Pool 1 Spa $0.00 0 ................up to 10 kvalkw $0.00 0 Lighting Fixts $103.76 132 .................up to 50 kvalkw $0.00 0 Recept Outlets $41.71 47 .................up to 100 kvalkw $49.50 1 Switches $13.20 42 ................over 100 kvalkw $0.00 0 Non Res Appl $47.50 10 Low Voltage Equipment $0.00 0 Res Appl $0.00 0 Low Volt Wiring System / Ckt $0.00 0 Service to 200a $0.00 0 Misc. Conduit $0.00 0 Service to 1000a $0.00 0 Misc. Conductor $0.00 0 Service over 1000a $0.00 0 Circus ( gen or ride) $0.00 0 Motors to 1hp $19.00 4 Circus (mech ride or lights) $0.00 0 Motors to 10hp $0.00 0 Christmas Tree Stand $0.00 0 Motors to 50hp $24.60 1 Fireworks Stand $0.00 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia statutes and related regulations. (Ord. No. 92.28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2448.46 (8100) a � • WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. ❑ 1 have and will maintain workers' compensation Insurance, as required by section 3700 of the labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed it the permit is valued at one hundred dollars ($ f 00) or less.) ❑ 1 certify that in the performance of the work for which this permit Is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California. and agree that 11 I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisions. Applicant Signature: Date: WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND C1v1L FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license Is In full force and effect. Uc, If Class ff Contractors Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lenders Name: Lenders Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penplty Of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole Compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professions Code, The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself Or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, f,e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection wlih work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) foot high, (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As Owner -builder, i will riot employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to d0 such work from the division. Signature: _ _ Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Wilt the applicant or prosgni or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? C] Yes 8 No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or groater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ..............._...._...,................—......... ......................................................................................................... .... ...,,,..0 -yo .. _..................._ ............ 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materlals7 Yo3 ❑ No (Section 25533 of the California Health and Selety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic foot of compressed gas at standard temperature and pressure). _— ............................... —............_..................... _........................... -.................................... ............................ _............. ....................... _ 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materiels with the Fire Department. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑Yes [3 No .......................................... ..._._._........................................................ ------....._.._—........... _.._—.._............. .................... ...... ............................................................................._.._............ -....._....... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of thisa plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency .? 8 Yes No (Section 65850.2 of the Cdliforrlia Government Code requires that the requested information be furnished on applications for non-residential building permits). .....................................................er -- --------ithi.............._............................................................. - ----•--.................................. a ................... ...........................---._............_ 8 Wilt any part of the facility to be constructed under this permit be within 1000 foal from the outer boundaries of a school? ❑Yes ❑ No (If 'fires', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ............................... .......... ............... ._....................... ........................................ .................. ................,......................................................................... ...-.................... ._.................. ..._ .... 7 If a pemlit from the Soutn Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by Califomia Health and Safety Code Section 42303 been made? ❑ Yes ❑ No B jf::; eS% attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: 1 certify that under penalty of perjury the Information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: _ Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state taws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow Occupancy of any building authorized by this permit until final inspection. Signature Of Legal Owner(s) Date And/Or Authorized Applicant Dale CODE t. INSPECTION TYPE 2M INTIT 5LCODE 11 INSPECTION TYLE QM jNTMALS 1616 Fixed System Final Fire PrGvenIIOn 206 Final Mechanical 1266 Pool Spa Final 20B Final Plumbing 200 Final Re -Root 210 Final Electrical 4 �� 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Plato 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ct.costa-mesa.ca.us BUILDING PERMIT Job Address: 3333 BRISTOL ST Suite: NORD Vicinity: 3RD LEVEL NORDSTROM'S CAFE Parcel Number: 41249108 Zoning: Applicant: OSBORN, DUNCAN Address: 77 FAIR DRIVE, COSTA MESA, CA 92626 t 1 � ISSUED BY: Status: ISSUED Applied: 12/04/2002 Issued: 03/04/2003 Phone: 415-454-2277 Phone: SAN RAFAEL, CA Zip: 94901 License: C23953 License: SCOPE OF PERMIT INTERIOR 5330 SF REMODEL OF AN EXISTING CAFE ON-NORDSTROM' 3RD LEVEL. WORK TO INCLUDE NEW FLOORIWALL FINISHES, EQUIPMENT AND FURNISHINGS. FEE SUMMARY Phone: 619-676-9627 Permit: $3,946.25 Zip: $0.00 Owner: SOUTH COAST PLAZA %NORDSTROM INC Address ATTN TAX DEPT Inspection: $0.00 SEATTLE, WA Phone: P O BOX 2229 Zip: 92626-1610 Contractor: C J TORRE CONSTRUCTION CO INC Address: 16980 VIA TAZON STE 250 Phone: (858) 676-9627 SAN DIEGO, CA Zip: 92127 License: 551575 Arch : ENGSTROM DESIGN GROUP Eng: Address: 1201 FIFTH AV Address: 77 FAIR DRIVE, COSTA MESA, CA 92626 t 1 � ISSUED BY: Status: ISSUED Applied: 12/04/2002 Issued: 03/04/2003 Phone: 415-454-2277 Phone: SAN RAFAEL, CA Zip: 94901 License: C23953 License: SCOPE OF PERMIT INTERIOR 5330 SF REMODEL OF AN EXISTING CAFE ON-NORDSTROM' 3RD LEVEL. WORK TO INCLUDE NEW FLOORIWALL FINISHES, EQUIPMENT AND FURNISHINGS. Total: $6,647:81 PLANNING & ZONING SETBACKS MAIN STRUCTURE Front 0- 0 Rear 0-0 Left 0-0 ACCESSORY Front 0-0 Rear 0-0 Left 0-0 PARKING Existing: 0 Required: 0 Proposed: 0 Calc Valuation: $650,000.00 Claim Valuation: $650,000.00 Right 0-0 Right 0-0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void it work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval wilt result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754,5626 f !44648 (8=) FEE SUMMARY Plan Check: $2,565.06 Permit: $3,946.25 SMIP Res: $0.00 SMIP Com: $136.50 Other: $0.00 Inspection: $0.00 Total: $6,647:81 PLANNING & ZONING SETBACKS MAIN STRUCTURE Front 0- 0 Rear 0-0 Left 0-0 ACCESSORY Front 0-0 Rear 0-0 Left 0-0 PARKING Existing: 0 Required: 0 Proposed: 0 Calc Valuation: $650,000.00 Claim Valuation: $650,000.00 Right 0-0 Right 0-0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void it work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval wilt result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754,5626 f !44648 (8=) WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: - ❑ I have and will maintain a certificate of consent to salt -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. bKt have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. My workers' compensati InBura c carrier and policy n be are: r- �7 Carrier: ✓� Policy Number: I W 0 1 520 -- 0?_ (This secBon need not be completed it tha permit Is valued at ore hundred dollars ($100) or less.) ❑ I certify that in the perIrMn this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of f ecome subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these proA ;17 Applicant Signature: Date: AkCiNL 2,41% �1 _ WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE (S100,0o0), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: 1 hereby affirm that I am licensed unde yLsl0 spfCh$ytgt q (commencing with Section 7000) of Division 3 o1 the Business Professions Code, and my license is in full force and effect. Lic. ajj r l/ jj Class >t Contractor's Signature: Date: L_l04'Z, CONSTRUCTION LENDING GENCY: ❑ I hereby affirm that there is a Construction lending agency for the performance o1 the work for which this permit is issued. (Sac. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER OECLARATtONS: I hereby affirm that under penalty o1 perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) o1 Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty o1 not more then five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). - ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner 1D verified by driver's license. es ❑ No Driver's License No, Expires: Verification of Ownership by (type of document, Le. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet In depth Into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Tlde 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Divislon of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: _ Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to lite and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic foot of compressed gas at standard temperature and pressure). .............................---•............:..............................,.,,.....,...,...,....,.................._ .................................................................................................................................... ................................................... ............................... 2 Daes ar wilt the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater then a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic foot of compressed gas at standard temperature and pressure). ....................................................................................................................................-..............__............................................---..........................................................._._........................,..................................... 3 Does or wilt the apPplicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ 1d0 (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department, 4 If an RMPP is presently required, has Sectlon 25534 of the California Health and Safety Code been fully complied with? ❑Yes ❑ No _ _......._._..........................._................... _...... -------.................—..... _....—_._..... _..I ........... ..................................... 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this a plication a pe,rmit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes a No (Section 65850.2 of the California Government Code requires that the requested information be fumishad on applications for non-residential building permits). --..........- --—.........................._..................................---........—_...._......---....................................................._.. fi Will any part of the facility to be constructed under this permit be within t000 feet from the outer boundarlas of a school? ❑ Yas ❑ No (If yes', the facility must meet the requirement of Sections 25534 and 42303 of the California....CalifoHealth and Safety Code). - . .............— _........... ._._.-.._.._—.......................... ....... _._ _. ..—....................- ........................_ . —__......................... ._............... ...... ----................................... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures Prescribed by Califomia Health and Safety Code Section 42303 been made? ❑ Yes [:1 No -. _ 8 (I1 yes', attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the abovo-doMk , bed property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. IS, a t al Owners) AA7Vt DPj( „D And/Or Authorized Ap t r Date J CODE s. INSPECTION TYPE 2LU lI{lMAL5 CODE # im$eEc71oN TYPE INTITIA 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final BlocklRetaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 .lob Address: 3333 BRISTOL ST Suite No NORD Vicinity: 3FtD FLOOR Parcel Number: 41249109 Applicant: MACHUCA, PORIFIRIO Address: 9322 14TH AVE SOUTH SE=ATTLE, WA MECHANICAL PERMIT Phone: 206-764-9663 Zip: 98108 Owner: SEARS, ROEBUCK & CO %NORDSTROM INC Address: ATTN TAX DEPT SEATTLE, WA Phone: P O BOX 2229 Zip: Contractor: PSF MECHANICAL Address: 9322 14TH AVE SOUTH Phone: 206-764-9663 SEATTLE, WA Zip: 98108 License: 628376 ISSUED BY: Status: ISSUED Applied: 0311 012 00 3 Issued: 03/10/2003 SCOPE OF PERMIT INTERIOR 5330 SF REMODEL OF AN EXISTING CAFE ON 'NORDSTROM" 3RD LEVEL. WORK TO INCLUDE NEW FLOORIWALL FINISHES, EQUIPMENT AND FURNISHINGS. REF: 802-01971. MECHANICAL TO INCLUDE: 1 HOOD WI EXHAUST, 1 VENT FAN, 2 SMOKE DAMPERS AND 1 AIR HANDLER < 10000 CFM FEE SUMMARY Quantity Repair/ Alt Absorbtion Unit $0.00 Quantity ISSUE FEE $23.50 0 Inst FAU <100 k BTU $0.00 0 Inst FAU >100 k BTU $0.00 0 Repair 1 Alt CoolinglHeat $0.00 0 Inst / Rep. Recess Wall Htr $0.00 0 Refrig Sys <100 k BTU $0.00 0 Refrig Sys >100 k BTU $0.00 0 Gas Piping $0.00 0 Factory Fireplace $0.00 0 Hood w/Meth Exhaust $10.65 1 VAV Box $0.00 0 Vent Fan 1 Single Duct $7.25 1 Appliance $0.00 0 Fire Dampers $0.00 0 Smoke Dampers $14.50 2 Inst or Relocate Appl Vent $0.00 0 Air Handlers < 10000cfm $10.65 1 Air Handlers > 10000cfm $0.00 0 Floor Fumace $0.00 0 Floor or Suspend Heater $0.00 0 FEE SUMMARY Quantity Repair/ Alt Absorbtion Unit $0.00 0 Repair/ Alt Refrigeration Unit $0.00 0 Ventillation System $0.00 0 Evaporative Cooler $0.00 0 Commercial Incinerator $0.00 0 Domestic Incinerator $0.00 0 Compressors 1 Absorption Systems Upto3hp/ 100k BTU $0.00 0 3 To 15 hp 1500 k BTU $0.00 0 15 To 30 hp 11,000 k BTU $0.00 0 30 To 50 hp 1 1,750 k BTU $0.00 0 Over 50 hp / Over 1,750 BTU $0.00 0 Boilers Up to 3 hp $0.00 0 3 To 15 hp $0.00 0 15 to 30 hp $0.00 0 30 to 50 hp $0.00 0 Over 50 hp $0.00 0 Other Mechanical Fee Investigation Fee $0.00 Plan Check Fee $0.00 Reinspection Fee $0.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work Is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL, (714) 7545626 2"e-46 J6=) WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. I ho and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. y workers' compensation Insurance carrier and policy number ere: arrier: Policy Number: (This section need not be completed it the permiJthat' t one hundred dollars ($100) or less.) ❑ I certify that in the performance of the workthis rmit €s I I shall not employ any person In any manner so as to become subject to the workers compensation law a ml and sorsad m su act to the workers' compensation provisions of Section 3 00 of th Labor Code, I shall forthwith comply with thes ovis' s .� Applicant Signature: Date: WARNING: FAILURE T ECUR ORKERS' COMPE SAT10N RAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND VIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE 100, 01)(11, ADDrIMN TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3709 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am Ilce d u ar provisionsof hapter 9 (comma n with Section 7000) of Division 3 of the Business and Professions Code, and my license Is In full force and effect. Lic. q Class M Conlractor's'S A0 Date: CONSTRUCTION LENDING ENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: ..,. _. „ _. Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty o1 perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to Its Issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professlons Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the struclure is not intended or offered for safe (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or Improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project {Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractors) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Slgnaturo: Date: Owner ID verified by driver's license. [j Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth Into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, fatsework, or demolilion or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, An 2, Sec. 341, Title 6, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: _ Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ...................._.—........................._—..._............................................._...........................................,...,,.....................................................,,..,,.... m..,...................._ ............. ......................... ....... ........ 2 Does or w€ll the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? d •Vas ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity o1 acutely hazardous materials equal 10 or greater than a welght of 500 pounds, or a volume of 55 gallons, or 200 Cubic last of compressed gas at standard temperature and pressure). ........... - ------------- ...... _..— .......... .... ................_.........................................................................................._.............-- _......_..—.__._... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ...................— ............._.... _ _;...._..._ .....— ...............—........... .................. _._...__.._.............. —_....... ...... 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No _.....—_............---------.... _... _..__..—�._._.................._................................................ ..... ...... _.._.... _._............. _....... -- --- --�_.. 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? 8 Yes �] No (Section 65650.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ...........— ............................ _......... —................... ,..... _........ ...................... _......................---......................_.... ................................................................. ................... ................................................... ................ --................... ... 6 Will any part of the facility to be construraed under this permit be within 1000 feel from the outer boundaries of a school? ❑ Yes ❑ N0 (I1 yes', the facility must meet the requ€cement of Sections 25534 and 42303 of the California Health and Safety Code). —.._._..........---........_.....------...,---•------. _..._. _............... _.__..................................................................................---.......... .—...-........... _.— ........... __� ._.. 7 If a permit from the South Coast Air Quality. Management District or other air pollution control district or agency is required for the work which is the subject of this appllcailon, have all of the disclosures prescribed by Califomia Health and Safety Coda Section 42303 been made? []Yes ❑ No ... ........ _............................ _._........ —........................ _..... ............................................................_..— - ...-•-•----- 6 (If fres', attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct, i agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Dale: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that l have read this application and state that the Information given is correct. I agree to comply with all stat s and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspect' n purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. SI u L it Ow 91r( 49ndfOr Ax6orilad App nt ate CONE It IWPECJJ0 TYPE, am Ifs$ 2QU 1 INSpf CT10N TYPE 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Relaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 MECHANICAL PERMIT Job Address: 3333 BRISTOL ST Status: ISSUED Suite No NORD Applied: 08/21/2003 Issued: 08/21/2003 Vicinity: NORDSTROM EXPRESSO/SANDWICH BAR Parcel Number: 41249109 ISSUED BY: MACHUCA, PORFIRIO_- _ Applicant: a v Address: 9322 14TH AVE SOUTH i - - - Phone: 206-764-9663 SEATTLE, WA 1 ! Zip: - -98108 • - f Owner:, SEARS, ROEBUCK -_&.O %NORDSTROM INC Addr�ess:� /ATTN TAX-� `SEATTLE;.WA; Phone: � P O SOX 2229' Zip: Contractor: PSF,MECHANICAL .��• \ Address: 932214TH AVE.SOUTH Phone: 206-764-9663 t , SEATTLE, WA 11, . xZip: 98108 y _ k License: 628376 ' • ` ' SCOPE OF PERMIT' ' 'MECH PERMIT TO ADD A.FEW DUCTS AND CHANGE DIFFUSER TYPES TO ACCOMODATE CEILING REVISIONS IN CONJUNCTION WITH THE•INTERIOR 436•SF REMODEL AND INTERIOR EXPANSION OF AN EXISTING,'EXPRESSO BAR' AT "NORDSTROM" TO ACCOMODATE A f 3 !' 'SANDWICH BAR.' WORK TO INCLUDE NEW FINISHES, EQbIPMENT AND FURNISHINGS. ; 1 REPAIRIALT COOLING/HEAT REF: B02-01970 — FEE SUMMARY = „ r Quantity Quantity ISSUE FEE- $23.50 RepaiFJ Alt Absorbtion Unit - $0.00 0 Inst FAU,<100. k BTU $0.00 0 Repair/ Alf Refrigeration Unit /. , ,$0.00, O! Inst FAU,>100'k BTU `\ $0.00 0 ^ Ventillation System $0.00 0 Repair /Alt Cooling/Heat `• $13.70 1 'f". ' '' 'Evaporative Cooler Inst /Rep. Recess Wall Htr ' • :. $0.60 0 `^ Commercial Incinerator $0.00 0 Refrig Sys`'<1OO k BTU,, $0.00 0 Domestic Incinerator '/, < $0.00 "o, Refrig Sys -?100 k BTU; �`:;�$O.Ofl _,0 ��'� ,� °Compressois Atisorption Systems'` ' Gas Piping \ ; ,`., '10.00 0 Up4o 3 hp 1 100'k BTU �' $OAO 0 Factory Fireplace ` i - ` $0:00 �, O 3 To 15 hp 1500 k BTU ;,� ' $0.00 0 Hood wlMech Exhaust i $0,06', -0 I? '• 15 To 30 hp 1 1,000 k BTU $0.00 0 VAV Boxy $0.00 ` D- 30 To 50 hp 11,750 k BTU $0.00 0 Vent Fan I Single Duct �• - ' , $0.00 .,}0 _ - Over 50 hp / Over 1,750 BTU i /$0.00 D Appliance \ ` x$0.00 0 Boilers Fire Dampers\;_-; $D.00',`,0 _ Up to 3 hp �. $0.00 0 Smoke Dampers �, ,_\ $0.00 , 0`, 3 To 15 hp ` $0.00 0 Inst or Relocate Appl Vent \ $0.00. O ,' ' 15 to 30 hp- ` $0.00 0 Air Handlers < 10000cfm $0.00_ , 0 - `s _ 30,to 50 hp- ' ; �' + $0.00 0 Air Handlers > 10000cfm $0.00.._0 Over 50 hp = " $0.00 0 Floor Furnace $0.04 0' -' ,` _ Other Mechanical Fees Floor or Suspend Heater $0.00 4 - ____ , _Investigation Fee $0.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446.46 (6100) DECLARATiONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to sell-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the rk for which this permit is Issued. �l have and will maintain workers' compensation insurance, as required by section 3700 of the tabor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier d pall y number are: Carrier: o7, r , e- s /.Y DS Z 49E . Policy Number: O� / 6 Sr 17% 0 (This section need not be complafed it the permit is valued atone ndred dollars ($100) or less.) ❑ I certify that in the perfo ante f the work for which thl pemti ' ssued, I shat mploy any person in any manner so as to become subject to the workers' compensation laws of Ilfoml , a gree that If I sh m ubject to a w rkers compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these p ion Applicant S' Date: WARNING: FAILURE TO CURE W RS' CQMPENSA COVE 1S UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL RNES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), I DITION 70 THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, tNTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am lice d der provisions o hapter 9 (ca�nenci ith Section 7000) of Division 3 of the Business aqd Professions Code, end my license is in full force and effect. LIc. a ,. Class fr Contractor's S' 4 Date:g"^ _7-/-Q 2� CONSTRUCTION LENDING NCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec, 3097, Civil Coda). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500)•): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Cade: The Contractors License Law does not apply to an owner of property who builds or Improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or Improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ i am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ............................................................................................................................................................................................................................................................................................................................................................................................ 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet at compressed gas at standard temperature and pressure). ........................................................... ...................... .................................................................................................................. ......................................................................... ....................... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. _...... ................................. _................................................. _........................... .......................................... .............................................................................................. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully compiled with7 ❑ Yes ❑ No ...... --................................ ........................ __......................._..........................r.................................................................................... _........... ................... I........... ..... ........ 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modlflcation from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes No (Section 65850.2 of the California Govemment Code requires that the requested information be furnished on applications for non-residential building permits). __......................._.........................._..............--••--------..-_.........................""I'._.......................Ye............._................................................................... fi Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? _ ❑ s ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). .... ................. .... ............... ............................................... _... ........................... _......................... ..._...................................................................... .....---.... _..... _............................................. ........................................ ...... 7 If a permit from the South Coast Air Oualiry Management District or other air pollution control district or agency is required for the work which Is the subject of this application, have all of the disclosures prescribed by Callfomia Health and Safety Coda Section 42303 been made? ❑ Yes ❑ No .......................................................................................................................................o'll'...........................off"--------......................................................................-•----------................................................................................................. 8 (If fres", attach certificate of compliance from the appropriate air pollution control officer). , CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described pr arty for inspection pu . I agree not to 0 or allow occupancy of any building authorized by this permit until final inspection: Signatu L Ow er(s) Date -z/-o_3 7-And/OrvAuttforized A15plicant Date CODE C ►NTIjIA CODE# IHSPECTIONTYPE )?eg 2 1616 Fixed System Final Fire Prevention 206 Final MechanicalC? J 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.cl.costa-mesa.ca.us - 77 FAIR DRIVE, COSTA MESA, CA 92626 PLUMBING PERMIT Job Address: 3333 BRISTOL ST Status: ISSUED Suite No NORD Applied: 08/18/2003 Issued: 08/18/2003 Vicinity: NORDSTROM EXPRESSO BAR Parcel Nunmber: 41249109 ISSUED BY: Applicant: HETTICK, RICK,, Address: 846 N 0ODSWORTH"AV- " Phone: 626-966-2884 COVINA.CA"• - Zip:, 91724 Owner:. SEAR S„ROEBUCK"&'CO%NORDSTROMINC Address ATTN TAX, DEPT, ' SEATTLE, WA”' Phone: P O BOX 2229 Zip:' , Contractor: HID PRODUCTION PLUMBING.CONTRACTORS INC Address: 846 N DODSWORTH AV = " ' Phone: 626-966-2884 ' 1 COVINA, CA= Zip: 91724 !' License: 817184 , Arch / Eng A 1 Address: Phone: - - - Zip: -. License: f SCOPE OF PERMIT PLUMBING PERMIT IN CONJUNCTION WITH THE INTERIOR 436'SF REMODEL AND INTERIOR EXPANSION OF AN EXISTING 'EXPRESSO BAR' AT.-NORDSTROM" TO ACCOMODATE A'SANDWICH; � ,BAR.- WORK TO INCLUDE NEW FINISHES?EQUIPMENT AND FURNISHINGS. 5 CONNECT (ICE, SODA, ETC), ,2 BAR SINKS, 1 COMMERCIAL SINK, 1 FLOOR SINK, 1 WATER PIPING (INSTIREP). ' ; \ REF: B02-01970 , ' FEE SUMMARY AMT/ QTY...` AMT QTY AMT QTY ISSUE FEE �, , 523.50, Laundry Tub / Washer $0.00 b" Sump Pump $0.00 0 Backflow irrigation $0.00 0, Landscape Irrigation . $0.00 0- Swimming Pool $0.00 0 Backflow Preventer Bathtub ",,$0.00 ' 0' : �" f P -Trap $0.00 0 "Pressure Trap Primer', ' " ', $0.00 0 S0.00- 0,, ,`; Regulator $0.00 0 r Urinal . : $0.00 0 Clarifier System $0.00 0 t : Process Pipind,(per 10 ft) $0.00 01 Vacuum Brkr Bkflow(1-4) $0.00 0 Connect (Ice,Soda,etc) $49.00` 5 - Receptors $0.00 01.. - -Vacuum Brkr Bkflow(5+) $0.00 0 Dental Units $0.00 0, Septic Tank \ , $0.00 " 0 ': , -/'Wash Basin $0.00 0 Dishwasher $0.00 0 �' Sewer Cap for Dema $0.00" _ p ; ' ' —"Wash Basin Set $0.00 0 Drain, Floor $0.00 0 Se - Sewer Connect _ , .,"_ - -$0.00 ' • 0 Waste and Vent System $0.00 0 Drain, Rainwater $0,00 0 Sewer Private"Line ­ - -_. $0:00--_0 Water Closet (Toilet) $0.00 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work Is not commenced within 180 days, or If work Is suspended or abandoned for a period of 160 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 44&48 (5=) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ i have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. ' I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code. for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and polity number are: �/ / �-1 Carrier. ^>?LA (jL� -- 7i(1 t Policy Number: _ e) h-1L�%�bZ, , f (74A- (This section need not be completed it the permit is valued at one hundred dollars ($ 100) or less.) ❑ I certify that in the performance of the work tot which this permit is Issued, I shall not employ any person In any manner so as to become subject to the workers' compensation taws of California, and agree that It I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisions. Applicant Signature: -/J WARNING: FAILURE TO $ECUR Q FG COMPENSATION ODVERAGE IS UNLAWFUL. AND SHALL SURIECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND OOLLARE (g00,000), IN ADDMON TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensedder p`o s ns o1 Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license Is In full force and effect. Uc. M 4 Class 061 Contractor's Signature: -Date: 021 CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work tot which this permit Is Issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: _ Date: OWNER-BUILDER D9CLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct. alter, Improve, demolish, or repair any structure, prior to Its Issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License taw (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): 0 I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or Improves thereon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not Intended or offered for sale. if, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or Improve for purpose of sale.). - El I, as owner of the property. am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who Contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership fry (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, talsework, or demolition or dismantling thereof, will be more than thirty-six (38) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Cade). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I Will the applicant or present or future building occupant need to file and canity, a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ YeS ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _ 2 Does or wl[I the —applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on nand a quantity of acutely hazardous materials equal to or greater than a welght of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .... .......................... ...�.„... _. ..................... _... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? f] Yes ❑ Nc ........ ............ _..............:........._...-------._._................—..................._..—.._........ .. _ _....................._........................................ ... ........................................... __._......... —............ _._..... _... 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this a plicalion a rmit for such construction or modl0catlon from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes LJ No (Section 85850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 8 WIII any part of the facility to be constnrced under this permit be within 1000 feet from the cuter boundaries of a schooff ❑ Yes ❑ No (if yes', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management Districtar other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No B (If yes", attach certificate of compliance from the approprtata air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above Is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the Information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for Inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature Of Legal nor(s) Date r A iorizd� pile Da e - CODE A. INSPECi N TYPE R= I1fTITIAL$ QOQE t INSPECTION TYPE peg WMA 1818 Fixed System Final Fire Preventlon 208 Final Mechanical 1288 Pool Spa Final 208 Final Plumbing -9 d 3 N 200 Final Re-Roof 210 Final Electrical, 201 Final Block(Reiaining Wail 212 Final Fire Prevention 202 Final Factory pre Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Bullding/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT Job Address: 3333 BRISTOL ST Suite No NORD Vicinity: NORDSTROM EXPRESSO BAR Parcel Nunmber: 41249109 Status: ISSUED Applied: 0811912003 Issued: 0 811 912 0 0 3 Applicant: BEREITER, BRAD ISSUED BY: Address: 20724 LOYALTON OR - i _ Phone: (909)598-4045 WALNUT, CA 'f Zip: 91789 / Owner!,' SEARS, ROEBUCK &•CO%NORDSTROM-INC.; Address �ATTN TAX DEPT •\ SEATTLE, WA r Phone: �. _. P O 136x2229 j' Zip: !' Contractor: PREFERRED ELECTRICAL CONTRACTORS INC Address: 20724 LOYALTON DR -.Phone: (909)598-4045., ` WALNUT, CA Zip: 91789 license: 427052 r' _ SCOPE OF PERMIT ELEC PERMIT IWCONJUNCTION WITH THE INTERIOR 436 SF REMODEL AND INTERIOR EXPANSION OF AN EXISTING 'EXPRESSO BAR' AT "NORDSTROM" TO ACCOMODATE'A'SANDWICH BAR.' WORK TO INCLUDE NEW FINISHES, EQUIPMENT AND FURNISHINGS. 25 LIGHT FIXTURES, 30 OUTLETS, 6 SWITCHES, 3 MOTORS TO 10 HP; -1 SUB PANEL TO 200A, 1_ TRANSFORMER UP TO 50 KVA/KW. , REF: B02-01970 FEE SUMMARY/' Recept Outlets /,$29.30 �, 30 :.........:......up to 100 kvalkw -$0.00 '-0, Switches $6.60- 'Quantity ..... ,......aver 100.kvalkw . Quantity 0 ISSUE FEE \ �, $23.50 Low Voltage Equipment Temp Dist System 1 Lighting $0.00 0! , Temp'service test J $0.00 'Low Volt.Widng System 1 Ckt .�,. ; Busway 1100 ft $0.00 0 . Res. a/c package $0.00 Misc. Conduit Standing Section P $0.00""'o Service to 1000a New Res (1-2 units) x$0.00 0 ' Y Misc Electrical Equipment $0.00 0 New Res (3+6nits) \$0.00 0 ": Transformers up to 1-kva/kw. $0.o0s'" 0 Pool 1 Spa i.\ $0.00, �: 0 .......up to 10 kva/kw.,. $0.00 ' , 0 Lighting Fixts\, �', $25.65':1. 25 ? ..............up to 50 kvalkw $24.60 1 Recept Outlets /,$29.30 �, 30 :.........:......up to 100 kvalkw -$0.00 '-0, Switches $6.60- _-6 ..... ,......aver 100.kvalkw . $0.00 0 Non Res Appl �` S0.00- , - 0 Low Voltage Equipment $0.00 0- Res Appl , . , $0.00 -; 0 'Low Volt.Widng System 1 Ckt $0.00 Service to 200a �• $0.00 '0 `_ Misc. Conduit $0.00 0 Service to 1000a \ $0.00 ; !% 0 ',' ° - Misc. Conductor. '$0.00 -"0 Service over 1000a -$0.00 0 Circus ( gen or ride), $0.4,- 0 Motors to 1 hp $0:00 _ 0 Circus (meth ride or lights) - %40.00 0 Motors to 10hp $12.30 l ' _1, f �• Christmas Tree Stand ,- . ' Ji'so.00 4 Motors to 50hp $0,00 —0 . , _ Fireworks Stand r' $0.00 0 Motors to 100hp $0.00 0 Other Electrical Fee $0.00 Motors over 100hp $0.00 0 " NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: ,This permit shall automatically expire and become void If work is not commenced within 180 days, or If work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and ail required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 2aa6-M Jeroal DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations; ❑ 1 have and will rnalntain a certificate of consent to soli-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work far whlch'ihis permit Is issued. 0 I have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. o My workers' comp nsation Insurance carrierpolicy number are: Carrier: * FS2 " 0 Policy Number. (Th1ss section need not be completed if the permit Is valued at one hundred dollars ($100) or less.) ❑ 1 certify that in the performance of the work for which 12tis permit Is Issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of allf la and agr hat hould become subject to the workers' compensation provisions of Section 3746 of the Labor Code, 1 shall forthwith comply with these 10 Applicant Signature: Date: v Q WARNING: FAILURE TO SECURE RS' 00MP TION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMNAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOL TARE (Stoo,000), I ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROMDED FOR IN SECTION 3706 OF THE LABOFI CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I arm licensed ro of Chapter 9 (commencing with Section 7000) of Division 3 of the Buslna d rofessions Code, and my license is In full force and effect. Uc. M — Class N Contractors Signature: gate: CONSTRUCTION LE14DING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is Issued. (Sec. 3097, Civil Code). Lender's Name: Landees Address: Signaturo: __ — _ Data: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demoilsh, or repair any structure, prior to Its issuance, also requires the applicant tar such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of DlvWon 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or Improves thereon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not intended or offered for sale. If, however, the building or Improvement Is sold within one yaar of completion, the owner-builder will have the burden of proving that he or she did not build or Improve for purpose of safe.). - ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to Construct the project (Sec. 7044, Business and Professions Code: The contractors Ucense Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: — _ - Data: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, 1.9. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation We (5) or more foot In depth into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, An 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner•bullder, 1 will not employ anyone to do work which would require a permit from the DMsion of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: _ _ Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 WIII the applicant or present or future building occupant need to fila and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Masa Fire Department by every business which has at any one time during a reporlad year a quantity of hazardous materials equal to or greater then a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas a1 standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a reglstrallon form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the Califomla Health and Safety Code, with some exceptions, requires reglstradon with the Costa Mesa Fire Department by each business which at any one (Ime has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑Yes 0N Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an pMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? �] Yes L7 No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a pllcatlon aermit for such construction or modlneation from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yea H No (Section 65850.2 of the California Government Code requires that the requested information be tumished on applications for non-residential building permits). 8 WIII any part Cf the faeliityto be Constructed under this permit be wlthin 1060 feet from the outer boundaries of a school? ❑ Yes ❑ No (If fires", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). _ ..................................__ _ .�- _ _... ......................... _........._—� . _. ._ _ 7 If a permit from the South Coast Air Quali Management District or other air pollution control district or agency is required for the work which 1s the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No _....--— 8 (if Nee attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the Information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date; CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: f certify under penalty of perl'ury that I have read this application and state that the Information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa Io enter upon the shove-described property for Inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. g Of Legal Owner(s) D `__ _ 9-4 _V3 _ And/Or Authorized Applicant Date CODE 0• INSPECTION TYPE QAIE KriTALCODE I INSPECMN TYPE QST, RflM1.6 1616 Fixed System final Fire Prevention 208 Final Mechanical 1288 Pool Spa Final 208 Final Plumbing 200 Final Roof 210 Final Electrical 201 Final BlocktRetelning Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.cl.costa-mesa.'961LDING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Status: ISSUED Suite: NORD Applied: 12/04/2002 Vicinity: NORDSTROM'S EXPRESSO (NEW SANDWICH) BAR issued: 08115/2003 Parcel Number: 41249108 Zoning: Applicant: CHAD CAPANDA ISSUED BY: Z Q Address: Phone: 619-933=0036 CELL- ELL-Zip: Zip: Owner: SOUTH -COAST PLAZA'%NORDSTROM INC Address ATTN�TAKDEPT ��SEATTLI=, WA < __.Phone:. �- P O BOX 2229 . ' - Zip: 92626-1610 / Contractor: C J TORRE'CONSTRUCTION CO INCA. Address:. 16980,VIA TAZON STE 250, �,� Phone: - (858) 676-9627 ; i SAN DIEGO, CA Zip: 92121' License: 551575 Arch :. ENGSTROM DESIGN GROUP ' Eng: Address: - 1201. FIFTH AV - Address: , /Phone: 415-454-2277 Phone: SAN RAFAEL; CA `Zip: 94901 License: C23953 License: SCOPE OF PERMIT INTERIOR 436 SF REMODEL AND INTERIOR EXPANSION OF AN EXISTING 'EXPRESSO BAR' AT,"NORDSTROM- TO ACCOMODATE A - ,,'SANDWICH 'SANDWICH BAR.' WORK TO INCLUDE NEW FINISHES, EQUIPMENT AND FURNISHINGS. FEE SUMMARY Plan Check: $718.74 - f , ` Calc Valuation: $120,000.00 Permit: $1,105.75 - Claim Valuation: $120,000.00 SMTP Res: $0.00 SMIP Com:_ $25.20 ` Other: t` ` $0.00 `Inspection: t `"$0A0 V_ I ' Total: $1,849.69: PLANNING & ZONING ` SETBACKS,, ; MAIN STRUCTURE ,Front 0-0 Rear: 0-0 Left 0-0 Right, - 0-0 ACCESSORY Front 0- 0 Rear 0-0 Left 0-.0 Right 0-.0 PARKING Existing:l' 0 Required: 0 - Proposed: 0 NOTICE: The work authorized by this permit shall comply wilh all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12.21-92) EXPIRATION: This permit shall automatically, expire and become void if work is not commenced within 180 days, or If work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspectlons and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 244848 MW DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby aifirm under penalty of perjury one of the following declarations: Wve and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the kfor which this permit is issued. ve and wm nugntaln workers' compensation Insurance, as required by section 3700 of the Labor Cade, for the performance of the work for which this permit is issued. wo� compensation`Insurance carrier and policy number are: Carrier. „ROE'S Lam_- 4 -lam S u X_ A C 4r, ,.) <,+2 /N C_ Policy Number. d % .3 a 4 — OL (This section need not be completed if the permit is valued at on hundredtaboo) or foss.) ❑ i certify that In the performance of the work for which this permit is Issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of C ria that If I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these p Applicant Signature: bate: �8�--�� /o Z WARNING: FAILURE TO SECURE WORKERS' COMPENSATNJN flE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMSNAL/PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100.0DO), IN ADDFTION TO THE COST A TION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed der provisions of C ter 9 (commencing with Section 7000) of Division 3 of the Business anfesslons Code, and my license Is in full force and effect. Llc. MS Class N IT Contractor's Signature: Date: S -z- CONSTRUCTION CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm lira there is a construction lending agency for the performance of the work for which this permit Is issued. (Sec. 3097, Civil Code). Lender's Name: y Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that t am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to constrict, attar, improve, demolish, or repair any structure, prior to Its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (Commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 t y any applicant for a permit subjects the applicant t0 a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their We compensation, WILL DO THE WORK, and the structure Is not intended or offered for safe (Sec. 7044, Business and Professions Code: The Contractors License law does not apply to an owner of property who builds or Improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or Improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or Improve for purpose of safe,), - ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WiTH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who Contracts for such project with a contradogs) license pursuant to the Contractors License taws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: _ Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, Le. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet In depth Into which a person is required to descend, will be made In connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (38) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as naiad above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number. HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION - 1 Will the applicant or present or future building occupant need to file and Certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gatlon% or 200 cubic feet of compressed gas at standard temperature and pressure). -F ­Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes No (Section 25533 of the California Health and Safety Code, with soma exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to Cr greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .............. _. t'h"............._..._.__..._.._..._..—.__..._.u.—._.....—_._...................... .................................... ........... _................ ........ —.._.- 3 Does or will the appplicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. --- .............�— M....... .... .. _........ __—._.............—............................................ .......................................... ................_............. ................... 4 If an RMPP is presontiy required, has Section 25534 of the California Health and Safety Code been fully compiled with? ❑ Yes ❑ No .. .... --- --...._....._..__.._—........_..-... ...................... ._.......................... .._�..................................—..... _ . __....._.................. _...... �..--- 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this a plication a rmll for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes LJ No (Section er4M.2 of the California Government Code requires that the requested Information be furnished on applications for non-residential building permits). 8 Will any part of the facility to be Constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes^, the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution contra d'utrict or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (If yes', attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the Information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state taws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree riot to occupy or allow occupancy of any building authorized by this permit until final inspection. S ature Of Legal Owner(s) % Date And/Of Authorized Applicant Date CODE 1. INSPECTION TYPE DRI): itTITIAl a CODE I INSPECTION TYPE PATE LNTMA 1819 Fixed System Final Fire Prevention 206 Final Mechanical 1288 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolltlon 250 Final BuildinglOccupancy (714) 754-5273 • Fax (714) 754-4856 • www.cl.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 FIRE SUPRESSION PERMIT Job Address: 3333 BRISTOL ST Suite: Vicinity: 7FIRST) Parcel Number: 41249109 Zoning: Applicant: Address: Phone: Zip: Owner: SEARS, ROEBUCK 8 CO %NORDSTROM INC Address ATTN TAX DEPT SEATTLE, WA Phone: P O BOX 2229 Zip: Contractor. X L FIRE PROTECTION COMPANY Address: 3022 HESPERIAN WAY Phone: (714)554-6132 SANTA ANA, CA Zip: 92607 License: 311681 Status: ISSUED Applied: 03/15/2004 Issued: 03/26/2004 ISSUED BY: SCOPE OF PERMIT FIRE SPRINKLERS FOR INTERIOR 99,810 SF INTERIOR STORE REMODEL FOR "NORDSTROM." REF: _ ,_.. B03-02189.. 1 ST FLOOR FEE SUMMARY Plan Check: $81.41 Permit: $125.25 Other: $0.00 Total: $206.66 Calc Valuation: $5,600.00 Claimed Valuation: $5,600.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become vold If work Is not commenced within 180 days, or it work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result In the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 2446-46 (6r00) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued, My workers' compensation Insurance carrier and policy number are: Carrier: a0),e r: <_r n Policy Number: (This section need not be completed it the permit Is valued atone hundrad dollars ($100) or lass.) ❑ I certify that in the performance of the work for which this permit Is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Callfomla, and agree that If I should become subject to the workers' compensation provisions of Section 37DO of the Labor Code, 1 shall forthwith comply with thasrovisions. / Applicant Signature:,K LL `��Date: WARNING: FAILURE TO SECURE WORKERS' COMPENSATI COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100.000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed undel provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Prolessicns Code, and my license is In full force and effect. Uc. k 7M 1. QX Class p Contractor's Signature: Date, CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031 .5. Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (5500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or Improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby cenity that no excavation five (5) or more feet in depth into which a person is required to descend, wit] be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I Will the applicant or present or future building occupant need to file and certity a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the Califomia Health and Safely Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume at 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .............. ....................... ............................................_.................__._.................._............. __............................................................ ...................................... ......... . ................... _ _.......... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Cade, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of comprmod gas at standard temperature and pressure). ................................... _................ ..............................._.....__......__.......---........... ..—.._........... -...... .................._.......................... .-........... .....................................-............ .._....... ...... --- 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No ection 25534 of the Califomia Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire 'apartment of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. _........................................................._ ......_... __......_..............__......................_................................................................ ...................................... ..........................,.............--.................................... ... . 4 If en RMPP is presently required, has section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 111611111111111111-11 ..................... .—..�......................................... _........................................................................................................................................ .............................. ........ ............................... _ _.... 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this a plication a Permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes IJ No (Section 65650.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). — ........................__..._.._....._..-- - - - - ...........—......................................................... ......._..................... ................ 6 wilt any pert of the facility to be constructed under this permit be within 1000 feet trom the outer boundaries of a school? ❑ Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the Calilomia Health and Safety Code). —_......... -- --..._................................... - ............................. ........ _.._.... ....... — ..... 7 It a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by Califomla Health and Safety Code Section 42303 been made? ❑ Yes ❑ No _ ._.............-........._.-- __._......te air pollution control ................................................................... ................. _._..............................---- ._.... _ .... 8 (If yes', attach certificate of compilanCe from the appropriate air pollution oontroi officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above Is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described paction purposes. I agree upy Or allow occupancy of any building author ed by this pernliknlfinal inspection. SignalurdY LegalOwner(s) ate And/Or Authorized Applicant Data CODE A. INSPECTION TYPE Bili INTIIA CODE INPECTIONTYPE QeIlr INIMAiS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1288 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final BIDck/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 www.ci.costa-nrFfEaSljPRESSION PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Suite: NORD Vicinity: NORDSTROM'S (EE) Parcel Number: 41249109 Zoning: Applicant: JOHNSON, BRONWYN Address: 3022 HESPERIAN WAY Phone: (714)554-6132 Phone: (714)554-6132 ISSUED BY: Status: ISSUED Applied: 03/22/2004 Issued: 03/31/2004 SANTA ANA, CA Zip: 92607 License: 311681 SCOPE OF PERMIT 224 NEW OVERHEAD FIRE SPRINKLERS FOR INTERIOR 99.810 SF INTERIOR STORE REMODEL FOR "NORDSTROM." 2ND FLOOR FEE SUMMARY Plan Check. $54.11 Calc Valuation: $3,000.00 Permit: $83.25 Claimed Valuation: $3.000.00 Other: $0.00 Total: $ti •'.35 I NOTICE: The work authorized by this permit shall comply with all applicable lments under California statutes and related regulations, (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commence(, .,,tnin 180 days, or if work Is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 R"6-46 i6r00) SANTA ANA, CA Zip: 92607 Owner: SEARS, ROEBUCK 8. CO %NORDSTROM INC Address- ATTN TAX DEPT SEATTLE, WA Phone: P O BOX 2229 Zip: Contractor: X L,FIRE PROTECTION COMPANY Address: 3022 HESPERIAN WAY Phone: (714)554-6132 ISSUED BY: Status: ISSUED Applied: 03/22/2004 Issued: 03/31/2004 SANTA ANA, CA Zip: 92607 License: 311681 SCOPE OF PERMIT 224 NEW OVERHEAD FIRE SPRINKLERS FOR INTERIOR 99.810 SF INTERIOR STORE REMODEL FOR "NORDSTROM." 2ND FLOOR FEE SUMMARY Plan Check. $54.11 Calc Valuation: $3,000.00 Permit: $83.25 Claimed Valuation: $3.000.00 Other: $0.00 Total: $ti •'.35 I NOTICE: The work authorized by this permit shall comply with all applicable lments under California statutes and related regulations, (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commence(, .,,tnin 180 days, or if work Is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 R"6-46 i6r00) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: Vave and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the rk for which this permit is issued. ave and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. workers' compensation Insurance carrier and policy number are: ��1rk I�(Z _ Policy Number. _ �y 1 - —(7 (This section need not be completed if the permit is valued alone hundred dollars (3100) or less.) ❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so is to became subject to the workers' compensation laws of California, and agree that If I should become subject to the workers' compensation provisions of Se Ion 3700 o the Labor Code, I shall forthwith Comply with then I Applicant Signature: Date: , 0 �:( WARNING; FAILURE TO SECURE W RS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL ENALTIES AND CAVIL FINES UP TO ONE HUNDRED THOUSAND DOL.LARE ($100,0001, WAD ONTO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am ticensed under ovisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is In full force and effect. Lk. # Class # .11 Contractors Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Londoes Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to Construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Divislon 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.$ by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her awn employees, provided that such improvements are not intended or offered for sale. if, however, the building or Improvement is sold within one year of compio6on, the owner -builder will have the burden of proving that he Or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a coniractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Drivars License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or dead): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby Certify that no excavation five (5) or more feet in depth Into which a person Is required to descend, will be made In connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) foot high. (Chap. 3.2, Grp 2, An 2, Sec, 341, Title S. California Administrative Coda). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I WIII the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal 10 or greater than a weight of 500 pounds, or a volume o1 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ...........................__..—_............................_._.................._...._..................................................................................................................................................._.................................. ...................... 2 Docs or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _......._........._ .............. ti _ _._ ......................._........................................ _ ----- 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No . LSection 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire apartment of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. .......................................................... ... _._.................................... _ ._.............._. -—......................................................................................... ................................_....................... 4 If an RMPP is presently required, has Section 25534 of the California Health and SafetyCode been fully complied with? ❑ Yes ❑ No ......._._ .... _............................... __._........................................................................................................................................................................................._..—..................__............. 5 Does or wilt the applicant or present or future building occupant require for the work which is the subject of this a plication aPermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes LJ No (Section 65850.2 of the California Government Code requires that the requested Information be furnished on applications for non-residential building permits). ............................................. ._...._....._.__-----...........—_.._................_—............—...................... _.......................,............................_.........................._.._.......... .........__ ........_ — ..... . 6 WIII any parl of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes j] No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ---._.._.........._._. ....... -- ... _... _.—....................-........................ ........_....................................................... _ -- .............._.._._ ... ... _ ............. .._..... _. — 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (11 'res", attach certificate of compliance from the appropriate air pollution control oNicerJ. CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all slate laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Data: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply wit ate laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the _gWve-described property for tion p I agree not to occupy or allow occupancy of any building authorized by this permit unfit final inspection. Signature Cf Lega ner(s) Date 0* An Or Authorized Applicant Data CODJ;-11, INSPECTION TYPE QAM Imlat. COOS / INSPECTION TYPE PAU INTMALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa- FIRE SUPRESSION PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Suite: NORD Vicini NORDSTROM CAFE ON 3RD LEVEL Parcel Number: 41249109 Zoning: Applicant: BRAZIL, CRAIG Address: 2505 MIRA MAR LONG BEACH, CA Phone: (562)498-6444 Zip: 90815 Owner: SEARS, ROEBUCK & CO %NORDSTROM INC Address ATTN TAX DEPT ' SEATTLE, WA Phone: P O BOX 2229 Zip: Contractor: CAL PROTECTION Address: 2505 MIRA MAR LONG BEACH, CA Phone:, (562)498-6444 Zip: 908115 License: 327195 Status: ISSUED Applied: 03/11/2003 Issued: 03/26/2003 ISSUED BY: SCOPE OF PERMIT FIRE ALARM SYSTEM UPGRADE IN CONJUNCTION WITH INTERIOR 5330 SF REMODEL OF AN EXISTING CAFE ON "NORDSTROM" 3RD LEVEL, REF: B02-01971 FEE SUMMARY Plan Check: $81.41 Permit: $125.25 Other: $0.00 Total: $206.66 Calc Valuation: $5,924.00 Claimed Valuation: $5,924.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12.21.92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 24ae.4e IS=) WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. ® ( have and will maintain workers' compensation insurance, as required by section 3700 o1 the Labor Code, for the performance of the work for which this permit is issued. .My workers' CompTation insurance carrier and policy number are: Carrier: 9oPv4pu2! I ,K Q&Yn l I +' -- Policy Number. 3` 80 " Z Z (This section need not be completed if the permit is valued at one hundred dollars ($100) or less.) ❑ 1 certify that in the performance of the work for which this permit Isjouod, i shall not employ any person In any manner so as to become subject to the workers' compensation laws of Callfamla, a gree that if I 1d born sutrjad to the workers' compensation previsions of Section 37170 of the Labor Code, I shall forthwith comply with these provisions Applicant Signature: Data: WARNING: FAILURE TOS O RS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUaIECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND OOLLARE (Si ), IN ADDITION To THE COST OF t:OMPF_NSATION, DAMAGES AS PROVIDED FOR IN SECTION 37os OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am tics ed under revisions of Chapter 9 mm ci g with Section 7000) of Division 3 of the Business and Pr99fesslons Code, and my license is in full force and effect. LIc. s t 727 f Class tf A e- to LC-/ L _ Contractors Signature: Date: '3-,2C-03 CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lenders Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to fllo a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for safe (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. 11, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WiTH LICENSED CONTRACTORS to construct the project (Sec. 70", Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractors) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. __- Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license, Yes ❑ No Driver's License No. Expires: . Verification of Ownership by (type of docume 1, Le. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feat in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, Scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, TIlle 8, Califomia Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number. HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present Or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of SW pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ..................___..............................I........... ............................... ..................................................................................................... _...................... _ 2 17oes ar will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight o1 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _ �•--- --.._........_............. ...................................................... __.................................... _..._ — 3 Does or will theappplicant or present of future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. .................... ..... ................................ ................. ......................—_...._................—......................_............................................................................................................................ I'll .............. _._.......... ......... ....... ............ —........... 4 If an RMPP is presently required, has Saction 25534 of the California Health and Safety Code been fully compliod with? ❑ Yes ❑ No ... -............................ _._.1111......................... ........... 1111,..... _..----------- -.. . 11..111.....—................ _...................................................................... ........................ ............................ 111 1.......— ............ 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication apermit for such construction or modification from the South Coast Air Ouality Management District or from any other air pollution control district or agency? Yes U No (Section 65850.2 of the California Government Code requires that the requested Information be furnished on applications for non-residential building permits). _.._._......... ---- 1 O feet _.....---._._._........_....s..........s......_..,..1111...- ---- .................— _ —, _. 6 Will any part of the facility to bg canStruGted under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes ❑ No (If 'yes", the facility must meet the requirement o1 Sections 25534 and 42303 of the California Health and Safety Code). 7 If apemtit from the South Coast Air Ouality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No -----......................... _............ _.-------------...................—................. _........................................................................... ................... .......-...................... ......................... _— ................. .._ 8 (If 'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that 1 have read this application and state that the Information given is correct. I agree to comply with all stale laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature Of Leg er( Date AncUOr Aut Applicant Data CODE f. INSPECTION TYPE 2AH INTMAL CQQE# INSPECTIONTYPE Qeg iNMIAL$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention + ✓ 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 2D4 Final Demolition 250 Final BuildinglOccupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-nPfflFaSUPRESSION PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Status: ISSUED Suite: NORD Applied: 03/19/2004 Vicinity: EE) Issued: 03/31/2004 Parcel Number: 41249109 Zoning: ISSUED B Applicant: JOHNSON, BRONWYN Address: 3022 HESPERIAN WAY Phone: (714) 554-6132 X227 SANTA ANA, CA Zip: 92607 Owner: SEARS, ROEBUCK & CO %NORDSTROM INC Address ATTN TAX DEPT SEATTLE, WA Phone: P 0 BOX 2229 Zip: Contractor: X L FIRE PROTECTION COMPANY Address: 3022 HESPERIAN WAY Phone: (714) 554-6132 SANTA ANA, CA Zip: 92607 License: 311681 SCOPE OF PERMIT OVERHEAD FIRE SPRINKLERS FOR INTERIOR 99,810 SF INTERIOR STORE REMODEL FOR "NORDSTROM." 3RD FLOOR. REF: B03-02189 FEE SUMMARY Plan Check: $63.21 Permit: $97.25 Other: $0.00 Total: $160.46 Calc Valuation: $3,800.00 Claimed Valuation: $3,800.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 1130 days, or it work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2"6-46 (6.+00) DECLARAMNS WORKERS' Cd PENSATION DECLARATION: I hereby air rider penalty of perjury one of the following declarations: ❑ I a and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 o1 the Labor Code, for the performance of [he ork for which this permit Is issued. ! have and will maintain workers' compensation Insurance, as required by section 370D of the Labor Code, for the performance of the work for which this permit is Issued. My w ars' compensation Insurance carrier and policy number are: Carrier: [`C1Jl�>t'v CC�� Policy Number: (This section need not be completed it the permit is valued atone hundred dollars ($t00) or less.) ❑ I certify that in the performance of the work for which this permit is issued, 1 shall not employ any Dotson in any manner so a to become subject to the workers' compensation laws of California, and agree that If I should become subject to the workers' compensation provisions of Sect, 3700 oft a tabor Code, I shall forthwith Comply with the tool ns. Applicant Signature; _ Date: WARNING: FAILURE 70 SECURE RS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PF_NALilES AND CML FIN UP TO ONE HUNDRED THOUSAND DOLLARS {5100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE U430R CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am Ilc nsed unde r Ions of Chapter 9 (Commencing with Section 7000) of Division 3 of the Business and Proi scions Code, and my license Is In full force and effect. Uc. # Class # Contractor's Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this perm,[ Is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of ft Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any Violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ ,, as owner of the property, or my employees with wages as their solo compensation, WILL DO THE WORK, and the structures not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or improvement Is sold within one year of completion, the owner -builder will have the burden of proving that he Or she did not build or improve for purpose of sate.). ❑ !, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a conlractor(s) license pursuant to the Contractors license Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth Into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, An 2, Sec. 341, Title 8, Califomia Administrative Coda). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industria, Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Wilt the applicant or present or future building occupant need to file and Certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any Ona time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 2GG cubic feet of compressed gas at standard temperature and pressure). 3 Dogs or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and riling with [he Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. _.—_.......... - - .......................... ._..._.................._ ........................_........................ --•--•.............._.......—........—...._.......-_ 4 [f an RMPP is presantly required, has Section 25534 of the California Health and Safety Code been fully complied with? [:)Yes ❑ No _........................................................................-............. ........... ........_...................... ....... ... ............,..................................... .................. .............................__...__ _ ......_.�...__._.... _— -_ � . 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this a�.pplication a ffrmit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes LI No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ...................... ...... ............................................ 1......................_................. ..... ..._......................................_..........................................................................................................................._..........---......_.._....._........ 6 W III any part of the facility to be constructed under this permit be within 1000 feel from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality, Management District or other air pollution Control district or agency is required for the work which is the subject of this application, have all of the disclosures proscribed by California Health and Safety Code Section 42303 been made? ❑ Yes ja No ........ ....... ._......................... ............................... -- - ----- -._.._ -- .....—(if'...........a control 8 (If 'fres", attach certificate of compliance from the appropriate air pollution Central officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that 1 have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to Occupy or allow occupancy of any building authorized by this permit until final inspection. Si nature alOwner(s) at And/Or Aut onzed Applicant Dat CODE 1. INSPECTION IYPE 2&H INTMALS CODE INSPECTIONTYPE INTITIAL$ 1616 Fixed System Final Fire Prevention 206 Final Machanlcal 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Well 212 Final Fire Prevention tot 202 Final Factory Fire Place 220 Final Planning Approval 203 Fina! Sign 222 Fina, Site 204 Final Demolition 250 Final Building/Occupancy 11 (714) 754-5273 • Fax (714) 754-4856 • www.cl.costa- FWAPRESSION PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92526 Job Address: 3333 BRISTOL ST Suite: NORD Vicinity: 3RD AND 4TH FLOORS AND ROOFrOP Parcel Number: 41249109 Zoning: Applicant: BRAZIL, CRAIG Address: 2505 MIRA MAR LONG BEACH, CA Phone: (562)49B-6444 Zip: 90815 Owner: SEARS, ROEBUCK & CO %NORDSTROM INC Address ATTN TAX DEPT SEATTLE, WA Phone: P O BOX 2229 Zip: Contractor: CAL PROTECTION Address: 2505 MIRA MAR Phone: (562) 498-6444 LONG BEACH, CA Zip: 90815 License: 327196 Status: ISSUED Applied. 03/11/2003 Issued: ■03126t20Q ISSUED BY: SCOPE OF PERMIT FIRE ALARM SYSTEM UPGRADE ON "NORDSTROM'S" 3RD AND 4TH FLOORS AND THE ROOFTOP. Plan Check: $117.81 Permit: $181.25 Other: $0.00 Total: $299.06 FEE SUMMARY Calc Valuation: $9,730.00 Claimed Valuation: $9,730.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically explre and become vold If work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspectlons and final approval must be obtained. Failure to obtain Inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2448.46 {8100) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which tftts permit is Issued. My workers' compensation Insurance carrier and policy number are: Carrier. i_L"roo Qc- - I 1YPC-OnLI n- Policy Number:' 1-SO - ?-'Z- (This Z(This section need not be completed 11 the permit Is valued at one hundred dollars (S l00) or less.) ❑ 1 Certify that In the performance of thew hich this permit i d, I shall employ any parson in any manner so as to become subject to the workers' compensation laws of California, that I1 I Id hec ubJect tq 1 vrkers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisions Applicant Signalure: Data: —3 WARNING: FAILURE TO Spj6REqsl COMPENSATION COVERAGE IS UNLAWFVL AND SHALL SUAIECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FIVES UP TO ONE HUNDRED THOUSAND DOLLARE (S J, IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 370a OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: hereby affirm that I am licansgf!}�n� r vis Chapter 9 ( cing wi tlon 7000) of Division 3 of the Business and Pirgiressions Coda, and my license is In full force and effect. LIc. a n ` (( Class N Contractor's Signature. a Date: - % "03 _ CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code), Lenders Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of pedury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professlons Cods) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building Or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sate.). - ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The conlrartors License Law does not apply to an owner 01 property who buWs Or improves thereon, and who contracts tvr Such pfojact with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Cade for this reason: Signature: Date: Owner ID verified by driver's license. �fos ❑ No Drivers License No, Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certity that no excavation five (5) or more toot In depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, An 2, Sec. 34 t, Title 8, California Administrelive Code). ❑ As owner-builder, I will riot employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to de such work from the division. Signature: Data: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or pront or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes No (Section 25505 of the California Health and Safety Code requires. with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). - .......................... --- -....---...._........................... .................... ............................. ..... Does or will the applicant Or present Or future building occupant need to file a registration form for acutely hazardous matedols? ❑ YOS ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, Or 200 cubic feet of compressed gas at standard temperature and pressure). ............................... .._....................................................._....................... ........................ ..................................................... - ......................... __ m....................._..................__............... 3 Does or will the applicant Or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP try businesses which are required to register acutely hazardous materials with the Fire Department. _ ........ _ ._.......California .......................................................................................................................................................................................-........._ .. . 4 if an RMPP is presently required, has Section 25534 of the Califomia Health and Safety Coda been fully complied with? ❑Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of thisa plication a ermil for such construction or modification from the South Coast Air Quality Management District or from any other air pollution Control district or agency? Byes No (Section 65850.2 of the Cgfifomia Government Code requires that the requested Information be furnished on applications for non-residential building permits). 6 will yan pof the faciiity to be constructed under this permit be within 1000 reel tram the outer boundaries of a anschool? ❑ Yes [J No (if 'yes", the facility must meet the requirement of Sections 25534 and 42303 Of the California Health and Safety Code). 7 If a permit from the South Coast Air Ouality Management District or other air pollutioncontrol djstrict Or agency is requjred for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? [:]Yes [I No _.._..... ..........^-----......... -...... -._................. ___....... - -_..................... .................... ,.......... .:............................................... ....... _ ..__._............ .._ . 8 (If yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty Of perjury the information given above is correct. I agree to comply with all state laws and city Ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE: AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given Is correct. I agree to comply with all state laws and city ordinances relating to building cxpa7uclion, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection pu S. I agree not to occupy or allow a of any building authorized by this permit until final inspection. rgnat Oflag r(s) Q to 3 -26 rod nd! Auth nz d plica Date } CODE n' INSPECTION TYPE 26IE INTMA4$ CODER INSPECTION TYPE: J78IE INTMA6L$ 1816 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final RO-Roof 210 Final Electrical I, 201 Final Block/Retaining Wall 212 Final Fire Prevention �S • �� ' �i3 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 MECHANICAL PERMIT Job Address: 3333 BRISTOL ST Status: ISSUED Suite No NORD Applied: 06/08/2005 Issued: 06108!2005 Vicinity: NORDSTROM SPA Parcel Number: 41249109 ISSUED BY: Applicant: PHELPS, ROGER %.. Address: 9322 14TH AVE SOUTH Phone: 206-764-9663 /'SEATTLE, WA, - Zip: 98108 owner:,', SEARS, ROEBUCK & CO %NORDSTROM INC Address: ATTN TAX DEP/T SEATTLE, WA' Phone: P O BOX 2229 Zip: Contractor: PSF MECHANICAL Address: 9322 14TH AVE SOUTH ° `Phone: 206-764-9663 SEATTLE, WA Zip: 98108 License: 628376 SCOPE OF PERMIT 2,500 SF INTERIOR TENANT'IMPROVEMENT FOR "NORDSTROMS EXPRESS SPA" AT THE 4TH FLOOR. DEMO EXISTING SALON AND INSTALL AN EXPRESS SPA. 1 REPAIR/ALT COOLINGIHEAT, 3 VAV BOXES, 2 VENT FANSISINGLE DUCT, 3 SMOKE DAMPERS, 3 FLOOR OR SUSPENDED HEATERS, 2 VENTILATION'SYSTEMS REF: B05-00605 FEE SUMMARY , Quantity Quantity ISSUE FEE $23.50 Repair / Alt Absorbtion Unit $0.00 0 Inst FAU <100 k BTU $0.00 0 Repair /Aft Refrigeration Unit $0.00 0 Inst FAU >lOO k BTU' $0.00 0 Ventillation System ; $21.30 2 Repair I Alt Cooling/Heat $13.70 1 �- ? Evaporative Cooler $0.00 0 Inst !Rep. Recess Wall Htr $0A0 0 y Commercial Incinerator ,; $0.00 0 Refrig Sys <100 k BTU ��� x$0.00 0 Domestic Incinerator. , , �, �' $0.00 0 Refrig Sys >100 k BTU = ,$D.OD. -.0. •. Compressors IAbsor on System/ s• Gas Piping ' . �_ ` $0.00 0 Up to 3 hp 1 100 k BTU $0.00 0 Factory Fireplace $0A0„,0 _ 3 To 15 hp 1500 k BTU ;� - " $0.00 0 Hood wlMech Exhaust $0.00.` 0' ­. `� ` , 15 To 30 hp 1 1,000 k BT $0.00 0 VAV Box �� �$31'.95 3::�_� , , 30 To 50 hp 11,750,k BTU $O.OD 0 Vent Fan ISingle Duct -Over 50 hp"!Over 1,750 -BTU "$0.00 0 Appliance A, $0.00 .'; 0 ., \, Boilers Fire Dampers $0.00 "'0. 0. Up to 3 hp $0.00 0 Smoke Dampers `�, -$21.75 3 3 To 15 hp $0.00 0 Inst or Relocate Appi Vent $0.00..0 ' 15 to 30 hp J $0.00 0 Air Handlers < 10000cfm $0.o0 -_0 - ' 30 to 50 hp $0,00 0 Air Handlers > 10000cfm $0.00 -0 Over 50 hp $0.00 0 Floor Furnace $0,00 0 Other Mechanical Fee Floor or Suspend Heater $44.40 3 Investigation Fee $0.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work Is not commenced within 180 days, or if work Is suspended or abandoned for a period of 180 days. INSPECTIONS: in order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 ' 2446.46 (6=) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 Of the labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' ompensation Insurance carrier and policy number are: fCanlsr - -[cA11/ 7,57- lNs, s sectfon n6ed not be completed if the permit is valued at one hundred dollars ($100) or less.) T- �— ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the labor Code, I shall forthwith comply with these pro 6lgnatu int t�✓X�' ,,,_ �[]eta� _ !Q � D � � ? . WARNING: FAILURE TO SECURE V113RKERS' COMPENSATIO OOVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($10D,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEY-$ FEES. LICENSED CONTRACTORS DECLARATION: I hereby afflrm that I em licensedun er rovisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and P ofessions Code, and my license is In full force and effect. Class C ntractnYa SrgrlIS,% Data: CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is Issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to Its Issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (Commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any viclatlon of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or Improves thereon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). - ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a Conlractor(s) license pursuant to the Contractors License Laws.). ❑ 1 em exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. Ayes ❑ No Driver's License No. Expires; Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet In depth Into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, lalsework, or demolition or dismantling thereof, will be more than thirty-slx (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As ownor•buildor, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the divislon. Signature: Data: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or tenure building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feat of compressed gas at standard temperature and pressure). ....................._............................-•----.....__..........---.._....-----._.........__............._.__................... —........................... - ... _........................... - ... 2 Does or will the applicant or present or future building occupant need to file a reglstratlon form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will theaappplicant or present or future building occupant need to prepare an RMPP (Risk Management and Prev ent€on Program for acutely hazardous materials)? C1 Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department, ................................................................................._......................... ................................ _....................................................................................... ................... _ ........_ _ .............. — ........_. 4 If an RMPP is presently required, has Section 25534 of the Califom€a Health and Safety Code been fully complied with? Y a 9 ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification y from the South Coast Air Quality Management D€stricl or from any other air pollution control district or agency? Yes U No (Section 65850.2 of the California Government Code requires that the requested information be fumished on applications for non-residential building permits). 6 Will any part of the fadlity to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code), _. ....._ r.......... _—......................... .._........ _............. ._.._.................... ._..................................................... --------.....---- -- 7 If a permit from the South Coast Air Quality. Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by Califomle Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (If 'yes", attach Certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I cartity that under penalty of perjury the information given above is correct. I agree to comply with all state laws and dry ordinances regarding Hazardous Materials and Emissions. Signature: Data: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given Is correct. I agree to compty with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for Inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final €nspectlon, Signal ur Leg Owner(s) Date 19 An Otho !tippllcarit �la� CODE INSPEC110TYP Qeff KTITLALS CODE/ INSPECTIOMTYFE Qsg, 1616 Fixed System Final Fire Prevention '206 Final Mechanical - - '1 1266 Pod Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final BuildinglOccupancy (714) 754-5273 a Fax (714) 754-4856 a www.cl.costa-mesa-Whi—DING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Status: ISSUED Suite: NORD Applied: 04/14/2005 Vicinity: 4TH FLOOR Issued: 06/02/2005 Primary Occ: M DisplaylSale Merchandise Type of Construction: I -FR Parcel Number: 41249109 Zoning: Applicant: BARO, REBEKAH Address: ISSUED BY: Phone: 714-850-3740 100117 Zip: Owner: SEARS, ROEBUCK.& CO %NORDSTROM INC, Address ATTN TAX DEPT SEATTLE, WA Phone: P O BOX 2229 zip. Contractor: MATT CONSTRUCTION $1,665.14 Address: 9814 NORWALK BL Permit: STE 100 ' Phone: (562) 903-2277 SANTA FE SPRINGS, CA $0.00 Zip: 90670-2936 License: 631020 Arch : CALLISON ARCHITECTURE, INC - Eng: Address: 1420 FIFTH AV Address: STE 2400 Phone: 206-623-4646 Phone: SEATTLE, WA Zip: 98101-2343 License: C21660 License: SCOPE OF PERMIT 2,500 SF INTERIOR TENANT IMPROVEMENT FOR "NORDSTROMS EXPRESS SPA" AT THE 4TH FLOOR. DEMO EXISTING SALON AND INSTALL AN EXPRESS SPA. FEE SUMMARY Plan Check: $1,665.14 Permit: $2,561.75 SMIP Res: $0.00 SMIP Com: $79.80 Other: $0.00 Inspection: $0.00 Total: $4,306.69 % PLANNING & ZONING SETBACKS MAIN STRUCTURE Front 0-,0 Rear 0-0 Left 0-0 ACCESSORY Front ' 0- 0 ` Rear 0= 0- Left 0-0 PARKING Existing: 01 Required: 0 Proposed: 0 Calc Valuation: Claim Valuation Right 0= 0 Right 0-0 $380,000.00 $380,000.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work Is not commenced within 180 days, or If work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result In the expiration of this permit. FOR INSPECTIONS CALL: (714) 754.5626 A 244645 (SM) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by section 3700 of the labor Code, for the performance of the [1work for which this permit is issued. 1 have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this penult is issued. My wo ers'rampensation Insurance carrier and policy number are: .-7 1 LCZRLli �VeE C6A4PAIVY P Number.ZCla3 20 J (This &wdon need not be completed if the permit Is valued at one hundred dollars ($1 00) or less.} ❑ I certify that in the performance of the work for which this permit is Issued, I shall not empioy any person in any manner so as to become subject to the workers' compensation laws of Callfojnla. and a 3 M ld became subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these gpgvisio Fa^ a is Ignature• tGClx� ( II�i L WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMSNAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOt-LARE ($100,000), IN ADDMW TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECI`ION 3708 OF THE LABOR OODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm thetLf@km licensed under provisions of Chapter g (commencing with Section 7000) of Division 3 of the Businpk and Professions Code, and my license is In full force and effect. Cmotor gIratOre: _AKe - 2 CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is Issued. (Sec. 3087, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of penury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 8 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a penult subjects the applicant to a civil penalty of not more than five hundred dollars ($500),): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Cade: The contractors Ucense Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date. Owner ID verified by driver's license. XYes ❑ No Drivers License No, Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth Into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Tille 8, California Administrative Code). ❑ As owner-bullder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Data: Division of Industrial Safety Permit Number. HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature end pressure). _ 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous mfllerials7 ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds. or a volume of 55 gallons, or 200 cubic fest of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ..........................is presently d,...............................__...................................................,.........................,.,...,,................................Iii;............. ...;............. ... ......................................._....................-- 4 If an RMPP is presently required, has Section 25534 of the Califomia Health find Safety Code been fully complied with? ❑Yes No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes (� No (Section 85850.2 of the California Government Godo requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes -ti-No (11'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ............................................._.......................... _._.... _..... _—.................... _—............................ _..................... ..................................._..._. 7 If a permit from the South Coast Air Quality Management District or other all pollution control district or agency is requ€red for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑Yes ❑ No 8 (If yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I cerlity undei penally of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for Inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. [gnat Legal or -Anpllcant CODE If INUEOQN TYPE RM WTITIA 000E i INSPECTION TYPE HATE Rf TnA 1816 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final elock/Rotaining Wall 212 Final Flre Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site _ 204 Final Demolition 250 Final BulldinglOccupancy �0 �� (714) 754-5273 • Fax (714) 754-4856 • www.cl.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Status: ISSUED Suite: NORD Applied: 07127/2005 Vicinity: 4TH FLOOR NORDSTROM EXPRESS SPA Issued: 09/012005 Parcel Nunmber: 41249109 Zoning: Applicant: AMICAY, SAM ISSUED BY: Address: Phone: 714-902-8000 Zip: O wnev SEARS, ROEBUCK & CO %NORDSTROM INC Address ATTN TAX DEPT SEATTLE, WA Phone:. P Q BOX 2229 Zip: Contractor. AMICAY, SAM Address:, Phone: 714-902-8000 Zip: License: 612153 i SCOPE OF PERMIT INSTALL FIRE ALARM SYSTEM DEVICES AND CONNECTING TO EXISTING FIRE ALARM SYSTEM FOR T.I. FOR 2,500 SF INTERIOR TENANT iMPROVEMENT FOR "NORDSTROMS EXPRESS SPA" AT THE 4TH FLOOR REF #1305-00605 FEE SUMMARY Plan Check: $29.15 Calc Valuation: $1,200.00 Permit: $44.85 - Claimed Valuation; $1,200.00 Other: $0.00 Total: $74.00 NOTICE: The work authorized by this permit shall compty with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or it work is suspended or abandoned for a period of ISO days. INSPECTIONS: In order for the work authorized under this permit to be oonsidered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. Fl- FOR INSPECTIONS CALL: (714) 754.5626 2449.49 (9!001 DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of podury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. L have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier nd poli number are: �YL -Carrier. = G. W 'r�¢S � i� v �-2 7'Z. � _ Poficy Number.- _ _ {This section need not be cofeted d the permit is valued at one hundred dollars ($100) or less, J ❑ 1 cortity, that in the performance of the w ich thishoulpermit is Issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and gree that is d become subjec a workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisions. Appiicant-Slgnatur . �pa _ WARNM: FAILURE TO SECURE WORKERS' ON COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,0001. IN ADOMON TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. \ LICENSED CONTRACTORS DECLARATION: I hereby affirm that I em licensed under provisio.as of Chapter 9 (commencing with Section 7000) of Division 3 of the Business gpd Professions Code, and my license is In full force and effect. Llor•#- Class Ort 4 Gonfractors•Slgnaturo__- Date. CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 71331.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for safe (Sec. 7044, Business and Professions Coda: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or Improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sate.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec, 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License laws.). ❑ I am exempt under sec. Business and Professions Codo for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Drivor's License No. Expires: Verification of Ownership by (type of document, i.e- - property tax bill or dead): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth Into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition of dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, An 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 WIII the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic foot of compressed gas at standard temperature and pressure). ............................._.............,.................................................................._..............................................._................ ,.,.,,.................................................................................................................. _.. ....... �....... ._........ _.� 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 o1 the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .........................- --- _. _ ...................... ...._................. ..-................... .......... .........._................................................................................................................... ...... ....................... _-- 3 Does or will theapppllcant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes 11No (5ectlon 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. _..................._ ................................................................................................................. ................................................................... _................... 4 if an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? []Yes ❑ No W -----.-....................—.................. __.................. -_........................................................................... ................................................................................................. _.................. _ 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a rrnit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? El Yes No (Section 65850.2 of the California Government Code requires that the requested Information be lumished on applications for non-residentlal building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes ❑ No (If 'fres', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Ouality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (11'yes", attach cerliTicate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and dry ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AN,__QAgHORIZATION OF ENTRY: I certify under penalty of perjury that i have road this application and state that the information given is correct. I agree to compI stat s and ' rdinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described prop for Ins on purpos , i ree not fo occupy or allow occupancy of any building authorized by this permit until final inspection. SI nature Of a1 Ow s Dat nd/Or.Authorized.Appilcant (-Date'-'t7 CODE INSPECTION TYPE PAM wnui.9 CODER INSPECTION TYPE GeIE INMLS 1616 Fixed System Final Fire Prevention 206 Final Mechanlcal 1266 Pool Spa Flnal 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retalning Wag " 212 Final Fire Prevention 1 1;V-doy &—J 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 FIRE SUPRESSION PERMIT Job Address: 3333 BRISTOL ST Suite: NORD Vicinity: 4TH FLOOR Parcel Number: 41249109 Zoning: Applicant: BROWN, MAXINE Address: 321 E GARDENA BL Phone: 323-321-5155 GARDENA, CA Zip: 90247 ' Owner. SEARS, ROEBUCK & CO %NORDSTROM INC Address , ATTN TAX DEPT SEATTLE,.WA Phone: P O BOX 2229, Zip: Contractor: COSCO,FIRE PROTECTION INC Address: 321 E GARDENA BL Phone: 323-321-5155 Status: ISSUED Applied: 04/26/2005 Issued: / 0 ISSUED BY: GARDENA, CA Zip: 90247 "License: 577621 SCOPE OF PERMIT FIRE SPRINKLER PERMIT FOR INTERIOR T.I. FOR "NORDSTROM'S EXPRESS SPA" (4TH FLOOR). RELOCATE 32 FIRE SPRINKLER HEADS. REF: B05-00605 ` FEE SUMMARY Plan Check: $63.21 Permit: $97.25 Other: $0.00 Total: $160.46 -711 t C i Calc Valuation: $3,200.00 Claimed Valuation: $3,200.00 NOTICE: The work authorized by this pfirmit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work Is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized ander this permit -to -be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result In the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 2.ae.48 tervol DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following dedaralions: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the labor Code, for the performance of the for which this permit Is Issued. [j ave and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance o1 the work for which this permit is Issued. _ orkers�compe tion Insurance cprrfer and po number are: cy �.. �`��a Ce /y Voll Number: his section need not bVcompleled if the perMt is valued atone hundred dollars ($100) or fess.) ❑ 1 cedly that in the performance of the work for which this perrgU is Issued, I shall not employ any person In any manner so as to become subject to the workers' compensation laws of Callfomle, and agree that if I shout d a subject to the workers' compensation provisions of Secti n 3700 of th Labor Code, I shall forthwith comply with th .p I cant Signature + K. �� Date FAILURE TO SECURE W RS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EAIRLQ�CRIIA PENALTIE AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (5700, 000), iN ADDRION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3705 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: hereby fflrm'1he1'I am Itceri u;urider rovisions of Chapter 9 (commencing with Section 7000) of Division 3 o1 the Business and Profess€ s Code, andm license is In full r lfectIIIM1111111110``` ' Glass p 01 c s — "a lgriature:,^ ►' Data: w CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is Issued. (Sec. 3097, Civil Cade). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031 .6. Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Sectlon 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License taw does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If. however, the building or Improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or Improve for purpose of sale.). ' ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License taws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Data: Owner ID verified by drivers license. ❑ Yes ❑ No Drtvees License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMrr CERTIFICATION: ❑ I hereby cenity that no excavation five (5) or more feet in depth into which a person is required to descend, will be made In connection with work authorized by this permit, and that no building structure, scaffolding, faisework, or demolition or dismantling thereof, will be more than thirty-slx (38) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, Califomia Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number. HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building oa upant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes 0 No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity o1 hazardous materials equal to or greater than a weight of 50D pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature end pressure). .........._ _ ..____ -- ----.....�.................... .....—............................... _.._............ ... 2 Does or will the appikant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with soma exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). — ------ _. ................. —............................... .._........................... ......................................................... _.._....—_...... _..._..---....—._..._..— 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may roquire the preparation, certification and filing with the Fire apartment of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department, _ W. ......................... _.............._...__ _........_._...............__._.............----....................................................................._..........❑ No.... ...... —......... _...... — — ..._ 4 If an RMPA is presemly required, has Section 25534 of the California Health and Safety Code been fully Complied with? ❑ Yes ........................... ........................................................ _ ._.. 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plleation a germll for such construction or modificadon from the South Coast Air Ouality Management District or from any other air pollution control district or agency? j] Yes LJ No (Section 65850.2 of the Califomia Government Code requires that the requested Information be furnished on applications for non-residential building permits). ....................... .................................................... —..... - ......... _ 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yas ❑ No (If 'yes', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7µ If a permit from the South Coast Air OualitY Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by Callfomla Health and Safety Code Sectlon 42303 been made? ❑ Yes ❑ No attach certificate of compliance from the appropriate alr pollution control officer). CERTIFICATE OF COMPLIANCE: I cerflty that under penalty of perjury the Information given above is correct. I agree to comply with all state taws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certlty under penalty of perjury that i have read this application and state that the infom%ation given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-doscribed property for Inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Sl slurs De Legal Ow Date Wim- Author M p lcarti CODE 0. INSPEMONTYPE RAFT, NTMA CODE! INSPECTION TYPE 2AR ItfDDiSLfl 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1288 Pod Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Bkr"otaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 2D4 Final Demolition 250 Final Bullding/Oocupancy (714) 754-5273 • Fax (714) 754-4856 www.cl.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 BUILDING PERMIT Job Address: 3333 BRISTOL ST Status: ISSUED Suite: NORD Applied: 03/17/2004 Vicinity: Issued: 05/26/2004 Parcel Number: 41250107 Zoning: PDC PDC Applicant: DIRICO, JUSTIN ISSUED BY: Address: 9814 NORWALK BLVD SUITE 100 Phone: 562-903-2277 SANTA FE SPRINGS, CA Zip: 90670 Owner: SOUTH COAST PLAZA Address ' COSTA MESA CA Phone: � 3315 FAIRVIEW ROAD. Zip: 92626 Contractor: ,MATT, CONSTRUCTION Address: 9814 NORWALK BL STE 100 Phone: (562) 903-2277, SANTA FE SPRINGS, CA ` Zip: 90670-2936 License: 631020 Arch : CALLISON ARCHITECTURE, INC., Eng: COFFMAN ENGINEERS - FIRTH, DENNIS Address: 1420 FIFTH AVENUE Address: 1601 FIFTH AVENUE Phone: 206 613-4925 Phone: 206 623-0717 SEATTLE, WA - ' SEATTLE, WA' Zip: 98101 License: 98101 License: SCOPE OF PERMIT SEISMIC UPGRADE OF EXISTING BLDG. STRUCTURAL SYSTEM, NON-STRUCT. ELEMENTS INCLUDING ELECT., MECH., & PLUMB. ARE ALREADY PERMITTED ON B03-02189. - - - NOTE: AN OVERALL REDUCTION OF 900 SQ.FT, WILL OCCUR WITH THIS PERMIT FOR STRUCTURAL UPGRADE WHICH OFFSETS THE 700 SQ.FT. INCREASE IN FLOOR AREA APPROVED BY PERMIT #803-02189, THEREFORE, NO NET INCREASE IN SQUARE FOOTAGE OCCURS AND NO TRAFFIC IMPACT FEE OR ' " ' TCA CORRIDOR FEE IS DUE AS A RESULT OF THESE TWO COMPANION PROJECTS. FEE SUMMARY Plan Check: \, $5,064.44 Calc Valuation: $1,597,500.00 Permit: $7;791.45 Claim Valuation: $1,597,500.00 SMIP Res:-' S0.00 SMIP Com: $335.47 Other: $0.00` , Inspection: $0.00 Total:,' ,$13,191.36 _ PLANNING & ZONING SETBACKS MAIN STRUCTURE Front 0-0 Rear 0-0 Left 0_0- Right' 0-0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92.28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work Is not commenced within 180 days, or it work Is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval Must be obtained. Faiture to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 244"8 teMl � e WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declaratlons: ❑ 1 have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is Issued. ve and will maintain workers'compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. workers' compensation Insurance carrier and policy number are:4ce1c: Policy Number: (This section need not be completed if the permit is valued at one hundred dollars ($100) or less.) ❑ I certify that in the performance of Via work for which this permit Is Issued, I shall not employ any person in any manner so M to became subject to the workers' compensation laws of California. gpd agree tht#f If I should become subject to the workers' compensation provisions of n 3700 of the La4or Cpde, I shall forthwith comply with these 0 Applicant Signatur Date: WARNING: FAILURE TO SE E wORKE CPE OMNSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO GRIM: Fl PENALTIES D CIVIL ES UP TO ONE HUNDRED THOUSAND DCILLARE fill ,OWl. IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under pr viSions of.Chapler 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Llc. a Class 0 Contractor s Slgnat Date: CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec, 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Sectlon 7000) of Division 3 of the Business and Professions Cade) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, I.e. - property tax bill or dead): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet In depth Into which a person Is required to descend, will be made In connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions. that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _ 2 Does or will the applicant or present or future building occupant need to file a registration form -for hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ................ -....................... —..__..... -.................... _....................... __....................... ,................,................................................................................................ -.............. -._................. .................. 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire [)apartment. _ —_...... --....................-_........._........... — 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? [:]Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? jI Yes INo (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a schoof7 ❑ Yes ❑ No (If 'yes', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 It a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by Califomia Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (If yes-, attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signalure: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes, I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. ler AndlOf Adthorizedf Applicant Dat CODE t. INSPECTION TYPE DAIS INTITIdl$ CODE r INSP_E0014 YPi DAIE INiITIAL$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Rotaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy �� SE SMITH -EMERY COMPANY An In&e wndcnr Cnmrncrcial Testing Labnewory, $a7abliyhed 1404 791 Fart IrlwhiRgtak Bbrl LarAnstlrs, C05fidmia 90021-304 3 (213) 744.3411 Fau (7 1.3) 14 1.8620 File No. 3402-1 Matt Construction 9814 Norwalk Blvd., Suite 100 Santa Fe Springs, CA 90607 PROJECT: Nordstrom South Coast Plaza 3333 Bristol Street Costa Mesa, CA 92626 Permit # B 0400 B 0401831 Tear Sirs, I-IutucraPartuSh0)=d, Bldg. 114 P. 0. Box 880330 Sir Fraw*m, Carifaryd4 r 1188 (415) 330-3000 Pax (415) 330-3030 August 24, 2005 This is to certify that the Reinforced Concrete, Reinforcing Steel, Structural Steel Welding & Bolting, Sheat Connectors, Fireproofing, Masonry Grouting, and Epoxy Dowels for this project was inspected by special inspectors employed by Smith -Emery Company and all work inspected and tested was in compliance with the approved plans and specifications, Uniform Building Code. Special inspection reports have been previously submitted. Respectfully Submitted, S11 I;7 St _e (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 PLUMBING PERMIT Job Address: 3333 BRISTOL ST Status: ISSUED Suite No NORD Applied: 06/07/2005 PLUMBING PERMIT FOR 2,500 SF INTERIOR TENANT IMPROVEMENT FOR Issued: 06/07/2005 Vicinity: SPA" AT THE 4TH FLOOR. DEMO EXISTING SALON AND INSTALL AN EXPRESS SPA. ISSUED BY: Parcel Nunmber: 41249109 Applicant: CASEY CHRISTOPHER CASTIALDO Address: 15100 TEXACO AVE • 'Phone: (562) 408-0400 PARAMOUNT, CA i.J - - Zip:_ 90723 Owner: SEARS, ROEBUCK & CO %NORDSTROM INC , Address ATTN TAX DEPT , SEATTLE;.WA Phone:. <' FEE SUMMARY ' P O BOX 2229 Zip: . AMT QTY _ - AMT QTY AMT QTY ISSUE FEE Contractor: 'DON BRANDEL PLUMBING INC.- NC_.Address: Sump Pump Address: 15100 TEXACO AVE Backflow irrigation $0.00 1 Phone: (562) 408-0400 $0.00 PARAMOUNT, CA Zip: 90723 •'($9.80' , 0 = �� License: 176778 $29.40 3 Bathtub 50.00 0 Pressure Regulator $0.00 0 Urinal NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work Is not commenced within 180 days, or If work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable code and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this rrnit. FOR INSPECTIONS CALL: (714) 754-5626 2446-46 (6/00) SCOPE OF PERMIT PLUMBING PERMIT FOR 2,500 SF INTERIOR TENANT IMPROVEMENT FOR "NORDSTROMS EXPRESS SPA" AT THE 4TH FLOOR. DEMO EXISTING SALON AND INSTALL AN EXPRESS SPA. REF #1305-00605 WORK TO INCLUDE: 1 BACKFLOW PREVENTER, 3 FLOOR DRAINS, 1 LAUNDRY TUB/WASHER, 1 SHOWER, 3 COMMERCIAL SINKS, 5 KITCHEN SINKS, 3 TRAP PRIMER, 1 WATER PIPING (IN ST OR REP.) 20', 1 SUZI'UNIT, 1 HOT WATER DISPENSER AND 5 MIXING VALVES. FEE SUMMARY ' AMT QTY _ - AMT QTY AMT QTY ISSUE FEE $2350 : ; Laundry Tub 1 Washer $9.80 1 Sump Pump $0.00 0 Backflow irrigation $0.00 1 Landscape Irrigation . $0.00 -0 ,,Swimming Pool $0.00 0 Backflow Preventer �'� •'($9.80' , 0 = �� �; , P -Trap . $0.00 0 Trap Primers - $29.40 3 Bathtub 50.00 0 Pressure Regulator $0.00 0 Urinal $0.00 0 Clarifier System `$0.00' 0. Process Piping (per.10 ft) $0.00 0 Vacuum Brkr Bkflow(1-4) $0.00 0 Connect (Ice,Soda,etc) `, - $0.00 : 0; Receptors $0.00 0 i Vacuum Brkr Bkflow(5+) $0.00 0 Dental Units �$O.qO.• _ 0 .. Septic Tank $0.00 0, Wash Basin $0.00 0 Dishwasher $0:00 -�­o Sewer Cap foi Demo $0.00 -- -0 Wash Basin Set $0.00 0 Drain, Floor $29.40 '3' , `' Sewer Connect $0.00 '0 -Waste and Vent System $0.00 0 Drain, Rainwater $0.00 0 •. - Sewer Private Line $0.00 d Water Closet (Toilet) $0.00 0 Drain, Roof $0.00 0 Shower $9.80 1, Water Heater! vent $0.00 0 Drinking Fountain $0.00 0 Sink„bar -,$0.00 _0 Water Piping (Inst or Rep.) $9.80 1 Expansion Tank $0.00 0 Sink, commercial - $29.40 3 Water Re -pipe $0.00 0 Gas Earthquake Valve $0.00 0 Sink, Floor $0.00 0 Water Service $0.00 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work Is not commenced within 180 days, or If work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable code and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this rrnit. FOR INSPECTIONS CALL: (714) 754-5626 2446-46 (6/00) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and wilt maintain a certificate of consent to self-Insure tot workers' compensation, as provided for by section 3700 of the tabor Code, for the performance of the or for which this permit is Issued. ve and will maintain workers' compensation Insurance. as required by sectbn 3700 of the Labor Code, for the performance of the work for which this permit is Issued. My works mpen5atlon Insurance carrier policy numbs1 are ,��` [� W ,,r►Tls/Ca H G7�ii�ll /r f � , � cf, • ! • ( 7 310 c on creed not be completed it the permit is valued at one hundred dollars ($ f 00) or less.) ❑ 1 comity that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Coda, I shall forthwith comply with these provision plitaznl a Da_ta��Cli/ 13' FAILURE TO SECURE W RS' COM TION 00VERAGE IS UNLAWFUL AND SHALT- SUBJECT AN EMPLOY-�+SO0 PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO`rHE COSY OF COMPENSATION, DAMAGES AS PROVIDED FOR iN SECTION 3706 OF THE LABOR CODE. INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereb atfl at I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Oivisio the iness nd Profasslons Code, and my license Is in full fo an c. Class r� OntrectRL3 a: Da e; CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there Is a construction lending agency for the performance of the work for which this permit Is Issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit to fife a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500),): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7D44, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not Intended or offered for sale. If, however, the building or Improvement is sold within one year of completion, the Dwner-builder will have the burden of proving that he or she did not build or improve for purpose Of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractors) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Data: Owner ID verified by driver's license. ❑ Yes ❑ No Drtvaes License No. Ex:piros: Verification of Ownership by (type of document, Le, - property tax trill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet In depth Into which a person Is required to descend, will be made In connection with work authorized by this permit, and that no building structure, scaffolding, falsawork, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, 7109 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division, Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Coda requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _—.__._....._....- -- ----. ._..............................._....._................_...........,..,.......................I.........................- 4—.............. ............. the 2 Does or will applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of comprossod gas at standard temperature and pressure). .. _ _ __ ....... _ ............................. 3 Does or will theapplicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? [3 Yes C3No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire bepariment of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP Is presently required, has Section 25534 of the California Health and Safety Cade been fully complied with? ❑Yes ❑ Np ............._.—.....---._...._ _...... W .._ ........ r _ ................................................................................................................. _ �_....... 5 boos or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ermil for such construction or modification__ from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes jf No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 8 Will any part at the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yas ❑ No (If tyes', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code), 7 If a permit from the South Coast Alt Ouality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Godo Section 42303 boon made? b! Yes ❑ No _...................... ----._......... --- -- 6 (IfW, attach certificate of compliance from the appropriate air pollution control Officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the Information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the Information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for Inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection, nature a1 s) ate g:�g 7/D� CODE I INSPECTION TYPE QAIE Ifs CODE INSPECTION-TYPE PAU KM 1616 Ffxed System Final Fire Prevention 206 Final Mechanical ll C 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final BlockiRetalning Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final BulldinglOccupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-masaft-ftTRICAL PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Status: ISSUED Suite No NORD Applied: 11/09/2005 Vicinity: NORDSTROM Issued: 11/21/2005 Parcel Nunmber: 41249109 Applicant: HAVENS, PAT Address: 9814 NORWALK BL STE 100 Phone: (562) 903-2277 ISSUED BY; SANTA FE SPRINGS, CA Zip.,,, —90670-2936..., 7 ; C r� -. d , Owner: SEARS, ROEBUCK & CO %N4RDSTROM INC ' .• `� ;,� Address ATTN TAX DEPT u' a x SEATTLE WA � � Phone � '�• � P O BOX 2229 Zip x� Contractor: MATT CONSTRUC�TT16N : Address' 9814 NORWALK _ 'STE 100 Phone: (562) 903-2277 6SANTA FE SPRINGS, CA Zip:f9D670-2936 .' = License:631020 v ..fit' c' A ; �` '' ..zr It 3 4 �,, .a.a' •� Y ..',�'f.SCOPE OF�PERMIT r 2F, r 3 SECURITY PUBLIC VIEW MONITORS AND LOW VOLTAGE EQUIPMENT AT TFiE BEAR ST, BRISTOL,,'t ST fAND MALL ENTRANCES ON THE FIRST FLOOR. FEE SUMMARY � N Quantity sQuantity ISSUE FEE $23 50 x Temp Dist System 1 Lighting�$0 00 tp- Temp service test $0 6o -;-' Busway 1100 ft fi $0 00 4 Res, a/c package $0 OOt Standing Section`, gN { '$0 00 0 a New Res (1 -2 -'units) $0:00 0 Misc Electrical E ui meni $0 d 0 K 0iez New Res (3+units) a $0.04 >'{) ,4 'Transformers,upgto 1 kva/kw $t) 00, o'. Pool I Spa, 6 $0.00?" 0 ....up to 10 kvafkw; $d.00 ,;; 0 Lighting'Fixts >„ r $0 00 0 :up to 50 kvalkw $0.00 0 <" >: Recept Outlets <. ,`=$0.00 "- 0 :up to' 100 kva/kw - "y$0.04 Switches _ $0 04 %' 0 ,., over,100 kvalkw $0 tl4 0 + P Non Res App! a. $0,001 0 Low Voltage Equipment 354.60 3 ` Res Appl -$0.00 A 4 Low Volt Wiring System / Ckt ) $0 00� 0 Service to 2DOa $0 OD 0 A+lisc. Conduit $0 00 ;' 0 , Service to 1000a $0 00 0 Mise Conductor :$0.00 0 Service over 1000a $0 00 0 d Circus ( gen or ride) -$0.00 0,, Motors to 1hp $O.Oq- 0 <' Circus (rnech rrcle or. hgFits),: $0.00 0 Motors to 10hp -$0.00 0 a r `'Christmas Tree"Stand �,, ;$0 00„ . 0 Motors to 50hp $0.00 °0 ., x Eirewoiks.Stand " $0 0o� 0 " Motors to 1 00h $0.00 ., �0V Other EIe tricai Fee $49 50' 1 '� Motors over 100hp $0`00. Communication drops Sub $0.00,0 ;io,oO lnvesUgation l ee $0.00 `$4:00 panel to 200a Plan Check Fee Pale Light Pkg $0 00 d� Reinspection Fee $0.00'."", Sign Circuits $0+00da` Temp Pwr Pole $0.00• , 4 „; " TOTAL CALCULATED FEES.: §127.60 Intermed Pole $0.00 �° 0 k € 4 9 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void it work is not commenced within 180 days, or if work Is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 244$-46 (6/00) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a Certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. R-My work rs' compensation Insurance carrier and policy number ere: CA—," dei _ rA-CurA"'P, olicyf+tum�er:ls section need not be completed If the permit is valued at one hundred dollars ($ f00) or less.) �c^tr"' ❑ 1 Certify that in the performance of the work for which this permit is issued, I shall not employ any person In any manner so as to become subject to the workers' compensation laws of Calliornia, and agree that If I s ould become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisl _ A�nLSignature: WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENKILTIES AND GVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm than m.11ce sed nder provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Busi ss a"nd/Prof scions Code, and my license is in full force and effect. LIc..N! A.0 C ass N Hsro Cbn�tra�0?s.Sigmature: /t/f� _ rData:-'_ CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, CIA Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions o1 the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more then five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not intended or offered for sale. If, however, the building or Improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ € am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Drivers License No. Expires: Vorllication of Ownership by (type o1 document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .............................................................................................................................................:...............................................................................................................................................................................I—-............ 2 Does or will the applicant or present or future building occupant need to filo a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .... ......................................................... ................... ................................... ..................................................................................................................................................................................................................................................... 3 Does or will the aPPpl€cant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes El No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. _.........................................................._.._..._...............................................................•................................................................................................................................ ............................................................................................ 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No ..................__._._......................._.._............................ .................__......-•............... ........................ __...................._.....................---..................................................................._........................ ....._................................... ... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plicat€on a ffrmit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? IJ Yes No (Section 65850.2 of the California Government Code requires that the requested Information be furnished on applications for non-residential building permits). ........................................................._....._............................................__...................................................................................................................................- ...................................-................................................................... 6 Will amy part of the facility to bo constructed under th€s permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (it 'yes*. the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). _.._............................................... ..............- 1 .......... ......................................... __................... ---............... _.._.................... _............................. --............. ......... _........ ............... _.. 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? [I Yes C] No ..............__.........................._ ----................ _-..`................. .._.................... ................................. ._........... ...................................................._ ................._..................._......................_ 6 (11 jres', attac_h certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the Information given Is correct. I agree to comply with all state laws and city ordinances relating to building construction,, and authorize representatives of the City of Caste Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. AVenap, Of Legal Owner(s) AndlOr Authorized-Appttcant;_?_, Date CODE II.r�pE 1Qi IKRCODE f INSPECTION TYPE 263 fNTMA 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block[Retaining Wall 212 Final Fire Prevention P 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy W (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa@L- ftTRICAL PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Suite No NORD Vicinity: NORDSTROM 1ST FLOOR Parcel Nunmber: 41249109 Applicant: HAVENS, PAT Address: 9814 NORWALK BL STE 100 Phone: (562) 903-2277 SANTA FE SPRINGS, CA Zip 90670-2936 _ Owner: SEARS,'ROEBUCK &;CO`%NORDSTROM INC'',", Address ATTN TAX DEPT h: - A SEAT Tt_E WA"Phone:_..,::: P O,BOX 2229 , ,;x Zip. Contractor:„, MATT>;CONSTRUCTION Address:” 9814 NORWALK Bl 5TE 100 Phone: (562) 903-2277 SANTA FE SPRINGS, CA Zip: <.90670-2936 ' License: 631020 SCOPE..OF PERMIT`:14:%,, ELECTRICAL PERMIT10RTHE'SEISMIC SUPPORTS FOR THE IST FLOOR ISSUED BY: Status: ISSUED Applied: 11/21/2005 Issued: 11/21/2005 AND LOW VOLTAGE NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 764-6626 /r kx- MYTArIAI,a, 01 T F FEE SUMMARY a REFERENCE 39090SF 1 ST FLOOR RENOVATIONS FOR NORDSTROMS =• Quantrty „r.:,::.: ., `<REF:,B04=01831 r ISSUE FEE "12150 r :. en , -mow Temp se`niice lest m06 F NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 764-6626 /r kx- MYTArIAI,a, 01 T F FEE SUMMARY =• Quantrty „r.:,::.: ., Quantity ;• r ISSUE FEE "12150 Temp Dist System/ t ghtmg $0 Go:.:.. 0 Temp se`niice lest m06 t Busway 1100 ft $0 04 0 Res, a/c package 'F $0,00 Standing Section $0 40 New Res (.1 2 units) t $0 04 0 k Mrsc Electrical'Equipment ;: $0 00 0` New Res (3+units) $0106 0 Transformers up to 1 kvalkw $0 OD' 0 Pool/ spa wwk• $0.00:. 0 ...............up to`10 kvalkw...._$0.00 0 t {4 Lighting Fixts w$0.00 0 *:...up to 50 kvalkw$0 00 0 ' Recept Outlets $0.00,' '" 0 " .....up to•104 kva/kw $0 00 0 Switches > � $0 00 0 ..................over 100 kvalkw $0"'00 0 Non Res Appl £ ;`'-$0.00.' 0 ; Low Voltage Equipment $0 00 0 Res Appl $D DO 0 Low Volt Wiring System I Ckt $0.00 0 Service to 200a' Service 1000a $D'.00� 0 " t Mrsc Coridwt ° ` sb-00 '0", to $0.00 • 0 4 Misc tConductor ; � $0.00 0 Service over 1000a,4 -$D.00` s 0 Circus•(gen ar ride} "{ - `*$0.00 0' Motors to 1 hp$0.00 0 Cercus (mech vide or lights} $0 00 0 Motors to 10hp$o.Do Motors to 50hp .° k $0 00`°^, 0 °� CFiristri�as Tree stand $. O OD, 0 's Motors to 100hp$0.00 Fireworks Stand 0 =w :,1 OtherElectncal $4 00 0 Motors over 1 00h $0 00.- 0 Fee •-.= , $0 00� ". Communication drops ; $0 00 0investigation Fee .`> $0.00 Sub panel to 200a $D 000 - C,�`= P.Ian Cheok Fee _ $0.00 Pole Light Pkg $0 00 P Reins ection Fee ice` " :moo Sign Circuits $0.00 Temp Pwr Pole $0.00 0 TOTAL CALCULATEt] FEES $23.50 Intermed Pole $0.00 0 COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 764-6626 /r kx- MYTArIAI,a, 01 DECLARATIONS WORKERS' COMPENSATION DECLARATION: , hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. %Rk I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' cam_p%nsatiioon Insurance carrier and policy number are: Grrt i � N TA5 /iirCG tPoT�Ph�mber: C. r a20 {Thls section need not be completed 1f the permit is valued at one hundred dollars ($100) or less.) ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that If 1 should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith na, cornsi with these prisip ��ppll, c�•nf!. _ignature: r�a, WARNING: � a�a�te_: WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: hereby affirm that I am license under pro .sions of Chapter 9 (commencing with Section 7000) of Division 3 of the Busine and Professions Code, and my license is in full s force and effect. ul r 0 Cla��i _ �' �/r GvntacloYsy Signature'` Tf�ter� _ CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction tending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code), Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Coda) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sola compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Coda for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 6, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every bus -mess which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ......... ..... ..................................•--•-------------................................................................................................................................................................................................................................................................ 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous metarials7 © Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ................................................................................................................................................................................................................................................................................................................................................................... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ...............................................o---n..................-ft.....................-n--i-...............................................................n-1--1.1...........................i-t-h............. ............................................................................................. 4 If an RMPP is presently required, has Section 25534 of the Galifornie Health and Safety Code been Cully complied with? ❑Yes ❑ No ...................illt............--------....................................................-ull........................ n't,..r'e- u-ir.............'h-8, .............w- h,........isth's".......,J'e-.......................................................................su"'....................................................c"'atl'o".... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes No (Section 65850.2 of the California Government Code requires that the requested information be fumished on applications for non-residential building permits). ..........................................................---•--..............................................................................------.................................................................................................................................................................................................................. fi Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). .............................•----..................................................................................................................---------............................................................................................................................................................................................................ 7 !f a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ............................................................................................................................................................................................................................................................................................................................................................... 8 (If fires", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penally of perjury the Information given above Is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signore f al Owner{s) ate _r7' - Bj An�dfOrpAu� �;Applicent;� Qate ", CODE It.N�$p TYPE DATE INTMAL CODE INSPECTIONTYPE DATE jy$JALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical_ 201 Final Block/Retaining Wall 212 Final Fire Prevention Pia 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Oocupancy M (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa ELECTRICAL PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Suite No NORD Vicinity: ENTRY WAYS Status: iSSUED Applied: 10118/2005 Issued: 1 011 812 00 5 Parcel Nunmber: 41249109 Appiicant: WENDY HIGA Address: 5400 W. ROSECRANS AV ISSUED BY: Phone: 310=725-2936 "'SCOPE%OF PERMIT DEDICATED. CIRCUIT FOR MERCHANDISE CONTROL SYSTEM FOR "NORDSTROM" ALL ENTRYWAYS , 4<. LOCATED ON 1ST, 2ND AND 3RD FLOORS.:; w New Res"(3+units) ', - $0.00 :, ;`- 0 ;FEE SUMMARY up to 1 kvalkw.,, t 0'`? Pool Spa Quantity; n}, Quantity,. ;:;.. up: to 10.kvalkw ISSUE FEE $23.50 Lighting Fixts Temp Dist System l Lighting �1$0.00 0 €,Temp service test.„ $0 00' 01- ' `Busway /100 ft $0.00 " F 0 Res. a/c package E ` $0 00 :':'".; $0.00', Standing Section $Q:QO 0 <, New Res (1 2 units):, $0 00'' 0 _ ,.Misc Electrical Equipment $0.00,• 0", New Res"(3+units) ', - $0.00 :, ;`- 0 ,. 'Transformers up to 1 kvalkw.,, $0.00 0'`? Pool Spa $0.00> 0 ti ': ;:;.. up: to 10.kvalkw $0.00 0 - " k Lighting Fixts $0.00. 0 0 ;;. _ ...:.'.:......up to 56 kvalkr'G . $0.00 01- Recept Outlets $8.80:F . 8 ....1.111. ...up to 100 kvalkw $0.00', Q Switches $0.00 0 $0.00. .......... .......over 100 kvalkw $0.00 0:;= Non"Res Appl :a $0.00 0 Low Voltage Equipment $145,60' 8 , Res App]: $0.00 ::z=. 0 Low Volt Wiring System / Ckt $OAO" s0.. Service to 2004 $0:00``" 0 Misc. Conduit $145.60 �B` Service to;1000a $0.00 , # 0 „ , . " Misc. Conductor $0:00 0 Service over1000a $0.00 "` 4 Circus ( gen or ride) $0.00 ,. 0 Motors to 1 hp $O:OQ 0Circus (meth ride or lights) $0:00 0 Motors to 10hp $0.00 0 , Christmas Tree Stand - ;= N '. ,$0.40 0 € ` Motors to 50hp' $0.00. • ., A R 0 Fireworks_Stand $0.00— 0 Motors to 100hp ;;.. $0.00 _ "0 Other Electrical Fee ; ,. �' $0.00 Motors over 100hp;' $0:00 0 Communication drops{ $0.00. `ko Investigation Fee, v, $0.00 Sub panel to 200a 1000 0 ;;. _ Plan Check'Fee' 5 $0.00 Pale Light Pkg $0.00 =. 0 Reinspectiori'Fee Sign Circuits °:. $0.00' �y, 3 0 1:111 Temp Pwr Pole $0.00. 0 TOTAL dALCULATED FEES $323.50` Intermed Pale $0.000 All -COMMENTS ! SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 244646 (SM) C r DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ' ❑ I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the _ work for which this permit is issued. 'have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. / My wo rs' compensation tnsura ce carrier and p licy number are: A /—',:5 7 41'9 %D6 ecfron need not becompleted if the permr rs valued at one hundred dollars ($100) or.less.) %T ❑ 1 certify that in the performance of the work for which this permit Is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those Rrovisio s. �t Applicant Signature: Date:_ / C�t1 WARNING: FAILURE TO SECURE WO KERS' COMPEl ATION COVERAGE IS UNLAWFUL AND SHALL SUa.IECT ANVEWTO CAIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN AIDDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE UWR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under pr visions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license Is in full force and effect. Lic. orttractor s IIate: R /L07iA6 —u-5 CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code), Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031 .5. Business and Professions Coda: Any City or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Cade: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ' ❑ I, as owner o1 the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of properly who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Saotlon 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .............................................................................................................................................................................................................."I'........ --. -----..---.......................................................................................................... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater then a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ................................................................................................................................................................................................................................ ....----........-•-•--------........................................... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ...... ........................................................................ ...................................................................................................................................................................................... ----...........................--------------....................................................... 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No ..........................................................................................................._.........................................................-..----...-•----------....................................-................................................................................................................................... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plicetion adirmit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes {� No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). :.............................................................................................................................. -........................................................................................................ ............ ....................................................................................... 6 Will any part of tha facility to be constructed under this permit be within 1000 feat from tha outer boundaries of a school? ❑ Yes ❑ No (It 'fres", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ............ ........................................................_.....................................................----.........................................................................",.............................................................................-...........------........................................ 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by Califomla Health and Safety Code Section 42303 been made? []Yes ❑ No ................................................................................................................................................................. 6 (I1 fres", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. 1211 g atu Of Legal Owner(s) Date CODE R, SPE pbi€ 1KTITI9 CODE t INSPE.00N TYPE _ DAM ;ffj 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention • 202 Final Factory Fire Place 220 ' Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy M 1 (714) 754-5273 • Fax (714) 754-4856 • www.ci-costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT Job Address: 3333 BRISTOL ST Suite No NORD Vicinity: 1ST FLOOR ST NORDSTROM Parcel Nunmber: 41249109 Applicant: STEPHENS, KELLY Address: 3 VANDERBILT Phone: 949-855-9610 IRVINE, CA Zip 92618 Owner: SEARS, ROEBUCK & CO %NORDSTROM INC Address ATTN TAX DEPT SEATTLE, WA Phone: P O BOX 2229 Zip: Contractor: CAUSEY ELECTRIC, INC. Address: 3 VANDERBILT Phone: 949-855-9610 IRVINE, CA Zip: 92618 License: 331064 SCOPE OF PERMIT INTERIOR 39090SF 1ST FLOOR RENOVATIONS FOR NORDSTROMS. 157 LIGHT FIXTURES, 75 OUTLETS, 10 SWITCHES, 1 SUB PANEL TO 200A REF: B04-01831 ISSUED BY: Status: ISSUED Applied: 02102!2005 Issued: 02/02/2005 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. N4. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: in order for the work authorized under this permit to be considered legal, such work must comply with all applicabla codes, and ail required inspectiore and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 . 11-1 2446 48 (6=) FEE SUMMARY Quantity _ Quantity ISSUE FEE $23.50 Temp DistSystem / Lighting $0.00 0 Temp service test $0.00 Busway 1100 ft. $0.00 0 Res. a/c package $0.00 Standing Section $0.00 0 New Res (1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0 New Res (3+units) $0.00 0 Transformers up to 1 kvalkw $0.00 0 Pool / Spa $0.00 0 r ................up to 10 kvalkw $0.00 0 Lighting Fixts $122.01 157 up, to 50 kvalkw $0.00 0 Recept Outlets $62.15 75 ................up to 100 kvalkw $0.00 0 Switches $11.00 10 ..................over 100 kvalkw $0.00 0 Non Res Appl $D.00 - 0 Low Voltage Equipment $0.00 0 Res Appl $0.00 0 Low Volt Wiring System 1 Ckt $0.00 '0 Service to 200a $0.00 0 Misc. Conduit $0.00 '0 Service to 1000a $0.00 0 Misc. Conductor $0.00 0 Service over 1000a $0.00 0 Circus ( gen or ride) $0.00 , 0 Motors to 1hp $0.00 0 Circus (mech ride or lights) $0.00 -"01 Motors to 10hp $0.00 0 Christmas Tree Stand ," $0.00 • 0 Motors to 50hp $0.00, 0 Fireworks Stand $0.00 " 0 Motors to 100hp $0.00 " 0 Other Electricai-Fee- $0.00 Motors over 1 00h $0.00 0 Communication drops $0.00 "--0 Investigation Fee $0.00 Sub panel to 200a $30.50 1 Plan Check Fee_ • $0.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. N4. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: in order for the work authorized under this permit to be considered legal, such work must comply with all applicabla codes, and ail required inspectiore and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 . 11-1 2446 48 (6=) WORKERS' COMPENSATION DECLARATION: f hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of Consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. qffI have and wilt maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My work rs' ompensativn Insurance carrier a�n 'p�olicy number are: q Carr' [O ,f? IA,,,r ., 4 ) Policyo=ber: � { � 240 `� (�ctlon need net be comp red it the permit is valued at one hundred dollars ($100) or less.) — ❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Gelifomi ,and agree that 111 should become subject to the workers' compensation provisions of Section 3700 of the labor Code, 1 shall forthwith comply with Chase pr Applic�ature: Ceti Z'Z�� WARTING: FAILURE TO SECURE WORKE S' COMPENS ON COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARE (Si 00,000). IN ADDITION TOTHE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3%06 OF THE LABOR GORE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed underproy�'slons of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. W ld (J `7 Clef Cm Contractor's Signature: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Dlvlslon a of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or Improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractors) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION, ❑ I hereby certify that no excavation five (5) or more feet In depth into which a person is required to descend, will be made In connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec, 341, T111e 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressurej. _............... __...................._....._._.._........_......—_._......_...._-....._.—_........ _w..........._.._.... .... _........... __ ... �........--.................-....._..... ................ .........�.................. ....---- 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 Cubic feet of compressed gas at standard temperature and pressure). ................................................................................................................................................................................................................................................................................................................................................................................ 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes [:1 No Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ........................................................................................................................................................................................................................_............................................................................---.......................................................... 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑Yes ❑.No 5 Does or wii) the applicant or present afuture lwlld1hg occupant require fa the work which is Cha subject of this a plication aPffrmit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? I] Yes J� No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). _.................................. ----_—...................... —................ ....................... _.................... .................... _............................ ._........_.........................__........................... —.................. _................ -- 6 Will any part of the facility to he constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (11'yes the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ................................................................................................................................................................................................................-----------•-.......................................................................................,.......................................................... 7 a a permit from the South Coast Air Duality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ Na .............................................................................. ......1------............................................................................................................ ....................................................... ........................--•---•-----------.............................................................................. i3 (If yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certity under penalty of perury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Sigry�ture Of Legal Owners) Z - Daae 4R�li/rfA-� Z—`'f' lKnd1Or t00321FRdApplicanta § COPE• t. INSPECTION TYPE fAfit TMA COPE INSPfCfONTYPE R&M INTITIA 1616 Fixed System Final Fire Prevention 206 Final Mechanical 12$6 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 2022 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.cl.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 MECHANICAL PERMIT .lob Address: 3333 BRISTOL ST Suite No NORD Vicinity: ROOF TOP AT NORDSTROM Parcel Number: 41249108 Applicant: MACHUCA, PORFIRIO.' _.., Address: 1361 HIGHRIDGE ST'-/-' - i Phone: 206-793-0690 1 ; RIVERSIDE -,'CA Zip: 92506 1Is Status: ISSUED Applied: 09/21/2001 Issued: 10/01/2001 ISSUED BY: SCOPE OF PERMIT ROOF TOP CHANGE -OUT OF ONE UNIT; WORK TO INCLUDE REWORK, ADDED DUCT WORK & FIRE DAMPERS. 3 FIRE DAMPERS;1 AIR HANDLER <,10000 CFM. NO OTHER WORK WITH THIS PERMIT. r � " 6M Owner: SOUTH COAST PLAZA %NORDSTROM INC ,- Address: PO SOX 2229 , Phone: S EATTLE. WA Zip: 98111-2229 Contractor: PSF MECHANICAL ISSUE FEE Address: 9322 14TH AVE SOUTH , Repair/ Alt Absorbtion Unit Phone: 206-764-9663 - SEATTLE, WA Zip: 98108 $0.00 License: 628376 1Is Status: ISSUED Applied: 09/21/2001 Issued: 10/01/2001 ISSUED BY: SCOPE OF PERMIT ROOF TOP CHANGE -OUT OF ONE UNIT; WORK TO INCLUDE REWORK, ADDED DUCT WORK & FIRE DAMPERS. 3 FIRE DAMPERS;1 AIR HANDLER <,10000 CFM. NO OTHER WORK WITH THIS PERMIT. r � " 6M r FEE SUMMARY Quantity' - Quantity ISSUE FEE $23.50 Repair/ Alt Absorbtion Unit $0.00 0, Inst FAU <100 k BTU $0.00 0 Repair / Alt Refrigeration Unit $0.00 0 Inst FAU >100 k BTU $0.00 0 Ventillation System $0.00 0 Repair/Alt Cooling/Heat $13.70 1 Evaporative Cooler $0.00 0 Inst 1 Rep. Recess Wall Htr $0.00 0 Commercial Incinerator $0.00 0 Ref rig Sys <100 k BTU $0.00 0 Domestic Incinerator _$0.00 0 Refrig Sys >100 k BTU $0.00 0 'Compressors 1 Absorption Systems Gas Piping $0.00 0 Up to 3 hp 1 100k BTU $0.00 0 Factory Fireplace $0.00 0 3 To 15 hp 1500 k BTU $0.00 0 Hood w/Mech Exhaust MOO., 0 t 15 To 30 hp 11,000 k BTU $0.00 0 VAV Box $0.00 0 30 To 50 hp 1 1,750 k BTU $0.00 0 Vent Fan 1 Single Duct $0.00 0 Over 50 hp / Over 1,750 BTU $0.00 0 Appliance $0.00, 0 Boilers Fire Dampers $21.75 3 Up to 3 hp $0.00 0 Smoke Dampers $0.00 0 3 To 15 hp $0.00 0 Inst or Relocate Appl Vent $0.00 01 15 to 30 hp $0.00 0 Air Handlers < 10000cfm $10.65 1 30 to 50 hp $0.00 0 Air Handlers > 10000cfm $0.00 0 Over 50 hp $0.00 0 Floor Furnace $0.00 0 Other Mechanical Fee Floor or Suspend Heater $0.00 0 Investigation Fee $0.00 Plan Check Fee $0.00 Reinspection Fee $0.00 TOTAL CALCULATED FEES $69.60 COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with ail applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become vold If work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446.0 (6=) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I ve"and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for• by section 3700 of the labor Code, for the performance of the ork for which this permit Is issued. I have and will maintain workers' compensation Insurance, as required by s ction 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' �gompensation Insur Ca�jj9r and po numbs are: V 9 Carrier: �1 f�irCl�! �i �:� �. fi �'�� Policy Number: vJ f1 (This section need not be Completed if the permit Is at one h dyed dollars ($? 00) or less.) ❑ I certify thin the pert once of the work f which this permit i ued, I shall not employ any person In any manner so as to become subject tot workers' compensaon laws Cal omi ,and agree at if I Quid bac me ubject to the workers compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply withee provi n y�� I Applicant Signal Date: U lo WARNING: FAILURE SECUR ORKERS' E SAT N COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100, , IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROWDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licpladder ovisions of Cher mmen ' g ith Section 7000) of Division 3 of the Business and Professions Code, and my license Is in full force and effect. Lic. q Class # t Contractor's Si Date: LJr CONSTRUCTION LENDI GENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lenders Name: '" Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: a„ II hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions :Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permar subjects the applicant to a civil penalty of not more then five,hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not intended or offered for sale. 11, however, the building or Improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license:pursuant to the Contractors License Laws.). am exempt udder sec. Business and Professions Code for this reason: Signature: s` Date: Ownor'ID verified by drl4ers'llcense. ❑ Yes ❑ No Drivers License No. Exp€res: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet 01 Compressed gas at standard temperature and pressure). ----................................................................................................................................................................................................................................................................................................. 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ............................................................................................................................---.-•----------...._.....................................................................--------...............---------............................................................ 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. •................................................................................................................. ...................... .......................................................................................................................................................................................................................... --.................. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No ................................................................................................................................................................................................................................................. 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modlf€cation from the South Coast Air Quality Management District or from any other air pollution control district or agency/ LJ Yes jf No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ............................................................................................................................................................................................................ - ....................................... -----.......... ................................................ fi Will any part of the facility to be constructed under this permit be within 1000 feet from the outar boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ........................................................................................................................................ ..................................... ........................................................................ __.............................................................................................................. ........... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ...... ...................... .......................... ............ .................................................................................................... ........................................ .......................... ........................................................................................ 8 (If "yes", attach certif€Cate of compliance from the appropriate air pollution control officer), CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all stale laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspa ion purposes. 1 agree not to occupy or allow occupancy of any building authorized by this permit unci€ final inspection. Date I f (ArldlO r A thorized Applicant Date CODE 0. &ASPE00PITYPE 2M INTMALS CODEf INSPECTIONTYPE �O ' 1616 Fixed System Final Fire Prevention 206 Final Mechanical i 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Root 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy .lob Address: 3333 BRISTOL ST Suite No NORD Vicinity: Parcel Nunmber: 41248108 Applicant: MCCAMY, DON Address: PLUMBING PERMIT Phone: Zip: Owner: SOUTH COAST PLAZA %NORDSTROM INC Address PO BOX 2229 Contractor: Address: Phone: SEATTLE WA Zip: 98111-2229 Phone: Zip: License: Status: FINALED Applied: 02/17/1998 Issued: 02/17/1998 ISSUED BY: l -1) NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12.21.92) EXPIRATION: This permit shall automatically expire and become void if worts is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 !446.48 (6100) SCOPE OF PERMIT TI FOR WASHING MACHINE OUTLET FOR NORDSTROMS. FEE SUMMARY AMT QTY AMT QTY AMT QTY ISSUE FEE $22.00 Laundry Tub /Washer $8.75 1 Sump Pump $0.00 0 BauxfivAr irrigation, $0.00 —0--..- Landscape Irrigation $0.00 0 Swimming Pool $0.00 0 Backflow Preventer $0.00 0 P -Trap $0.00 0 Trap Primer $0.00 0 Bathtub $0.00 0 Pressure Regulator $0.00 0 Urinal WOO 0 Clarifier System $0.00 0 Process Piping (per 10 ft) $0.00 0 Vacuum Brkr Bkflow(1-4) $0.00 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12.21.92) EXPIRATION: This permit shall automatically expire and become void if worts is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 !446.48 (6100) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the fallowing declarations: ❑ 1 have and will maintain a certificate of consent to sell -Insure for workers' compensation, as provided for by section 3700 of the tabor Code, for the performance of the work for which this permit Is Issued, ❑ 1 have and will maintain workers' compensatlon insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy number are: Carrier: _ Policy Number: {this section need not be completed it the permit Is valued at one hundred dollars ($100) or less.) ❑ 1 certify that in the performance of the Work for which this permit is Issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agfee that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith Comply with these provisions. Applicant Signature: Date: WARNING: FAILURE TO SECURE WORKERS' CWPENSATiON COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic. # Class # Contractor's Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under pe u that 1 am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county whi it 1M.Ponstruct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that or u AR the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions C or that a is eta lh retrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a clv}Ipanalry of ra t H five h rad dollars ($500).): ❑ I, as owner of the property, or my e 1 ge0 their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The ntr .- cense Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or improvement Is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ' ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who Contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: „ - _-, Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person Is required to descend, wail be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 6, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ............... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at an one time has on hand a quantity of acutely hazardous materials equal to or greater than a walght-.of 500 pounds, or a volume of 55 gallons. nr 200 m.Wo teat Orr compressed gas at standard temperature and pressure). ....................................... ...­--........................................_.............................._..................._......................................._.........,..............^........----.........................................._.............._.._. 3 Does or will the appplicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes C1 ;T1 (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, cerlification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. _..............................................................._...._.........................................................................�.............................................. ......................_......................_._....................._._....._........................ _ ............................. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No _........... ........ ...... _... _.._............. __...._.1111 ....... ................ =.. .—..._..........................................._....... ..................... ........................................_............... ................... _........................................ _..._............. ......................... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plicatlon armit for such construction or modification from the South Coast Ali quality Management District or from any other air pollution Control district or agency? L) Qe Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ................................................................................................................................................. .................. 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yas ❑ No (if 'yes , the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ........._ _................ ........:..............................._.._.................... _.—_......... _._...................... __.._............... ......................._................................. .......... ..... _............ __.... —...... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ................................................................................................................................................................................................................................................................................................. .. ...............................•--.......................................... 8 (If yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the Information given above is correct. i agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature Of Legal Owner(s) Date And/Or Authorized Applicant Date COPE #. INSPECTIONTYPE 2M lid CODE 1 INSPECTION TYPE DAM lid$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing -C— R;,J 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy ' CITY OF COSTA MESA Vol BUILDING DIVISION } 77 FAIR DRIVE, COSTA MESA, CA 92626 - (714) 754-5273 - Fax (714) 754-4856 www.ci.costa-mesa.ca.us FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BX11-00041 PERMIT TYPE B_MISC STATUS: ISSUED APN: 41250107 DATE ISSUED: 04/29/2011 Zoning: PDC, ISSUED BY: RMD JOB ADDRESS: 3333 1224'BRISTO iV CM Suite/Unit: 1224 Vicinity: SPACE 12' Primary Occ: Const Type :?? SQ. FT: 0 Valuation: $7,500.00 . SCOPE OF WORK: REMOVAL OF EXISTING SALES FIXTURES AND FINISHES AND REPLACEMENT FOR "GUESS", SPACE 1224. ADD 8 OUTLETS. OWNER: SOUTH COAST PLAZA City/State: COSTA MESA, CA Phone: APPLICANT: PADGETT, JEFF City/State: Phone: 951-795-5149 CONTRACTOR: SOLEX CONTRACTING Address: 27450 YNEZ ROAD City/State: TEMECULA, CA Zip Code: 92591 FAX ARCHITECT: GOGLIA, FREDERICK Phone 314-428-3500 ENGINEER: Phone FEE SUMMARY Building Plan Check: Building Permit: Electrical Permit: SMIP Residential SMIP Commercial Bldg Std Admin Fund Address:: 3315 FAIRVIEW RD Zip Code: 92626 Address: Zip Code: License No. 842101 Phone 951-308-1706 License No. C20788 License No. $99.61 $153.25 $32.30 $0.00 $1.57 $1.00 Unit Unit: Unit: STE 222 Cell: 951-308-1556 TOTAL FEES $287.73 HOURS FOR CONSTRUCTION ACTIVITY: EFFECTIVE 3/1812010 - PER CMMC Sec. 13-279 Monday thru Friday - 7:00 am thru 7:00 pm, Saturdays -9:00 am thru 6:00 pm. Prohibited all hours - Sundays and the following Federal Holidays: New Years Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day and Christmas Day NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE Z INSPECTION TYPE DATE INTMAL CODE i INSPECTION TYPE DATE INTMAL 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electricak X b_� ►I �►i� - 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy T< WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by section 3700 of the Labor'Code, for the performance of the work for which this permit is issued. [7 I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work'for which this Permit, is issued. My workers' compensation Insurance carrier and policy number are:Jj 1A d p (This section need not be compleled A the perml is valuedat one hundred dollars ($100) or less.) y,Number: 7 �,W QT2 �C? `o[TC [] I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should becorne subject to the workers' compensation provisions of Section 3700 of the labor Code, I shall foi th these provisions. dai'i ignature-gyp le WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100.000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and mylicense is in full force and effect. d Cass# ora Signature" Da CONS CTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the Performance of the work for which this permit is issued. (Sec. 3097, Civil Code). I Lender's Name: I ' Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: Uhereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and ]the basis for the alleged exemption. Any violation of Section 7031.5 by any iapplicant for a permit subjects the applicant to a civil penalty of not more than (five hundred dollars ($500),): ❑ I, as owner of the property, or my employees with wages as their sole Compensation, WILL DO THE WORK, and the structure is not intended or i offered for sale (Sec. 7044, Business and Professions Code: The Contractors I License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for Sale. If, however, the building or improvement is sold within one year of Completion, the owner -builder will have the burden of proving that he or she Mid not build or improve for purpose of sale.). [] I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). d lam exempt under sec. l3usiness and Professions Code for this reason: Signature r 3057-46 (X07) Date Owner ID verified by drives... license. D Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will! not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Date Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be fumished on applications for non-residential building permits). 6. will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (if -yes-, attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct.' 1 agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. nature F Legal Owmegsl date �,ltmrtzedAppl�caM.r—..--- --_ . �wOate� (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 BUILDING PERMIT Job Address: 3333 BRISTOL ST Status: ISSUED Suite: Applied: 12/1912001 Vicinity: WEST MALL ENTRANCE Issued: 01/31/2002 Parcel Number: 41250107 Zoning: PDC PDC Applicant: BIRCHER, DAVID PLANNING & ZONING ISSUED BY: „%,�,.,e Address: '' ' - - SETBACKS Phone: 818-247-9020 Right `� 0-0 Zip' -� SOUTH COAST, PLAZAS PARKING Existing: 0 Re uired: 0 Proposed: 0 '- owner: Address %C: SSERGERSTOM NOTES: COLLI -KJ 01/30/2002 WAITING FOR SCP SAFETY PLAN. BOB /COSTA'MESA, FERNANDEZ IS SUPPOSED TO BRING IN ON 1128102. AFTER PLAN IS CA Phone: NOTICE WHEN PERMITS IS ISSUED. CHANGED FROM "NOTICE" TO FAIRVIEIN Zip: 92626 BURT'S DIRECTION IS TO ALLOW THE ISSUANCE OF THIS PERMIT PER HIS CONVERSATION WITH BOB FERNANDEZ, Contractor: RON'POULSON ASSOCIATES INC COLLI -KJ 01/30/2002 SAFETY PLAN RECEIVED FROM SCP. Address: 28219 AGOURA RD ATTACHED A COPY TO EACH SET FOR PERMIT PURPOSES. / Phone:! -(818) 879-4818 AGOURA'HILLS, CA Zip: _ , r 91,30,11,_ 'License:!" 677351 / _ - be � • , Arch . F AND A ARCHITECTS / Eng: Address: 116 E. BROA❑WAY f Address' Phone: 818-247-9020 Phone: GLENDALE,,CA Zip: 91205 \ ,"License: C6910 License: SCOPE OF PERMIT , DEMOLITION PERMIT FOR THE, WEST MALL ENTRANCE FOR "SOUTH COAST PLAZA." WORK TO INCLUDE REMOVAL OF, EXISTING SIDEWALK CONCRETE, 2 PALM TREES,,TENANT GLASS STOREFRONT & TENANT INTERIOR. REF: B01-01973 _ _FEE SUMMARY/ Plan Check: $418.76 ' ; ' Calc Valuation: Permit: $644.25 ;' Claim Valuation: •, " -SMIP Res: $0.00 SMIP Com: $10.50 Other: Inspection -.600 $50,000.00 $50,000.00 `,Total: $1,073.51'-,\,, PLANNING & ZONING SETBACKS MAIN STRUCTURE -Front-�0- 0 '. Rear__ 0-0 Left 0- 0 ��� Right `� 0-0 ACCESSORY Front �0 0�� - Rear 0-0 Left 0-0 Right,0 0� PARKING Existing: 0 Re uired: 0 Proposed: 0 '- NOTES: COLLI -KJ 01/30/2002 WAITING FOR SCP SAFETY PLAN. BOB FERNANDEZ IS SUPPOSED TO BRING IN ON 1128102. AFTER PLAN IS RECEIVED, OK TO ISSUE DEMO PERMIT. PLEASE DELETE THIS NOTICE WHEN PERMITS IS ISSUED. CHANGED FROM "NOTICE" TO "COMMENT AFTER BURT'S DIRECTION. BURT'S DIRECTION IS TO ALLOW THE ISSUANCE OF THIS PERMIT PER HIS CONVERSATION WITH BOB FERNANDEZ, COLLI -KJ 01/30/2002 SAFETY PLAN RECEIVED FROM SCP. ATTACHED A COPY TO EACH SET FOR PERMIT PURPOSES. NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work Is not commenced within 180 days, or If work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result In the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446.46 {8100) DECLARATIONS WORKERS' COMPENSATION DECLARATION: hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. -[j\ I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance o1 the work for which this permit is issued. y workers' compensation Insurance carrier and policy number are: Carrier: b'C Policy Number: (This section need not be completed it the permit Is one hundred dollars ( or less.) ❑ I cortify that in the performance of th t h this ermil is issue , s 1 not employ any person in any manner so as to become subject to the workers' compass rrii�rs o! Celitomia, III e me s Je o the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith th these provisi s. I gnature: W G: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE L AND SHALL ECT AN EM O CRIMINAL PENALTIES AND CAVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE (St00,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PRO E FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENS TORS DECLARATION: by affir at I am licensed under provisions o t mme ting wi tion 7000) of Division Ines and Professions Code, and my license is in full I Oct. Lir.# Ca"1-7 "SS C act Signature: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Coda: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the properly, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec, 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or Improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. It, however, the building or Improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of Sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type o1 document, i.e. - property tax bill or dead): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Data: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity at hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure), 2 Doesor will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one lime has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _ ............ _....................... _.. ... ... _........ — ....................... .......................... ..........................................................................- _.... ...—.......................... 3 Does or will the appplicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required, has Section 25534 o1 the California Health and Safety Code been fully complied with? ❑Yes ❑ Na 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ermil for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yas No (Section 65850.2 of the California Government Code requires that the requested Information be furnished on applications for non-residential building permits). ..................................................................................._---............................_...__................._....................... _..................... -----•----.............. ............................ _--......_.........._................---.......—_.... 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? []Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). .................. ............................................................................................ -._................... _......................... .................................................................................................... _............................ ....................... ..._._.......... _ 7 If a ermit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (If yes", attach certificate of compliance from the appropriate air pollution control officer}. CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Data: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: 5ingto fy and salty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state law city ordinances relabu 1 construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for ins ti rpos . 1 agree not to occupoccupancy of any building authorized by this permit until final inspection. 5' to r(s / n/ An Or Aut z plicanl Date CODE I• INSPECTION TYPE DATE ItITTUALS CODE INSPECnoNT1'PE jNTITIA� 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Root 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval , 203 Final Sign 222 Final Sita 204 Final Demolition 250 Final Building/Occupancy l Y CITY OF COSTA MESA BUILDING DIVISION } DEVELOPMENT SERVICES DEPARTMENT, PERMIT BI PERMIT 0-00278 (714)754-5273 • Fax(714)754-4856 ELECTRICAL PERMIT .lob Address: 3333 BRISTOL ST Suite No Vicinity: ROOF TOP AIR HANDLER Parcel Nunmber. 41250106 Applicant: JACK KUBACKI Address: 3422 W. MAC ARTHUR ST. UNIT"B" Phone: 714-751-6133 SANTA ANA Zip: 92704 Owner: SOUTH COAST PLAZA Address Phone: Zip: Contractor: J A K ELECTRIC Address: 3422 W. MAC ARTHUR ST. UNIT "B" Phone: 714-751-6133 SANTA ANA Zip: 92704 License: 405289 UNIT, REF: B00-00072 77 FAIR DRIVE, COSTA MESA, CA 92626 ISSUED BY: t Status: ISSUED Applied: 03/29/2000 Issued: 03/29/2000 SCOPE OF PERMIT INSTALL 1 OUTLET, 2 15 HP MOTORS AND 1 VARIABLE SPEED DRIVE FOR NEW AIR HANDLER 1 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not -commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inapectlons and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 FEE SUMMARY ' Quantity Quantity ISSUE FEE S23.50 Temp Dist System / Lighting $0.00 0 Temp service test $0.00 Busway 1100 ft $0.00 0 Res. a/c package $0.00 Standing Section $0.00 0 New Res (1-2 units) $0.00 0 Misc Electrical Equipment $18.20 1 New Res (3+units) $0.00 0 Transformers up to 1 kvalkw $0.00 0 Pool / Spa $0.00 0 ................up to 10 kvalkw $0.00 0 Lighting Fixts $0.00 0 .................up to 50 kva/kw $0.00 0 Recept Outlets $1.10 1 .................up to 100 kva/kw $0.00 0 Switches $0.00 0 ..................over 100 kvalkw $0,00 0 Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0 Res Appl $0.00 0 Low Volt Wiring System / Ckl $0.00 0 Service to 200a $0.00 0 Misc. Conduit $0.00 0 Service to 1000a $0.00 0 Misc. Conductor $0.00 0 Service over 1000a $0.00 0 Circus ( gen or ride) $0.00 0 Motors to 1hp $0.00 0 Circus (mech ride or lights) $0.00 0 Motors to 10hp $0.00 0 Christmas Tree Stand $0.00 0 Motors to 50hp $49.20 2 Fireworks Stand $0.00 0 Motors to 100hp $0.00 0 Other Electrical Fee $0.00 Motors over 100hp $0.00 0 Communication drops $0.00 0 Investigation Fee $0.00 1 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not -commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inapectlons and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintaln a certificate of consent to sett-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the yvork for which this permit is issued. -0 1I have and will maintain workers' compensation insurance, as required by section 3700 of the labor Code, for the performance of the work for which this permit is issued. i�My workers' compensation Insurance carrier and policy number are: . Carrier: Policy Number: (This section need not be completed it the permit is valued at one hundred dollars f$ 100) or less.) jL I certify that In the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation la alitomia,and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with th rpv ions. C pplicant Signature: Date: - { G j��-- WARD iWGFFA1LURH'TO' r CURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE (SWO.000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of 1he.Business and Professions Code, and my license is in full force and effect. Lie# O 9 Class p Onuactors Signature: Date: 105 CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Londer's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that l am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter. Improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he Cr she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Seo. 7044, Business and Professions Code: The Contractors license Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need 10 file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25633 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 Cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 if an RMPP is presently required, has Section 25534 of the California Health and Safety Coda been fully complied with? ❑ Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of thisa plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? eyes g NO (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If `yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by Califomia Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (if 'fres", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I cortitY that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspeclion purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final Inspection. Signature Of La al Owners)D3 /oz Palo of rAnd/Or Authorized Applicant f Date�� CODE 0. INSPECTION TYEF(g INTITAL CODE INSPECTION TYPE 2&M INMAL� 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbingoo 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wali 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final BuildinglOccupancy 244&4& J 1 of Costa' 2W a Development Services, Divisidn of ai i g f lbo a !i CERTIFICATE OF OCC This certificate is issued pursuant to, thefrequirement's oft ection 308 �. ,. Ir adopted by the City of Costa Mesa cer"tifiesrth{at,at-the time of its.issuance the building structure erel below described was inspected/Jandy\�a�pproved;for.�occupancy,-aslollows: Building Address 3333 BRISTOL /ROBINSON'S/HAY Bldg. Permit No. B99-01404 Use RETAIL Group M Type,of Construction _ _T_—FRggyy��''RR Fire'Zone 4' `' Use Zone - Jnr. Owner of Building _ J E� - Tenant ' Address 611 Olive St: 41555; Saint 16uia;-:M07 /63101-1721/- 1 Rick Brown. CBO ,� By, -- BUILDING OFFIC D �� ate' March 14, 2000 T1 ORARY 180 Days \ ' Win_;1 REQUIRED TO BE POSTED INA CONSPICOUS PLACE tA• City of Costa Mesa Building Safety Department CERTIFICATE OF OCCUPANCY N?, 2335 C P. O. Box 317 Costa Meso, California The Building located of 3331 Briatol StR6t.. has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group Occupancy. Use of Building Legal Description __ _ 14 m% (See reverse side for Metes and Bounds) Building Permit No. �'� Electrical Permit No. 24326 Plumbing Permit No.�_ Floor Load Signs have been installed as - Room Capacity Signs -have -been instaled as required under Sec. 2308 U.. B. C. required under Sec. 3301 (1) U. B. C. 17050. CERTIFICATE OF OCCUPANCY. (a) No apartment house, hotel, or lodging house shall be used or occupied until the owner or operator has been issued a valid certificate of occupancy by the enforcement. agency. (b) A new certificate of occupancy shall be obtained whenever there is a change in: 1) Occupancy classification of a building or portion thereof 2) The number of apartments or guest rooms 3) Ownership If Group H Occupancy, number of apartments and/or guest rooms as required under Sec, 17050.1 (d), California Administrative Code, Title 8, Chapter 9, Article 8. Number of apartments and/or guest rooms ISSUED TO- Building Official ��r:►,�'�*..! � moi- ��,'! Date This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 306 (e) U.B.C. Form sU"M—ii-63--s-s P r 1 City of Costa Mesa 2340 � � O Building Safety Department CERTIFICATE OF OCCUPANCY NO P. O. Box 317 Costa Mesa, California` ~' The Building located at 3133Bristol Street has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group F2 &% F1 Occupancy. Use of Building auto accessory and 1r'L'Pair Legal Description A. P.. #140-052-Ql (See reverse side for Metes and Bounds) Building Permit No. 24825 Electrical Permit No. 215330 Plumbing Permit No. 46279 Floor Load Signs have been installed as Room Capacity Signs have been instaled as required under Sec. 2308 U. B. C...— required under Sec. 3301 (1) U. B. C 17050. CERTIFICATE OF OCCUPANCY. (a) No apartment house, hotel, or lodging house shall be used or occupied until the owner or operator has been issued a valid certificate of occupancy by the enforcement agency. (b) A new certificate of occupancy shall be obtained whenever there is a change in: 1) Occupancy classification of a building or portion thereof 2) The number of apartments or guest rooms 3) Ownership If Group N Occupancy, number of apartments and/or guest rooms as required under Sec. 17050.1 (d), California Administrative Code, Title 8, Chapter 9, Article 8. Number of apartments and/or guest rooms ISSUED TO: Building Official �y Company by 4, W Of - Date March 11, 1966 _ This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 306 (e) U.B.C. Form BU34-1M--u-63—s-s P (714) 754-5273 • Fax (714) 754-4855 • www.ci.costa-mesa.ca.us 77 FAN DHIVL, L;U5IA NEtSA, UA F$ZbZb PLUMBING PERMIT Job Address: 3333 BRISTOL ST Suite No ROBM Vicinity: Parcel Nunmber: 41250103 ISSUED BY: Status: ISSUED Applied: 07/06/2000 Issued: 07/06/2000 Applicant: SKIP BRADSHAW,,- Address: 614 W. COLORADO ST Phone: (818) 240-2040 , GLENDALE, CA, Zip:- 91204 Owner: CMF INC Address %MAY DEPT STORES CO ST LOUIS, MO Phone: 611 OLIVE ST #1300 Zip:.,, 63101 Contractor: H L MOE PLBG CO INC Address: . ,614 W. COLORADO ST Phone: (818) 240-2040 ' GLENDALE, CA, Zip: 91204 J License: 254678 -Arch / Eng Address: Phone: Zip: License: SCOPE OF PERMIT SUPPLEMENTAL PLUMBING PERMIT FOR TWO DRINKING FOUNTAINS FOR ROBIMAY. 10 ROOF DRAINS " AND 10 OVER FLOW DRAINS. _- - REF:B99-00701 & P99-00565 p. . FEE SUMMARY , AMT QTY _-. t_< ' " " AMT HQ11' AMT QTY ISSUE FEE- $7.25 Laundry Tub /Washer $0.00 0 `Sump p Pum % $0,00 0 Backflow irrigation �, $0.00 ; 0 �� .,� _ Landscape Irrigation $0.00 0 ; `Swimming Pool i $0.00 0 Backflow Preventer $0.00' , 0 �`P-Trap $0.00 0 ', Trap Primer;, $0.00 0 Bathtub ,�,�� $0.00', 0' Pressure Regulator $0.00 °_ 0 . = •Urinal" $0.00 0 Clarifier System $0.00. q' Process Piping (per iOft) $0.00 0 " Vacuum Brkr Bkflow(1-4) $0.00 0 Connect (Ice,Soda,etc) $0.00 0 . Receptors $0.00 0 Vacuum,Brkr Bkflow(5+) $0.00 0 Dental Units $0.00. " - 0 ' " Septic Tank $0.00 0 . -,Wash Basin" ' $0.00 0 Dishwasher $0.00' ", 01. Sewer Cap for Demo ` $0.00 0 Wash Basin Set $0.00 0 Drain, Floor $0.00 '01 Sewer Connect $0.00 0 Waste and Vent System $0.00 0 Drain, Rainwater $0.00 0". Sewer Private Line ' $0.00 _0 Water Closet (Toilet) $0.00 0 Drain, Roof $196.00 20 Shower $0.00 . 0 Water Heater / vent $0.00 0 Drinking Fountain $19.60 2 Sink, -bar $0.00 0 Water Piping (Inst or Rep.) $0.00 0 Expansion Tank $0.00 0 Sink, commercial $0.00 0 Water Re -pipe $0.00 0 Gas Earthquake Valve $0.00 0 Sink, Floor $0.00 0 Water Service $0.00 0 Gas (1-4 outlets) $0.00 0 Sink, kitchen $0.00 0 Water Softener $0.00 0 Gas (Over 4 outlets) $0.00 0 Sink, servicelmop $0.00 0 OTHER $0.00 Gas Repipe $0.00 0 Spa (private) $0.00 0 VIOLATION $0.00 Gas Service $0.00 0 Spa (public) $0.00 0 PLAN CHECK $0.00 Interceptors (Grease, Oil) $0.00 0 REINSPECTION $0.00 0 Interceptors (Sand Auto ) $0.00 0 TOTAL CALCULATED FEES: $222.65 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. - - INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 244646 (6100) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Coda, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed if the permit is valued at one hundred dollars ($100) or less.) ❑ I certify that in the performance of the work for which this permit is issued, i shall not employ any person in any manner so as to become subject to the workers' compens California, and agree that f I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, t shall forthwith A cant Signa f�� T�aie`1�•ct�C_ a0 Q U W LURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMP NAL PE IES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'$ FEES, LICENSED C DECLARATION: I her that I am ticens under revisions of hapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full I d effect. Lic. # (O o rector's Sign Date: O CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professions Coda: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement Is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, Califomia Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of industrial Safety, as noted above, unless such person has a Permit to do such work from the division. Signature: Data: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ...................................................................................................................................................................................................................................-......................................................................................................................... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ............. ........... .............................................................. ........................................... I ............................................. .................................................................. ................................................................................................................................... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ........................................... .._............................................................................................................... .................... ................... 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No _................................................................................................._...---................................................--.......................................................................... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification from the South Coast Air Cluality Management District or from any other air pollution control district or agency? IJ Yes 1TNo (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ..i E;.................................................................................................................................................................................................. ............................................................................................. 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). .................................................._..................................................................I..........................................................................................................................................................._...................................................................... _.............. 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ........................................................................................................................................................................................................................................................................................................................................... attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that l have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. ignature Of Le I Owner(s) fe AndtOC ate CODE '• INSPECTION TYPE DATE INTIT6LS CODE/ INSPECTIONTYPE LATE 1fiM1� 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 PLUMBING PERMIT Job Address: 3333 BRISTOL ST Status: ISSUED Suite No ROBM Applied: 08/22/2000 Issued: 08/22/2000 Vicinity: ROBM Parcel Nunmber: 41250103 ISSUED BY: Applicant: VALDEZ,LARRY Address: 614 W. COLORADO ST Phone: (818) 240-2040 GLENDALE, CA, Zip: 91204 Owner: CMF INC Address %MAY DEPT STORES CO ST LOUIS, MO. Phone: 611 OLIVE Si #1300 Zip: 63101 Contractor: H L MOE PLBG CO INC Address: 614 W. COLORADO ST Phone: (818)240-2040 GLENDALE, CA, Zip: 91204 License: 254678 40 Arch / Eng Address: Phone: Zip: License: SCOPE OF PERMIT REF P99-00565. ROB MAY. 1 HAND SINK AND 1 FLOOR SINK. FEE SUMMARY AMT QTY ,r AMT QTY AMT QTY ISSUE FEE $7.25 Laundry Tub / Washer $0.00 -. -,0 Sump Pump $0.00 0 Backflow irrigation $0.00 0 Landscape Irrigation $0.00 ."0 Swimming Pool $0.00 0 Backflow Preventer $0.00 0 ; P -Trap $0.00" 0' - Trap Primer $0.00 0 Bathtub $0.00 0 Pressure Regulator $0.00 0 Urinal $0.00 0 Clarifier System $0.00 0,,,,-- Process Piping (per 10 ft) $0.00 0 Vacuum Brkr Bkflow(1-4) $0.00 0 Connect (Ice,Soda,etc) . $0.00, " 0 '0 Receptors $0.00 0 Vacuum Brkr Bkflow(5+). $0.00 0 Dental Units $0.00 ' Septic Tank $0.00 0 Wash Basin $9.80 1 Dishwasher $0.00 0 Sewer Cap for Demo $0.00 0 Wash Basin Set $0.00 0 Drain, Floor $0.00 01 Sewer Connect $0.00 0 Waste and Vent System $0.00 0 Drain, Rainwater $0.00 0 Sewer Private Line $0.00 0 Water Closet (Toilet) $0.00 0 Drain, Roof $0.00 0 Shower $0.00 0 Water Heater / vent $0.00 0 Drinking Fountain $0.00 0 Sink, bar $0.00 0 Water Piping (Inst or Rep.) $0.00 0 Expansion Tank $0.00 0 Sink, commercial $0.00 0 Water Re -pipe $0.00 0 Gas Earthquake Valve $0.00 0 Sink, Floor $9.80 1 Water Service $0.00 0 Gas (1-4 outlets) $0.00 0 Sink, kitchen $0.00 0 Water Softener $0.00 0 Gas (Over 4 outlets) $0.00 0 Sink, service/mop $0.00 0 OTHER $0.00 Gas Repipe $0.00 0 Spa (private) $0.00 0 VIOLATION $0.00 Gas Service $0.00 0 Spa (public) $0.00 0 PLAN CHECK $0.00 Interceptors (Grease, Oil) $0.00 0 REINSPECTION $0.00 0 Interceptors (Sand Auto ) $0.00 0 TOTAL CALCULATED FEES: $26.85 COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or it work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446.46 (6/00) C DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the r� work for which this permit is Issued. I have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed It the permit is valued at one hundred dollars ($ 100) or less.) ❑ I certify that in the perfo a co of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws o al rnia, and that if should come subject to the workers' compensation provisions of Section 3700 of the Labor Cade, I shall forthwith comply with;Me" ov ns. Applicantignatur WARNING: FAILU SECURE W KERS' 0916APENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND ($100,000), IN ADDITI O THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm thal.i.am-41cansed u r fro sions of C apter 9 (commencing with Section 7000) of Division 3 of-the,Busirtass nd Professions Code, and my license is in full iorca.and'BfteCt..LiC�� Class CCaniract�gnature: Datee _ Z-,,73 i CONSTRUCTION I ENWNG AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lenders Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, after, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty o1 not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. Ii, however, the building or Improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Data: Owner ID verified by driver's license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deod): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet In depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sac, 341, Title 8, California Administrative Code). ❑ As owner-bullder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and Certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet o1 compressed gas at standard temperature and pressure). ............................................................................................................................................................................................................................................................................................................................................. 2 Doas ar will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .................._.........................__._.................................................................. ----........................... _......................................................... --................................................... _...................... _... -_................................................_.. 3 Does s or will th❑e applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ..............................................................................�............................�...............................�.................................................................................................w........................................................................_.......... 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑Yes ❑ No ... ................._. ................................_.................__....-_.._........................_.-.......................................................................................... ................. _................ .........-..................................................................................... 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this a plication amrmit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency[ IJ Yes Q No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within i 000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ............................ _.._._................... _......................... ........................................................ ..._........................... ............ ................ ..... ........... ................._.. _ ................-_..................._..................... -................... _............... _.. 7 If a permit from the South Coast Alr Quality Management District or other air pollution control district or agency Is required for the work which Is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ............................................................... ..................................................................................................................... _....................._.................. ........... .............. .................. .8 (If 'yes', attach certificate of compliance from the appropriate air pollution control officer), CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the Information given above is correct. 1 agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the Information given is correct. I agree to ply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-dascribe ro arty for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Sig a Le Owner(s) Date — =—l/ Ci ' :? 2 rrtj ndlOr ho •zed Applicant INSP£CT141,11TYPE fiAI€ IiQIDALS CODE t INSPECTION TYPE 2AH IN I IAII 5 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbingaf 200 Final Re -Roof 210 Final Electrical 201 Final BlocklRataining Wall 212 Final Fire Prevention 202 Final Factory Fire Placa 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy a�,o5t Esq CITY OF COSTA MESA ' BUILDING DIVISION r DEVELOPMENT SERVICES DEPARTMENT ;EMIT NUMBER ''• PERMIT M00-00016 (714) 754-5273 Fax (714) 754-4856 77 FAIR DRIVE, COSTA MESA, CA 92626 MECHANICAL PERMIT Job Address: 3333 BRISTOL ST Suite No ROBM Vicinity: ROOF Parcel Number: 41250103 ISSUED BY: Applicant: FRYER, TOM , ISSUE FEE Address: 915 E. WASHINGTON AVE Inst FAU <100 k BTU $0.00 0 J Phone: (714) 547-7431 Repair/Alt Cooling/Heat SANTA ANA,CA , Zip: 92701 Owner: CMF INC _ $0.00 Address: %MAY DEPT STORES CO $0.00 " 0 Gas Piping ''ST LOUIS, MO'. =. Phone: Factory Fireplace $0.00 611 OLIVE ST 91300 Zip: 63101 Contractor: - PROGRESSIVE AIR SYSTEMS r $0.00 Address: 915 E: WASHINGTON AVE $58.00 8 Appliance $0.00 Phone: (714) 547-7431 $0.00 SANTA ANA,CA /' Zip: 92701 14 ` , '• ,. License: 381220 Arch 1 Eng : {" 1 Address: _+ Phone: - Zip: License: SCOPE OF PERMIT MECHANICAL PERMIT FOR T.I. FOR-ROBINSONS MAY-. INSTALL 8 VENT FANS, 14 SMOKE DAMPERS, 4 AIR HANDLERS, 1 COMPRESSOR 3 T0.15 HP,, i COMPRESSOR 15 TO,30 HP, REPAiR,2 COOLIHEAT SYSTEMS, & REPAIR 1A& UNIT. REI-; B99-01405 Status: ISSUED Applied: 01/06/2000 Issued: 01/06/2000 FEE SUMMARY Quantity ISSUE FEE $23.50 Quantity Inst FAU <100 k BTU $0.00 0 Inst FAU >100 k BTU $0.00 0 Repair/Alt Cooling/Heat $27.40 2 Inst I Rep. Recess Wall Htr $0.00 0' Refrig Sys <100 k BTU $0.00 0 Refrig Sys >100 k BTU $0.00 " 0 Gas Piping $0.00 0 Factory Fireplace $0.00 0 Hood w/Mech Exhaust $0.00 0 VAV Box $0.00 0 Vent Fan 1 Single Duct $58.00 8 Appliance $0.00 0 Fire Dampers $0.00 0 Smoke Dampers $101.50 14 Inst or Relocate Appl Vent $0.00 0 Status: ISSUED Applied: 01/06/2000 Issued: 01/06/2000 FEE SUMMARY Quantity 'Repair/ Alt Absorbtion Unit $0.00 0 - Repair/ Alt Refrigeration Unit $14.80 1 Ventillation System $0.00 0 Evaporative Cooler . $0.00 0 Commercial Incinerator $0.00 0 Domestic Incinerator $0.00 0 Compressors 1 Absorption Systems Up to 3 hp 1 100 k BTU $0.00 0 3 To 15 hp 1 500 k BTU $0.00 0 15 To 30 hp 11,000 k BTU $0.00 0 30 To 50 hp 1 1,750 k BTU $0.00 0 Over 50 hp I Over 1,750 BTU $0.00 0 Boilers Up to 3 hp $0.00 0 3 To 15 hp $27.15 1 15 to'30 hp $37.25 1 NOTICE: The work authorized by this permit shall comply with al) applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insuranarrier and policy number are: ,t Carrier: /� ce n . � ; / v Policy Number: _[4� _, _ _,4 -Z1 V0 (This section need not be completed if t B permit is valued at one hundred dollars ($100) or lass.) ❑ I certify that in the porformanco of the work for which this permit is issued, t shall not employ any person in any manner so as to become subject to the workers' compensation laws of Calif rola, and a ree that If I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provf Applicant Signature: Date: WARNING: FAJLURE TO SECUR WORKE MPEG 0. COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL NAL? S AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE (5100.0001, IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CO , INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTOR% DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and affect. Lic. # Z% Class # Contractor's Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the app[icant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter S (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (5500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year Of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under see. Business and Professions Code for this reason: Signature: Date: Owner lD verified by driver's license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec, 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: _ __ Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the CaUomia Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ------------------------------------ --- - - - 3 Does or will the applicant or present or future building occupant need to prepare -- an R—MPP (R-isk M- anaa gement and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 It an RMPP is presently required, has Section 25534 of the California Health and Safety Code boon fully complied with? ❑ Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a hermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes jJ No (Section 65650.2 of the California Government Code requires that the requested information be furnished on applications for nonresidential building permits). 6 Will any part of the facility lobe Constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yas ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Ouality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (it -yes-, attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: _ Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. � S; re Of Legal Owner(s) Zte� An5pr Authari Applicant Date CODE >r, INSPECTION TYPE ¢M IHTT11AL5 CODE t' INSPECTION TYPE INTRIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Well 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final BvIlding/Occupancy 244846 (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 PLUMBING PERMIT Job Address: 3333 BRISTOL ST Status: ISSUED Suite No ROBM Applied: 10/25/2000 Issued: 10/25/2000 Vicinity: Parcel Nunmber: 41250103 ISSUED BY: Applicant: GLEASON, LEW , Address: 614 W. COLORADO ST ' Phone: (818)240-2040' GLENDALE, CA, Zip: 91204 " Owner: , CMF INC Address • %MAY DEPT STORES CO ST LOUIS, MO, Phone: . 611 OLIVE ST #1300 Zip;y_ 63101 Contractor: H L MOE PLBG CO INC Address: 614 W. COLORADO ST , + Phone:" -"(818) 240-2040 ' GLENDALE, CA, Zip: 91204 License: 254678 Arch / Eng ; Address: A Phone; Zip: Licenser COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit--- FOR ermit)FOR INSPECTIONS CALL: (714) 754-5626 !_Y u %-) SCOPE OF PERMIT -. SUPPLEMENTAL PLUMBING PERMIT FOR 1 COMMERCIAL SINK. REF: P99-00565 & B99-00701 f' , ' ,"`FEE SUAAIVIARY , ISSUE FEE AMT $7.25 QTY -' . Laundry Tub 1 Washer .AMT $0.00 `QTY•, •, ; r •„� .. f . 'Sump�Pump AMT ' $0.00 QTY 0 Backflow irrigation` $0.00 0 Landscape irrigation $0.00 0 Swimming. Pool $0.00 0 Backflow Preventer_'. $0.00 , 0,,' • �' �� P -Trap $0.00 "0 - ;Trap Primer , � $0.00 0 Bathtub $0:00,;0 ``Pressure Regulator $0.00 0 _ �` Urinal. ��' $0.00 0 Clarifier System $0.001, 0 Process Piping (per 10 ft) $0.00 0 VacuumBrkr Bkflow(1 4) $0.00 D Connect (Ice,Soda,etc) . $0.00 , 0 Receptors 40.00 0 Vacuum Brkr Bkflow(5+) $0.00 0 Dental Units $0.00 ' 0 Septic Tank $0.00 0 Wash Basin,, / $0.00 0 Dishwasher $0.001 ' . 0" Sewer Cap for Demo $0.00 01 Wash Basin set $0.00 0 Drain, Floor $0.00' 0 Sewer Connect $0.00 0 Waste and Vent System $0.00 0 Drain, Rainwater $0.00 0 Sewer Private Line $0.00 0, Water Closet (Toilet) $0.00 0 Drain, Roof $0.00 0` Shower $0.00 0 Water Heater / vent $0.00 0 Drinking Fountain $0.00 0 Sink, bar $0.00, 0" :" Water Piping (Inst or Rep.) $0.00 0 Expansion Tank $0.00 0 Sink, commercial $9.80 1 Water Re -pipe $0.00 0 Gas Earthquake Valve $0.00 0 Sink, Floor $0.00 0 Water Service $0.00 0 Gas (1-4 outlets) $0.00 0 Sink, kitchen $0.00 0 Water Softener $0.00 0 Gas (Over 4 outlets) $0.00 0 Sink, service/mop $0.00 0 OTHER $0.00 Gas Repipe $0.00 0 Spa (private) $0.00 0 VIOLATION $0.00 Gas Service $0.00 0 Spa (public) $0.00 0 PLAN CHECK $0.00 Interceptors (Grease, Oil) $0.00 0 REINSPECTION $0.00 0 Interceptors (Sand Auto ) $0.00 0 TOTAL CALCULATED FEES: $17.05 COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit--- FOR ermit)FOR INSPECTIONS CALL: (714) 754-5626 !_Y u %-) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a Certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the r-:�Crk for which this permit is issued. 2,rrdIerr—:_ ave and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit Is Issued, workers' compensationn Insurance car ' r and policy number are:(JN`�� [T� rPolicy Number:—.% ��/_f _�Tlris section -need not be completed if the permit rs valued at one hundre dollars ($100) or less.) l ❑ 1 certify that in the performance of the work for which this permit Is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, andas that if i should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these ovisions. Applicant'Sfgnature:` 69NING`.'FAILURE TO SE RE WORKERS' COMPENSATkON COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,0001, IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provi Ions of Chapter 9 (commencing with Section 7000) of Division 3 o}.the Business and Professions Coda, and my license is in full force and efface o—E Z s (a -7 rdass cont Signature:_. - --�- rDate"4 CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lenders Name: Lenders Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031 .5. Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of DIvlslon 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professions Coda: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title S, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I Will the applicant or present or future building occupant need to file and certity a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). -•......................_......_........................_.....................................................__-•--..................._............................. .-............. ................ .............. ......................... ..... . .................... .........--...................... ........................................ _ ............_ 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater then a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). --................................................................................. _............................... .................. ..................... ..............-­-_........................................................................... ..................................................... -.. .................. -............ 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No {Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ............................•-15i5.:......................._......................................................................-........I.....--....................................................................................................................... .....................I............................................................... . . 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No __._....._.._....................----........................_................................................. _ .......................................................... _....__-.................................... ....................... -.................. -..................... _ 5 Does or wilt the applicant or present or future building occupant require for the work which is the subject of this 11 plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes jf No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ................... i...................... t' --•--•c*o..'s.t'.......................................'er'....................'h.[n'....0-0-0, f'•---Fi'r'-......................'r-*........d,a'........._........................................e"s....................................._................... _..................... _....... 6 Will any pari of the facility to be constructed under this permit be within 1000 feat from the outer boundaries of a school? ❑ Yss ❑ No (if 'yes', the facility must meet the requirement of Sections 25534 and 42303 at the California Health and Safety Code). _.. ---........... ............................... _..................................... ........... ....--...................... ........_.. _ ...................._ ............................................................................................... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which Is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (If'�s , attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: i certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Data: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with ail state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection, S'gt Of Legal Owner(s) Date _ .ter 1(And/Or Authorized Applicant`- — Date x mak; CODE P. INSPECTIONTYPE DATE ( I,$ CODED, INSPECPON TYPE 2M IbML 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 240 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy 44 (714)754-5273 • Fax(714)754-4856 CITY OF COSTA MESA BUILDING DIVISION DEVELOPMENT SERVICES DEPARTMENT PERMIT Job Address: •3333 BRISTOL ST Suite No ROBM Vicinity: Parcel Nunmber: 41250103. Applicant: H L MOE PLBG CO INC Address: 614 W. COLORADO ST GLENDALE, CA, Owner: CMF INC Address %MAY DEPT STORES CO ST LOUIS, MO 611 OLIVE ST #1300 Contractor: H L MOE PLBG CO INC Address: 514 W. COLORADO ST GLENDALE, CA, Arch / Eng: Address: PLUMBING PERMIT Phone: (818) 240-2040 Zip: 91204 Phone: Zip: 63101 Phone: (818)240-2040 Zip: 91204 License: 254678 Phone: Zip: License: IT NUMBER P99-00565 . 77 FAIR DRIVE, COSTA MESA, CA 92626 Status: ISSUED Applied: 10/5/1999 Issued: 101511999 ISSUED BY: SCOPE OF PERMIT 5 RAINWATER DRAINS, 5 ROOF DRAINS, 1 DRINKING FOUNTAIN, 12 RECEPTORS, 1 SERVICE SINK, 3 URINALS, 9 WASH BASINS, 14 WATER CLOSETS & 1 WATER HEATER FOR ROBINSONSlMAY. REF: B99-00701 OTY FEE SUMMARY AMT ISSUE FEE $23.50 Backflow irrigation $0.00 Backflow Preventer $0.00 Bathtub $0.00 Clarifier System $0.00 Connect (Ice,Soda,etc) $0.00 Dental Units $0.00 Dishwasher $0.00 Drain, Floor $0.00 Drain, Rainwater $49.00 Drain, Roof $49.00 Drinking Fountain $9.80 Expansion Tank $0.00 Gas Earthquake Valve $0.00 Gas (1-4 outlets) $0.00 Gas (Over 4 outlets) $0.00 Gas Repipe $0.00 Gas Service $0.00 Interceptors (Grease, Oil) $0.00 Interceptors (Sand Auto ) $0.00 OTY FEE SUMMARY AMT QTY AMT OTY Laundry Tub 1 Washer $0.00 0 Sump Pump $0.00 0 Landscape Irrigation $0.00 0 Swimming Pool $0.00 0 P -Trap $0.00 0 Trap Primer $0.00 0 Pressure Regulator $0.00 0 Urinal $29.40 3 Process Piping (per 10 ft) $0.00 0 Vacuum Brkr Bkflow(1-4) $0.00 0 Receptors $117.60 12 Vacuum Brkr Bkflow(5+) $0.00 0 Septic Tank $0.00 0 Wash Basin $88.20 9 Sewer Cap for Demo $0.00 0 Wash Basin Set $0.00 0 Sewer Connect $0.00 0 Waste and Vent System $0.00 0 Sewer Private Line $0.00 0 Water Closet (Toilet) $137,20 14 Shower $0.00 0 Water Heater! vent $12.30 1 Sink, bar $0.00 0 Water Piping (Inst or Rep.) $0.00 0 Sink, commercial $0.00. 0 Water Re -pipe $0.00 0 Sink, Floor $0.00 0 Water Service $0.00 0 Sink, kitchen $0.00 0 Water Softener $0.00 0 Sink, servicelmop $9.80 1 OTHER $0.00 Spa (private) $0.00 0 VIOLATION $0.00 Spa (public) $0.00 0 PLAN CHECK $0.00 REINSPECTION $0.00 0 COMMENTS / SPECIAL CONDITIONS TOTAL CALCULATED FEES: $525.80 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-26, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the /work for which this permit is issued. L'� I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed if the permit is valued at one hundred dollars ($100) or less.) ❑ 1 certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith Comply with these pro ions. f� �j p Applicant Signature:. [r—iL]L tY�IAr Date: fl i — / WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed u er prow ns of Cha ter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in lull force and effect. Lic. ft _ _ _ _, _ Tin Class p (e Contractor's Signature: ii r M! NS 2-4 Aiwn&L-V Date: .IfLQ =!T4__ CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and ProfeIthe Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.), ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contracfor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or dead): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ t hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec, 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do Such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure) - 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? IJ Yes] No (Section 65850.2 of the California Government Code requires that the requested information be fumished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 Ii a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 6 (if 'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. f agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. J Signatu O egOwner(s) /0 r � — 9D�e And/Or Authorized Applicant Dale CODE +. INSPECTION TYPE Im IN MALS CODE • INSPECTIONTYPE PM INTRIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Root 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final BuildinglOccupancy 2446-46 CITY OF COSTA MESA BUILDING DIVISION DEVELOPMENT SERVICES DEPARTMENT �• PERMIT (714)754-5273 • Fax(714)754-4856 ELECTRICAL PERMIT PERMIT NUM E99- 22 77 FAIR DRIVE, COSTA MESA, CA 92626 .lob Address: 3333 BRISTOL ST Status: ISSUED Suite No ROBM Applied: 1212311999 Vicinity: NEW SHELL BUILDING ADDITION Issued: 12/2311999 Parcel Nunmber: 41250103 Applicant: KEVIN MEETER Address: 6820 ORANGETHROPE AV ISSUED BY: REF:1399-00701 $0.00 Phone: (714)522-1690 $23.50 BUENA PARK CA Zip: 90620 Owner. " CMF INC, $0.00 0 Address %MAY DEPT STORES CO 0 New Res (3+units) $0.00 ST LOUIS, MO Phone: $0.00 0 611 OLIVE ST #1300 Zip: 63101 Contractor: SNOWDEN ELECTRIC CO INC Switches Address: 6820 ORANGETHROPE AV ' $0.00 0 Res Appl •Phone: (714)522-1690 Service to 200a BUENA PARK CA "� = Zip: 90620 $0.00 0 License: 395601 0 Motors to 1 hp SCOPE OF PERMIT 0 2 MOTORS UPTO 50 HP, 9 MISC,CONDUITS AND 8 MISC CONDUCTORS FOR ROBINSONS/MAY SHELL BUILDING. 0 Motors to 50hp $49.20 REF:1399-00701 FEE SUMMARY,' Quantity Temp Dist System 1 Lighting $0.00 Quantity ISSUE FEE $23.50 0 Temp service test $0.00 0 Res. a/c package $0.00 0 New Res (1-2 units) $0.00 0 New Res (3+units) $0.00 0 Pool / Spa $0.00 0 Lighting Fixts $0.00 0 Recept Outlets $0.00 0 Switches $0.00 0 Non Res Appl $0.00 0 Res Appl $0.00 0 Service to 200a $0.00 0 Service to 1000a $0.00 0 Service over 1000a $0.00 0 Motors to 1 hp $0.00 0 Motors to 10hp $0.00 0 Motors to 50hp $49.20 2 Motors to 100hp $0.00 0 Motors over 1 00h $0.00 0 Communication drops $0.00 0 Sub panel to 200a $0.00 0 Pole Light Pkg $0.00 0 Sign Circuits $0.00 0 Temp Pwr Pole $0.00 0 Intermed Pole $0.00 0 FEE SUMMARY,' Quantity Temp Dist System 1 Lighting $0.00 0 Busway 1100 ft $0.00 0 Standing Section $0.00 0 Misc Electrical Equipment $0.00 0 Transformers up to 1 kvalkw $0.00 0 ................up to 10 kvalkw $0.00 0 .................up to 50 kvalkw. $0.00 0 .................up to 100 kvalkw $0.00 0 ..................over 100 kvalkw $0.00 0 Low Voltage Equipment $0.00 0 Low Volt Wiring System / Ckt $0.00 0 Misc. Conduit $163.80 9 Misc. Conductor $145.60 8 Circus ( gen or ride) $0.00 0 Circus (meth ride or lights) $0.00 0 Christmas Tree Stand $0.00 0 Fireworks Stand $0.00 0 Other Electrical Fee $0.00 Investigation Fee $0.00 Plan Check Fee $0.00 Reinspection Fee $0.00 TOTAL CALCULATED FEES $382.10 COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 DECLARATIONS WORKERS' COMPENSATION DECLARATION: I her y affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed it the permit is valued at one hundred dollars ($100) or less.) ❑ I certify that in the perfor ce of the work for which this permit is issued. I shall not employ any person in any manner so as to become subject to the workers' compensation laws of C amts, a d agree that if I sho became subject to the workers' compensation provisions of Sectio 3700 of the Labor Coda, I shall forthwith comply with these pr ons. Applicant Signature: Date: WARNING: FAILURE TO URE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMIN L PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE (6100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provis ons of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic, p Class q G',f Contractors Signature: 4arze3 Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that 14m EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL 00 THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year o1 completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractors) license pursuant to the Contractors License Laws.). ❑ l am exempt under sec. _ Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet In depth into which a person is required to descend, will be made in Connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone t4 do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous malerials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure)._ 2 - — -- th Does or will e applicant or present or future building occupant need to file a registration form for acutely hazardous Ye �� ar s materials? []Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fhre Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Cade been fully complied with? ❑ Yes ❑ No from the South Coast Air Quality Management District or from an other air pollution control district or 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification ty g y p agency? � Yes � No (Section 65850.2 of the California Govemmehl Code requires that the requested information be furnished on applications for non-residential building permits). _. _ -- ---- --_..,---- - - ----------------------- 6 ---------.---------- 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If "yes", the facility must meet the requirement at Sections 25534 and 42303 of the California Health and Safety Code), 7 It a permit from the South Coast Air Quality Management District or other air pollution control disinct or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No .,-.--.---;.------ 8 (If `yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree 10 comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: _ _ Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described rop arty for inspection purposes, I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Si or s) Date �3 " 'And/Or Authorized Applicant Dae CODE s. INSPECTION TYPINTfiIALS CODE INSPECTION TYPE �'[� IJP 1616 Fixed System Final Fire Prevention _ 206 Final Mechanical 1266 Pool Spa Final �208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wali 212 Final Fire Prevention 202 Final Factory Fire Place^ 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy 2446.46 CITY.OF COSTA MESA BUILDING DIVISION DEVELOPMENT SERVICES DEPARTMENT PERMIT (714) 754-5273 - Fax (714) 754-4856 - www.cl.costa-mesa.ca.us ELECTRICAL PERMIT ,lob Address: 3333 BRISTOL ST Suite No ROBM Vicinity: ROB -MAY PARKING LOT Parcel Nunmber: 41250103 Applicant: RICKEY, TY Address: 3188 AIRWAY #C COSTA MESA Owner CMF INC Address 0/.MAY DEPT STORES CO ST LOUIS, MO 611 OLIVE ST #1300 Contractor: DAY CONSTRUCTION CO Address: 3188 AIRWAY #C COSTA MESA PERMIT NUMBER -00260 77 FAIR DRIVE, COSTA MESA, CA 92626 Status: ISSUED Applied: 04/05/2001 Issued: 04/05/2001 ISSUED BY: WV Phone: (714) 885-8950 Zip: 92626 Phone: Zip: 63101 Phone: (714) 885-8950 Zip: 92626 License: 610643 SCOPE OF PERMIT INSTALL CONCRETE LIGHT POLE BASE & ELEC FOR A STANDARD 1N THE "ROB -MAY" PARKING' AREA. ; 1 POLE LIGHT PKG REF: 1301-00447 FEE SUMMARY-' Quantity _ Quantity,�� �� f -1 ISSUE FEE $23.50 Temp Dist Sys stem`I'Lighting $0.00 0,�// �l " Temp service test 50.00 Busway 1100 ft $0.00 Res. alc,package- ' S0.00 Standing Section $0.00 i 0 % New Res,(1-2 units) $0.00 0 Misc Electrical Equipment $0.00, /' 0 New Res (3+units) $0.00 0 Transformers up to,i kvalkw $0.00,-, 0 r � Pool I Spa $0.00 - 0. ........up to 10 W"a vc`'; - $0.00/ 0 Lighting Fixts ,,. �. 50.00 _0 1 .........up to 50 kvalkw x$0:00 `0 Recept Outlets,,'\`,• $0 00 \,\ �0:c.....up to 100 kvalkw.", %$0.00 C/i 0, Switches ` ��� 50.000\ `' ....:.:c.......:bver 1003ivalkw�$0.00� �Oi i Non Res Appl \` `' . $O.OD 0 �� ;;Low Voltage Equipment' /$0.00,� C0� Res Appl \" $0.00 0 ~ v Law -Volt Wiring System 1 Ckt�\ X50:00 ,0 Service to 200a $0.00 0~ Misc. Conduit _ 1 $0.00 % 0 Service to 1000a 50.00 `� .10 - ' . Misc. Conductor : �1 �•,�_ x$0.00-", 0� Service over 1000a �50:00�, - 0 Circus (-gen or ride) • + $0:00 j� 0 Motors to 1hp $0.001, 0-, , Circus (mech ride or lights)__ -"_1$'0.'00 0 Motors to 10hp 50.00`x, 0__ Christmas Tree Stand -$0.00 0 Motors to 50hp $0.00 0 Fireworks Stand,_-,, - �"� $0.00 0 Motors to 1 00h 50.00 0, Other Electricai Fee- $0.00 Motors over 100hp $0.00 0 Communication drops 50.00 0 Investigation Fee $0.00 Sub panel to 200a 50.00 0 Plan Check Fee $0.00 Pole Light Pkg 533.50 1 Reinspection Fee $0.00 Sign Circuits $0.00 0 Temp Pwr Pole $0.00 .0 TOTAL CALCULATED FEES $57.00 Intermed Pole S0.00 0 COMMENTS I SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and rotated regulations. (Ord. No. 92.28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work Is not commenced within 180 days, or it work Is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result in the expiration.of this permit. FOR INSPECTIONS CALL. (714) 7545626 244648 IBM) DECLARATIONS WORKERS' COMPENSATION DECLARATIL. . I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. tvI have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this penult is Issued. My workers' compensation insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed if the permit 1s valued at one hundred dollars f$ f 00) or lass.) ❑ I certify that in the perforate ce o1 the work for which this permit is issued, I shall not employ any person in any manner so as to ocome subject to the workers' compensation laws of CeymiaI should become subject to the workers' compensation provisions of Sectio 700 the Labor Code, I shall forthwith comply with these pr si Applicant Signature: Date: WARNSNG: FAILURE TO SECURE W ERS' COMP SA COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMI PENALTIES AND CIVIL ANIS UP TO GIVE HUNDRED THOUSAND DOLLARE ($100,0001, l ADDITION TO TH T OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SEC110N 3709 OF THE LABOR CODE. INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under pr visions of Chapter 9 (commencing with Section 7000) o1 Division 3 of the Business and Profossions Code, and my license Is in full force and effect, Lic. tf Class ft Contractor's Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lenders Name: Lenders Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to Its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 70x4, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her awn employees, provided that such improvements are not Intended or offered for sale. If, however, the building or Improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). Cl I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of properly who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and Certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume o1 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ............................................................................................................................................................................................................................................................................................................................................................................ 2 Does or will the applicant ar present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greeter than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the appplicant or present or Futuro building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No Section 25534 of the California Health and Safety Code provides that the Costs Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPA by businesses which are required to register acutely hazardous materials with the Fire Department. .......................................................................................................534._..._...................._....................................................................,.,....,......,...............ii................["J............._................_. ..............�. 4 If en RMPP is presently required, has Section 25534 of the California Health end Safety Coda been fully complied with? ❑Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of thisa plication aFermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? 8 Yes Lj No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Wilt any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes ❑ No (if 'yes, the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). -................._..............................._._....__...... — _ __ . _...._..................................................................................... _._......_.. - -- -- 7 If a permit from the South Coast Air Quality. Management District or other air poffudon control district or agency is required tot the work which is the subject of this application, have all of the disclosures prescribed by Califomia Health and Safety Code Section 42303 been made? ❑ Yes ❑ No _............ ---.._......................_ __..__.....____._... _...--.."a-I..r......._................_.........................................................................................._......................................................................... 8 (If yes", attach certificate of compliance from the appropriate aipollution control offfficicer). .... CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above Is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: f certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described propeA r inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. SI a galOwner(s) Is /And/Or Authorized plicant Date CODE r. INSPECTION TYPE V 2[n• INTITA CODE INSPECTIONTYPE ora 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical �L 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final BuildinglOOoupency (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT Job Address: 3333 BRISTOL ST Suite No ROBM Vicinity: ROBINSON'S MAY Parcel Nunmber. 41250103 Applicant: EVEN, EPHRAIM Address: 1667 N O'DONNELL WY Phone: (714) 685-0186 ORANGE, CA Zip: 92867 Owner: CMF INC Address %MAY DEPT STORES CO ST LOUIS, MO Phone: 611 OLIVE ST #1300 Zip: 63101 Contractor: FRED EVEN ELECTRIC Address: 1667 N O'DONNELL WY Phone: (714) 685-0186 ORANGE, CA Zip: 92867 License: 588969 ISSUED BY: Status: ISSUED Applied: 12/04/2000 Issued: 12/04/2000 SCOPE OF PERMIT SUPPLEMENTAL ELECTRICAL PERMIT TO INSTALL 30 ADDITIONAL ELECTRICAL OUTLETS FOR CHRISTMAS DECORATIONS FOR "ROBINSON'S MAY". REF: E00-01087 COMMENTS I SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 X 24x8-48 (6=) FEE SUMMARY Quantity Quantity ISSUE FEE $7.25 Temp Dist System 1 Lighting $0.00 0 Temp service test $0.00 Busway 1100 ft $0.00 0 Res. a/c package $0.00 Standing Section $0.00 0 New Res (1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0 New Res (3+units) $0.00 0 Transformers up to 1 kvalkw $0.00 0 Pool 1 Spa $0.00 0 ................up to 10 kvalkw $0.00 0 Lighting Fixts $0.00 0 .................up to 50 kvalkw $0.00 0 Recept Outlets $29.30 30 .................up to 100 kvalkw $0.00 0 Switches $0.00 0 ....over 100 kvalkw $0.00 0 Non Res Appi $0.00 0 Low Voltage Equipment $0.00 0 Res Appl $0.00 0 Low Volt Wiring System I Ckt $0.00 0 Service to 200a $0.00 0 Misc. Conduit $0.00 0 Service to 1000a $0.00 0 Misc. Conductor $0.00 0 Service over 1000a $0.00 0 Circus ( gen or ride) $0.00 0 Motors to 1hp $0.00 0 Circus (mech ride or lights) $0.00 0 Motors to 10hp $0.00 0 Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 0 Fireworks Stand $0.00 0 Motors to 1 00h $0.00 0 Other Electrical Fee $0.00 Motors over 100hp $0.00 0 Communication drops $0.00 0 Investigation Fee $0.00 Sub panel to 200a $0.00 0 Plan Check Fee $0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $0.00 0 Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $36.55 Intermed Pole $0.00 0 COMMENTS I SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 X 24x8-48 (6=) DECLARATIONS WORKERS' COMPENSATION DECLARAT1t I hereby affirm under penalty of perjury one Of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the rk for which this permit is issued. have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Cade, for the performance of the work for which this permit is issued. My workers' compensation Insurance cWrier and policy number are: r Carrier, Policy Number: (This section need nor be completed if the perrnh is valued at one hundred dollars ($100) or less.) ❑ I certify that In the performance of the work for which this permit Is Issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisions. 0ri. Appticant Signature: Dated 1 —^ v WARNING: FAILURE TO SECU E WORKERS' COMPENSATION OOVERAGE IS UNLAWFUL AND SHALL SUBJECT LOYER TO CRI ANAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), AN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed u deApr aions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and o e Ions de, and my license is In full force and effect..Lic..q--- Class p �Con�s.Signmure: Date: _ �--- CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is issued. (Sec. 3097, Civil Code). Lenders Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) Of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Coda: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her Own employees, provided that such improvements are not intended or offered for sale. If, however, the building or Improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Lew dogs not apply to an owner of property who builds Or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner 10 verified by drivers license. ❑ Yes ❑ No Drivers License No, Expires: Verification of Ownership by (type of documeht, i.e. - property tax bill or dead): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more teat in depth into which a person is required to descend, will be made In connection with work authorized by this permit, and [hat no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, An 2, Sec. 341, Title 8, California Administrative Cbde). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Data: Division of Industrial Safety Permit Number.. HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 W III the applicant or present or future building occupant need to fie and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ..................... ....................... _............ .............. ....................... __..............................._.._....................... ............................ .................................................. .................. ........ .......................—................... ..................... ......... 2 Does ar will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet Of compressed gas at standard temperature and pressure). ............._..__..........—.__......................................,............_...._._....... _—........................ ._............................................................................... __.......... ............ —_._...._._....... .. -- 3 DOGS or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costd Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 I1 an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑Yes ❑ No .........................................___........''n"t............................."iu,t-ur....b"u".............._r_.—._..........o,"i...__...o.'r'..............................................of ---••-....................ion a--................_._..........st __...----- 5 Does or will the applicant or present pr future building occupant require for the work which is the subject of this a plication a germit lar such construction or modification from the South Coast Air duality Management District or from any other air pollution control district or agency? LJ Yes U No (Section 65850.2 of the California Government Code requires that the requested Information be furnished on applications for non-residential building permits). 6 Will any par of the facility to be constructed under this permit t>e within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (it "yes", the facility must meet the requirement of Sections 25534 and 42303 of the Califomia Health and Safety Code). _...................---... – -- -- _-----------------..................... .............................................._— ....................._.-- -- _ 7 If a permit from the South Coast Air Oualq, Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (If 'fres", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emi4sions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: 1 certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city Ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the abovo-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature Ofypgal Owner s (� q / Date 1--And/Or-Authortxed-Appftcant - % Date CODE 1. INSPECTIONTYPE 2&N WTITIA S CQoe INSPECTIONTYPE Q�� IiY�18ti$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electnt l 201 Final BlocklRetalning Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.cl.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT Job Address: 3333 BRISTOL ST Status: ISSUED Suite No ROBM Applied: 11/14/2000 Vicinity: ROBINSONS MAY Issued: 11/14/2000 Parcel Nunmber: 41250103 Applicant EVEN, EPHRAIM Address: 1667 N O'DONNELL WY Phone: 714.685.0186 ORANGE, CA Zip: 92867 Owner: CMF INC Address %MAY DEPT STORES CO ST LOUIS, MO Phone: 611 OLIVE ST #1300 Zip: 63101 Contractor. FRED EVEN ELECTRIC Address: 1667 N O'DONNELL WY Phone: 714.685,0186 ORANGE, CA Zip: 92867 License: 588969 ISSUED BY: SCOPE OF PERMIT ELECTRICAL PERMIT FOR "ROBINSON-MAY" FOR CHRISTMAS LIGHTING/DECORATIONS. 40 RECEPT OUTLETS. FEE SUMMARY Quantity Temp Dist System! Lighting $0.00 0 Quantity ISSUE FEE $23.50 $0.00 0 Temp service test $0.00 Transformers up to 1 kvalkw Res. a/c package $0,00 $0.00 0 New Res (1-2 units) $0.00 0 New Res (3+units) $0.00 0 Pool / Spa $0.00 0 Lighting Fixts $0.00 0 Recept Outlets $36.60 40 Switches $0.00 0 Non Res Appl $0.00 0 Res Appl $0.00 0 Service to 200a $0.00 0 Service to 1000a $0.00 0 Service over 1000a $0.00 0 Motors to 1 hp $0.00 0 Motors to 10hp $0.00 0 Motors to 50hp $0.00 0 Motors to 100hp $0.00 0 Motors over 100hp $0.00 0 Communication drops $0.00 0 Sub panel to 200a $0.00 0 Pole Light Pkg $0.00 0 Sign Circuits $0.00 0 Temp Pwr Pole $0.00 0 Intermed Pole $0.00 0 FEE SUMMARY Quantity Temp Dist System! Lighting $0.00 0 Busway 1100 ft $0.00 0 Standing Section $0.00 0 Misc Electrical Equipment $0.00" 0 Transformers up to 1 kvalkw $0.00 0 ................up to 10 kvalkw $0.00 0 .................up to 50 kvalkw $0.00 0 .................up to 100 kvalkw $0.00 0 ..................over 100 kva/kw $0.00 0 Low Voltage Equipment $0.00 0 Low Volt Wiring System / Ckt $0.00 0 Misc. Conduit $0.00 0 Misc. Conductor $0.00 0 Circus ( gen or ride) $0.00 0 Circus (mech ride or lights) $0.00 0 Christmas Tree Stand $0.00 0 Fireworks Stand $0.00 0 Other Electrical Fee 5(3.00 Investigation Fee $0.00 Plan Check Fee $0.00 Reinspection Fee $0.00 TOTAL CALCULATED FEES $60.10 COMMENTS I SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work Is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 2448.0 MAX) DECLARATIONS ft - IQ WORKERS' COMPENSATION DECLARATIG._. I hereby affirm under penalty of perjury one of the following declarations: IV I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the worts for which this permit is issued. V'11 have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed if the permit is valued at one hundred dollars ($ 100) or less.) ❑ I certify that in the performance of the work for which this permit is issued, I shalt not employ any person In any manner so as to become subject to the workers' compensation laws of California, and agree that If I should become subject to the workers' compensation provisions of Section 3700 o1 the Labor Code, 1 shall forthwith Comply with the i Applicant Signature: rows rows Date: WARNING: FAILURE TO SE RE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CAVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license Is in full force and effect. Lic. # Class # Contractor's Signature: Date: ep CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction fending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who Contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No, Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five {5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thlrty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ................_..----_......................................................................................................_ ._........................................................ ............ 2 Docs or will the applicant or present or future building occupant need to file a registration form for aouiely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet o1 compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? . ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the COStd Mesa Fire Deparlment may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. _.......................................................----..._.........._.._......-......................................................._................................................_.1__........................................................... 4 I1 en RMPP Is presently required, has Section 25534 of the Catifomia Health and Safety Code been fully complied with? ❑ Yes ❑ No -._............_..--....................................................................... ..................................—........................... .-......... ............................................................. ........... ....._....................... -...... .......... ............................. ... ..................... 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this a plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes [ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ...... ---...... ................... ................................................................................................................................ ................................................................................................................................... -........................................................ 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries o1 a school? ❑ Yes ❑ No (If `yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). -_..................................................................................._..................--...-----._..................,...............................-------..................................................................... —-............................................................ 7 11 a permit from the South Coast Air Ouality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ NO __.......of _------................__..._.................................................. _._............. - ..... _.......... ... _.............. .--.............................. ...._...... te 8 (If "yes", attach cartificacompliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to Comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that i have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signat Of Legal Owner(s)/ Dat© ` 11— / 4d And/Or Authorized Applicant Date CODE t• INSPECTION TYPE 2AN KMLS CODE o INSPECTION TYPE QAIE 1NTITIA $ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Ra -Root 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy 1-1 (714) 754-5273 • Fax (714) 754-4856 www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA ELECTRICAL PERMIT _% Job Address: 3333 BRISTOL ST Status: ISSUED Suite No ROBIVI Applied: 08123/2000 Vicinity: BTS EQUIPMENT ON ROOF Issued: 08123!2000 Parcel Nunmber: 41250103 , Applicant: SIMPSON, GERI Address: 27450 YNEZ ROAD #300 Phone: (909) 694-4114 TEMECULA, CA Zip: 92531 Owner: CMF INC Address %MAY DEPT STORES CO ST LOUIS, MO Phone: 611 OLIVE ST #1300 Zip: 63101 Contractor: BROOKSTONE TELECOM INC Address: 27450 YNEZ ROAD #300 Phone: (909) 694-4114 TEMECULA, CA Zip: 92531 License: 711591 ISSUED BY: SCOPE OF PERMIT ELECTRICAL PERMIT FOR INSTALLATION OF NEW 70 AMP ELEC SERVICE & OUTLET FOR NEW BTS EQUIPMENT FOR EXISTING CELL SITE FOR "PACIFIC BELL WIRELESS". REF: B00-00779 COMMENTS 1 SPECIAL CONDITIONS 92626 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. -l - FOR INSPECTIONS CALL: (714) 7545626 2"6-4e (6=) v FEE SUMMARY Quantity Quantity ISSUE FEE - $23.50 Temp Dist System 1 Lighting $0.00 0 - Temp service test $0.00 Busway 1100 ft $0.00 0 " Res. a/c package $0.00 Standing Section $0.00 0 New Res (1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0 New Res (3+units) $0.00 0 Transformers up to 1 kvalkw $0.00 0 Pool 1 Spa $0.00 0 ................up to 10 kvalkw $0.00 0 Lighting Fixts $0,00 0 .................up to 50 kvalkw $0.00 0 Recept Outlets' $1.10 1 ........up to 100 kvalkw $0.00 0 Switches $0.00 0 .......over 100 kvalkw $0.00 0 Non Res Appl $0.00 0 Low Voltage Equipment $0.00, 0 Res Appl $0.00 0 Low Volt Wiring System 1 Ckt $0.00 /0 Service to 200a Service to I 000 $30.50 $0.00 1 0 Misc, Conduit Misc. Conductor $0.00 $0.00 0 0 Service over 1000a $0.00 0 Circus ( gen or ride) $0.00 0 Motors to Shp $0.00 0 Circus (mech ride or lights) $0.00 0 Motors to 10hp $0.00 0 Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 0 Fireworks Stand $0.00 0 Motors to 1 00h $0.00 0 Other Electrical Fee '$0.00 Motors over 100hp $0.00 0 Communication drops $0.00 0 Investigation Fee $0.00 Sub panel to 200a $0.00 0 Plan Check Fee $0.00 Pole tight Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $0.00 0 Temp Pwr Pale $0.00 0 TOTAL CALCULATED FEES $55.10 Intermed Pole $0.00 0 COMMENTS 1 SPECIAL CONDITIONS 92626 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. -l - FOR INSPECTIONS CALL: (714) 7545626 2"6-4e (6=) v DECLARATJONS WORKERS' COMPENSATION DECLARAT10n: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the tabor Code, for the performance of the work for which this permit is issued. 91--'l have and will maintain workers' compensatlon Insurance, as required by section 3700 of the tabor Code, for the performance of the work for whkh this permit is issued. My orkers' comps at n I uran rd r and oil number are: Carrier-. ►%�3 LLL Policy Number: (This section need not be completed If the perrrlt is valued at one hundr& dollars ($1170) or fess.) ❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject the workers' compensation provisions of Section 3700 of the Labor Code, i shall forthwith comply with these ovisigns. O /� Applicant Signature: Date: 6 WARNING' FAILURE O SECURE WO RS' COMPENSATION OWAAGEWUNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENAL ES AND CML FINES UP TOONE HUNDRED THOUSAND DOLL4RE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under rovisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business an,�,Protass ions Code, and my license Is In full force and effect. Lic. 11 s Class a /a Contractors Signature: Date: Z 4-021122 CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is issued. (Sec. 3097, Civil Code). Lender's Name: Lenders Address: Signature: Dale: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than rive hundred dollars ($51]0).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Low does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. 11, however, the building or Improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License taws.). ❑ I am exempt under set. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - properly tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet In depth Into which a person Is required to descend, will be made In connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with sumo exceptions, that a Business Plan be tiled with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ._........................................................................ W_............................................................... ........................................ ,,,,,.,.,,....,..............................................__............. .—.—_..............---..... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight o1 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). —_............... ---- _.-....................... ._.................................. ...... ......._......._W..................... _.... __._... _......... _...._.._ 3 Does or will the applicant Cr present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and fling with the Fire Department of an RMPP by businesses which are roquited to register acutely hazardous materials with the Fire Department. 4 If an RMPP Is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? 0 Yes U No (Section 65850.2 of the California Government Code requires that the requested information be fumished on applications for non-residential building permits). - - -- ......._............................................ 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If yes', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution Control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No _.....................—_..._._._......_—....._.�.__—_ _ __ ... _.—. .._ _........................—......................................................_.......... _ ...... 8 (if yes', attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for Inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature Of at Owner(s) Date AndlOr AV1hodzWAppIIcjrhI Data CODE I. INSP£CTIONTYPE RATE INIMACODE i INSPECTIONTYPE PAIS KrrnA1� 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 'p 201 Final Block/Retalning Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy r (714).754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa. A&DING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Status: ISSUED Suite: ROBM Applied: 11/2712000 Vicinity: Issued: 02/26/2001 Parcel Number: 41250103 Zoning: PDC PDC Applicant: JONES, BILL ISSUED BY: Address: 27450 YNEZ RD SUITE 300 Phone: (909) 694-4114 TEMECULA, CA- . Zip: 92591 , Owner: CMF INC Address /%MAY.DEPT STORES CO ST LOUIS, MO - Phone: 't 611"OLIVE ST#1300 Zip: 63101 Contractor: BROOKSTONE TELECOM INC Address: 27450 YNEZ ROAD #300 Phone:' (909) 694-4114 TEMECULA, CA Zip: 92531 License: 711591 Arch : BOJORQUEZ & ANDERSON '. Eng: I PEYTON - TOMITA & ASSOCIATES Address: 3185 AIRWAY AVENUE Address:" 954 TOWN & COUNTRY ROAD SUITE H - Phone: 714-444-3030 Phone: 714-245-4931 COSTA MESA, CA ORANGE, CA' Zip: 92626 License: C9702 92868 License: 3304 �> SCOPE OF PERMIT - - INSTALLATION OF A BASE TRANSCEIVER_STATION MOUNTED.ON A STEEL.PLATFORM ON AN EXISITNG ROOF BEHIND AN EXISITNG SCREEN. WILL NOT BE VISIBLE FROM OFF-SITE. MCUP DOES NOT PROHIBIT THE INSTALLATION OF ADDITIONAL BTS CABINETS. WBK - — —= - - FEE SUMMARY .Plan Check: $6321 J Calc Valuation! $4,000.00 Permit: $97.25 Claim Valuation: $4,000.00 -SMTP Res: $0.00 _ .S. MIP Com:' $0.84 Other: - r_ • ; ` ,$0.00 Inspection: $0.00 'Total:$161.3 PLANNING & ZONWG SETBACKS MAIN STRUCTURE Front . 0-0 Rear. 0-0 Left 0-0 Right '0-0 ACCESSORY Front '•0- 0 - 'Rear 0-0 Left" 0-0 - Right - 0- 0' PARKING Existing: 0 Required: 0 Proposed: 0 NOTES: NOTICE., The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: in order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545628 2446.46 (6100) DECLARATIONS C', WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' cgpensation Insurance carrier and policy number are: _ Carrier ? !p %+:►� „lr p b– fi� C�i i C' (q S - _ Policy Number: ' (�1 lJ--- 3 6o 5 U _(This section need not be completed if the permit Is valued at one hundred dollars ($15-0) or less.) ❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these pro ' 'ons. Applicant Signature: rWARNING'FAfLURE TO SECURE WORKEW PENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm thatl,am,licensed under provisions of Chapter 9 (commencing with Section 7000) of Division`3'of theBusiness d Professions Code, and my license is in full force and effectftjc.•R. 1 511 �CIasS a) _-- Contractors Signatur Date: 1:1- a 6- G 1 I" CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code), Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Coda: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031,5 by any applicant for a permit subjects the applicant to a civil penally of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or Improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sate.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS 10 construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ i hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 6, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ............................................................................................""I'.......................................................................................................................---------------------------•--...................................................................................................•................. 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ...11............11................ .--............................................................................................................................................................................................ ................................................................................... ........................ 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ...................................................................................................................................................................................................................... ............................... 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No ........................................................•---................................................................................................................................................................................................................................................-----------............................................. 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ermil for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes No (Section 65850.2 of the California Govemment Code requires that the requested information be furnished on applications for non-residential building permits). ill....................................cili.........................ii-r-............-u-n....................-ar...........a-----.-In......0.0........................ha o ------..................ias................b-6-..................................................................----------............................----------- 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the cuter boundaries of a school? ❑Yes ❑ No (It "yes", the facility must meet the requirement o1 Sections 25534 and 42303 of the California Health and Safety Code). ............................................................................................................................................................................................................................................................................................................................................ ............... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No -......................................................................................................................................................................................•.......................................................................................................................................................................... 6 (U rtes", attach certificate of compliance from the appropriate air poIJution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signal Ot Legal Owner(s) Date nd/Or AuthItked App Data CODg # INSPECTION TYPE j?AIIE ILLS CODE / INSPECTION TYPE ljbjf, 1tTITIAL$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 206 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site �_ r 204 Final Demolition 250 Final Building/Occupancy 4t, P, q CITY OF COSTA MESA - BUILDING DIVISION y PERMIT NUMBER ' DEVELOPMENT SERVICES DEPARTMENT PERM Existing: 0 Required: 0 proposed: o B99-02001 (714) 754-5273 • Fax (714) 754-4856 77 FAIR DRIVE, COSTA MESA, CA 92626 BUILDING PERMIT Job Address: 3333 BRISTOL ST Status: ISSUED Suite: ROBM Applied: 12/27/1999 Vicinity: Issued: 02/01/2000 Parcel Number: 41250103 Zoning: PDC PDC Applicant: DAVID GARCIA ISSUED BY: Address: -Phone: Zip: Owner: ROBINSONS MAY SOUTH COAST PLAZA Address 611 OLIVE ST Phone: ST. LOUIS, MO - Zip: 63101 Contractor: DAY CONSTRUCTION CO Address: 3188 AIRWAY #C Phone: (714)885-8950 COSTA MESA Zip: 92626 License: 610643 Arch : ROY TANAKAIAP&T '' - Eng: Address: 950 S ARROYO PRKWY Address: - Phone: 626-578-1115 Phone: PASADENA,CA", Zip: 91105 License: C4842 License: SCOPE OF PERMIT. ADDING.1,759 SF OF RETAIL SPACE;. ADDING 742 SF OF CANOPIES; REMOVING EXTERIOR PRECAST CONCRETE RIBS. MODIFYING PERMIT #B99-00701 FEE SUMMARY Plan Check: $3,599.38 f Calc Valuation: $985,000.00 Permit: $5,537.50 Claim Valuation: $985,000.00 SMIP Res: $0.00 _- SMIP Com: $206.85 Other:$0.00 Inspection: $0.00 Total: $9,343.73 PLANNING & ZONING SETBACKS MAIN STRUCTURE Front 0-0 Rear 0-0 Left 0-0 Right 0-0 ACCESSORY Front 0-0 Rear 0-0 Left 0- 0. Right 0-0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12.21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 DECLARATIONS WORKERS' COMPENSATION DECLARATION: hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of Consent to self -Insure for workers' compensation, as provided for by section 3700 o1 the Labor Code, for the performance of the work for which this permit is Issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed it the permit is valued at one hundred dollars ($100) or less.) ❑ 1 certify that in the pertorm ri of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of C ' mia, agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these pro ' i s. Z — ` I� Applicant Signature: Date: WARNING: FAILURE TO SECURE W R FESS' COMPE ODVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND OVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), I ADDITION iO THE T OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed underns of Chapter 9 {commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic. # provisioClass Contractors Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there Is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lenders Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. It, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractors) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, Califomia Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare all RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 at the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 It an AMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication armit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Li gge Yes L.J No (Section 65850.2 of the California Govemment Code requires that the requested information be fumished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (it yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code), 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (11 'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penaily of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Sig ure Of Legal Owner(s) Date r And/Or A orized Applicant Date CODE y. tNSPECTION TYPE QAU INTITIAL CODE INSPECTION TYPE Jig IN TnALS 1616 Fixed System Final Fire Prevention 208 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Relaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy J - 2446-46 (714) 754-5273 • Fax (714) 754.4856 • WWW.cl.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 BUILDING PERMIT Job Address: 3333 BRISTOL ST Status: ISSUED Suite: ROBM Applied: 04/05/2001 Vicinity: ROB -MAY PARKING LOT Issued: 04/05/2001 Parcel Number: 41250103 Zoning: PDC PDC Applicant: RICHEY, TY ISSUED BY: Address: 3188 AIRWAY #C Phone: (714) 885-8950 COSTA MESA Zip: 92626 , Owner: CMF INC Address , %MAY DEPT STORES CO ST"L6, is, MO Phone'. ' 611 OLIVE ST #1300 Zip: 63101 , 'L Contractor: DAY CONSTRUCTION CO Address: 3188 AIRWAY#C Phone: (714) 885-8950 !� � COSTA MESA Zip: ' 92626 'License: "610643 Arch Eng:. Address: Address_:' Phone: Phone: Zip: License: License: `• ,n SCOPE OF PERMIT', INSTALL CONCRETE LIGHT POLE'BASE & ELEC•FOR A STANDARD IN THE'"ROB-MAY" PARKING AREA. I }' FEE SUMMARY Plan Check: $25.19 Calc Valuation: , ` $1 000!66: 'Permit: , $38.75 Y _ Vii' ., - Claim Valuation: I ;,'; $1,000.00, `SMIP Res: $0.00 SMIP Cam:. $0.50 Other:" . $0.00 Inspection: $0.00//` Total: 164:44. PLANNING_ ,& ZONING SETBACKS MAIN STRUCTURE Front 0 0 Rearms ; 0-'0' Left. 0- 0 "= % Right 0; 0? ACCESSORY Front , � 0- 0 �•; Rear '0_0 Left 0- 0- 1 Right -'0- 0- ' l PARKING Existing: 4 Required: 0_ Proposed: 0,' NOTES: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 2446-46 (6=) C/ 0-4 VYDRKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: a Policy Number: (This section need not be completed if the permit is valued at one hundred dollars ($100) or less.) ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Rom an agree that if t should become subject to the workers' compensation provisions ofS Z1�9 700 of the Labor Code, i shall forthwith comply with these pr I ions /Applicant Signature: Date: T WARNING: FAILURE TO SECC4E ORKERS' MP NSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION T E COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am lice n ed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license Is in full force and effect. Lic. # Class # Contractors Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lenders Name: Lenders Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .......................................................................................................................................................................................................................................................................................................................................... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Masa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). IT Does or wilt the applicant or present or future building occupant need to prepare en R M P P (Risk Management and Prevention Program for acutely hazardous matorials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. .............................................................................................. �.........................................................................................---.--........................,............................................................I...................... 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No ............................................................................................................................................................................................................................................................................................................................................................................ 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication apermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? )l Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ...................................................................._........................... .................................................................................................................................................................................................... ........---------.................................................... 6 Wlll any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ................................................................................................................................................................................................................................................................................ ............................. ­­ ..................... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by Califomia Health and Safety Code Section 42303 been made? ❑ Yes ❑ No .....................................................................................................................................•--•--....................................................................................................................................................................................................................... 8 (If jes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the inforrmaUon given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHOR6ZATION.OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until fine; inspection. 'gna a Of Legal Owner(s) t ale And/Or A ed Applicant / Date CODE P. 11,15PECTI TYPE INTrriAL2 CCDE0 INSPECTION TYPE DATE INTITIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy�L (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT Job Address: 3333 BRISTOL ST status: ISSUED Suite No ROBM Applied: 04/10/2001 Vicinity: ROB -MAY ROOF TOP Issued: 04/10/2001 Parcel Nunmber: 41250103 Applicant: JONES, BILL Address: Owner: CMF'INC Address %MAY DEPT STORES CO ST LOUIS, MO 611 OLIVE ST #1300 Contractor: , BROOKSTONE TELECOM INC_ Address: r 27450 YNEZ ROAD #300 Phone: (909) 694-4114 Zip: 92531 License: 711591 Phone: 909-232-3686 Zip: Phone: Zip: 63101 TEMECULA, CA ISSUED BY: SCOPE OF PERMIT INSTALLATION OF BASE TRANSCEIVER STATION ON AN EXISTING,ROOF (kOB-MAY) FOR "PAC ' BELL." _ - �. 1 MISC ELEC EQEJIPMENT REF: B01-00472 600-00779,1398-02161 r • . = �� ;%�. '�_:�� �- � l E01-00242, E00-00835, E88096924 ) /4. , r \ FEE SUMMARY ., Quantity? _ %' tity Quan ISSUE FEE' $23.50 - Temp Dist System I Lighting $0.00 0 Temp serJice test \$0.00 Busway I100 ft" $0.001% 0 1 / Res. a/c package $0.00 _ y� ; Standing Section -,-z $0.00/ 0 New Res (1-2 units) $0.00 \, _ 0 §-. - Misc Electrical Equi men! . ti-,� q P $18:20 1 New Res (3+units) ,\ % $0,00, .`�, `0 �r Transformers up to 1 kvalkw � �/ $0.00! 0, Pool /Spa \� � L� $000 ��\�0� �< < ° .::.........up to 10 kvalkw �' $O.DO�� �0' Lighting Fixts ��_� $0.00. ' 0� -�� - �...... up -to 50 kvalkW- .. V � - j Recept Outlets ` $d.00 �" ' 0 ....up to 1001iv -- w 0/ Switches $6.60!" 0 .............over 100 kvalkw \ ` $0.00 ,�0'/ Non Res Appi $0.00 0. Low Voltage Equipment, ` $0.00! 0` ' Res Appl x$0.00 0 / Low V o l tWir'ing System 1 Ckt $0.00) i �Z` 0 � Service to 200a $0.00- 01 : _ Misc. Conduit �$0.00� 0 Service to 1000a $0.00\- ,-'0. - `Misc. Conductor /$0.00 0 Service over 1000a $0.00 0 Circus-� ( gen or ride)-, $0.00 0 Motors to 1 hp $0.00 0 Circus_(mech-ride.or lights} $0.00 0 Motors to 10hp $0.00 D - -Christmas Tree or $000 0 Motors to 50hp $0.00 0 Fireworks Stand $0.00 0 Motors to 100hp $0.00 0 Other Electrical Fee $0.00 Motors over 1 00h $0.00 0 Communication drops $0.00 0 Investigation Fee $0.00 Sub panel to 200a $0.00 0 Plan Check Fee $0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $0.00 0 Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $41.70 Intermed Pole $0.00 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92.28, § 1, 12.21-92) EXPIRATION: This permit shall automatically expire and become void if work Is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration.of this permit. FOR INSPECTIONS CALL: (714) 754-5626 j 2446.46 (&W) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by section 3700 of the Labor Cade, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. My workers' compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed if the permit is valued at one hundred dollars ($100) or less.) ❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and ag a that If I should become subject to the workers' compensation provisions of Section 3700 of the Labor Coda, I shall forthwith comply with these provision . Applicant Signature: Date: b `� WARNING: FAILURE TO SECURE WORKERS' COMPENSAT I5 UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE T COMP ATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: t I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic. # Class # Contractor's S' Date: y • 11b - 41 CONSTRUCTION LENDING AGENCY: ❑ t hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a Civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sola compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Cade for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No, Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Ari 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ............................................................................................................................................................................................................................................................................................................................ 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ............ ............. ................................................ .... .............. ............-......-•.------................................ ....................... I.............. ..................................................................................................................................................... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program tot acutely hazardous materials)? ❑ Yes ❑ No Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ............................................................................................................................................................................................................................................................................................................................................................................................ 4 If an RMPP is presently required, has Section 25534 of the Celifomia Health and Safety Code been fully complied with? ❑ Yes [I No ............................... ............................... .................................................................................................. ...............--........................................................................................................................................................ 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). .............................n.d.................................... w. 'i'.h. i'............................................................................................ c'h' ...............................................................................-.---............................... 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ................................... .•--............................................................. ................ ...................................... ................................................................................................................................................ .................... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ............................................................................................................................................................................................................................................................................................................................ ......................................... 8 (it -yes". attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION.OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state taws and city ordinances relating 10 building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signaore f 1\69 61 ner(s) Date ^40^61 And/Or Authorized Appiic Date CODE t• INSPECTION TYPE INTMA145 CODE N INSPECTIONnp mu WjT8 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof % 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92625 ELECTRICAL PERMIT .lob Address: 3333 BRISTOL ST Suite No ROBIVI Vicinity: RBM Parcel Nunmber: 41250103 Status: ISSUED Applied: 03/30/2001 Issued: 03/30/2001 Applicant: JONES, BILLY f - ISSUED BY: Address: 27450 YNEZ ROAD #300 r -;�C ­/_" hone: i (909) 694-4114 TEMECULA; CA- t Zip: 92531 194 Owner: ;CMF INC Address %MAY DEPT�STORES C6-' ST LOUIS ,.MO%_ Phone: 43 ,� ti 611 OLIVE•ST #1300 Zip: 63101 �•, '�W/ \ �, �S Contractor. BROOKSTONE TELECOM INC r Add: 27450 YNEZ ROAD #300 resss (909)694-4114s��� ,TEMECULA, CA ��_t���`� Zip: 92531 License: 711591 COPE .-... ERMIT 4 L'OW VOLTAGE AND,3 MIS ,REF.600 01906:.F ROOF ANTENA..AT,,ROBlNSON MAY. M1 `� r� �' (;�• ; ,,- -' ..._ =} FEE SUMMARY_' Quantity \ISSUE.FEE�Ij r Jf � ��`?� $23.50 Temp Dist System l Lighting $0,00 0 Temp service fesk , ;, $0.00 Busway 1100 ft % $0.00 0 Res `ah package 10V $0.00 �' Standing Section "$0.001, k 0 New Res (1 -2•u -nits) ti\�1 $0.00 0 Misc Electrical -Equipment $54.60 3` 1\ �;" / New Res (3+units) \\c $0.00 0 Y„Transformers up to 1 kva/kw $0.00 Pool ! Sp, t / 1� $0.00 0 r ,; f�;1 %..": ..up to 10 kvalkw $0.00 0 Lighting Fitts` \x,$0.00 0 Y,'c �" ...:.-"!,:rup.to 50 kvalkw $0.00 G'�0 Recept Outlets, �'� $0.00 0 �w.;,�'-i• ;` " .Q.........Z...up to 100 kvalkw $0.00 0 Switches �\ ;� $0:00•e�:...."..." . °over 100:kva/kiiv"^"- $0 00 0 �yti . � r� .. Non Res Appl /) $0.0001 , ' ,, ;, .,'Low Voltage Equipment> .$0:00 \0 0 Res Appl C//f $0.00 �`0 0 j ' <Low Volt Wiring System 1 Ckt� $100 00 4 Service to 200\� \ p - �0 o �. o $0.00 \ 0 oo Misc. Conduit $0.00 f0% Service to 1000a \\\ ! !� C " �$o.00�} 0 �Misc.;Conductor��==�� $b.00 0 Service over 1000a $0.00 �j � 0��� 1i: --- Circus:(gen:or,ride)' '$0:00` of (� Motors to 1hp $0.00, f 110` _-` = _Circu_s=(mech-_ride or fights) �$O.Q4��0J Motors to 10hp ~ ,$0.00 /////0% Christmas Tree Stand• $0100 0, Motors to SOhp $0:00 1 r0 / c 1 j ---,-Fireworks Stand531\ \ $0-0020 Motors to 1 00h $0.0�� 0� , J�� ,` ? �' Otfier'Elect�ical:Fee,� Motors over 100hp $0.00 0-` �_ �\,! r-. I t �� � Communication drops $0.000 = -- , . ry fnvestigation.Fee: "JCS $0.00 Sub panel to 200a $0.00 0'c-=�P�Iari:Check:Fee -� $0.00 Pole Light Pkg $0.00 0 Reinspection -Fee $0.00 Sign Circuits $0.00 0 Temp Pwr Pole 40.00 0 TOTAL CALCULATED FEES $178.10 Intermed Pole $0.00 0 COMMENTS I SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or it work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration. of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2aas•46 (6=) I DECLARATIONS WORKERS' COMPENSATION DECLARATION: f hereby affirm under penalty of perjury one of the following declarations: , ❑ 1 have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the 11_7y work for which this permit is issued. �10 l have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. My workers' compensation insurance carrier and policy number are: Carrier: Policy Number: (This section need not bo completed if the permit is valued at one hundred dollars ($100) or less.) ❑ 1 certify that In the performance of the work for which this permit is issued, I shall not employ any person In any manner so as to become subject to the workers' compensation laws of California, an gree that If I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provi Appllcant-Si ��' Date•�� �'�D` b r i i WARNING: FAILURE TO SECURE WORKERS'N T10N COVE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE: HUNDRED THOUSAND DOLLARS ($100,000), iN ADDITION TO TH T OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (Commencing with Section 7000) of Division 3 of the Business ani rafessions Code, and my license Is in full force and effect..Llc. #-- ) Class # Contractors Signature: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: 4 I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensatidn, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or improvement Is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certity that no excavation five (5) or more feet in depth into which a person is required to descend, will be made In connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Ari 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _ --._..................._._.__.._..............................._.-.-......................_.__ .................. _............... ._...................... ..._........ .................................................. .__...—................. —_................. ... 2 Daes or will tha applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). __..........................-............... ...._..................................................... ..................... _....................._................... _....................... __................................................................. -....... ........................................... ........................ 3 Does or will theaappplicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes C] ;T Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. _..................._................................................._..............................................................................................._................................................................_........................ _.................... __..................... 4 If an RMPP is presently required, has Section 25534 of the Califomia Health and Sefety Code been fully Complied with? ❑ Yes ❑ No ..........................._..-—._._.............................................__...................._.................. - - ................ --- r...................._ .._.......... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes I� No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). _.........:.........................................................................................................._......................................................................................................................................................... .......................................................................................... fi Wrll any part of the facility to be constructed under this permit be within 1000 feat lrom the outer boundaries of a school? ❑ Yes ❑ No (If yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). _..__........................_......................_...................._...................._._..---..-•--•-••--•............ ......___.-----.................-................... _----................ 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency Is required for the work which Is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No _............... ........... .... ........................ ................. ............... .................... ................................................................................ attach certificate of Compilance from the appropriate air pollution Control officer). CERTIFICATE OF COMPLIANCE: I certity that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE D A,=ORIZATION.OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with ell ata laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described propsaction Urposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. re O Date 3' 30 AndlOrAu &Al9ant —')Dale\ CODE i. INSPECTION TYPE INjFIAL$ CODE IF IN5PECTIONUPE Q,U IMITTIAL 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 206 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition ' 250 Final Building/Occupancy IN CITY OF COSTA MESA BUILDING DIVISION DEVELOPMENT SERVICES DEPARTMENT PERMIT PERMIT NUMBER E99-00024 (714) 754-5273 Fax (714) 754-4656 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT ,lob Address: 3333 BRISTOL ST Suite No ROBM Vicinity: ROBINSON MY Parcel Nunmber: 41250103 Applicant: YSLAS, THOMAS Address: 27450 YNEZ ROAD 300 Phone: 90-694-4114 TEMECUTA Zip: 92531 Owner: CMF INC Temp service test Address %MAY DEPT STORES CO $0.00 New Res (1-2 units) ST LOUIS,MO Phone: $0.00 611 OLIVE ST #1300 Zip: 63101 Contractor:. BROOKSTONE TELECOM INC Recept Outlets Address: 27450 YNEZ ROAD $1.00 Non Res Appl 300 Phone:. 90-694-4114 $0.00 TEMECULA Zip: 92531 Service to 1000a -License: 711591 SCOPE OF PERMIT 1 SWITCH & 1 CONDUIT. REF B98-2161. Quantity ISSUE FEE $22.00 Temp service test $0.00 Res. a/c package $0.00 New Res (1-2 units) $0.00 New Res (3+units) $0.00 Pool 1 Spa , $0.00 Lighting Fixts $1.00 Recept Outlets $0.00 Switches $1.00 Non Res Appl $0.00 Res Appl $0.00 Service to 200a $0.00 Service to 1000a $0.00 Service over 1000a $0.00 Motors to 1 hp $0.00 Motors to 10hp $0.00 Motors to 50hp $0.00 Motors to 100hp $0.00 Motors over 1 00h $0.00 Communication drops $0.00 Sub panel to 200a $0.00 Pole Light Pkg $0.00 Sign Circuits $0.00 Temp Pwr Pole $0.00 Intermed Pole $0.00 Status: ISSUED Applied: 01/14/1999 Issued: 01/14/1999 FEE SUMMARY Quantity - Temp Dist System /.Lighting $0.00 0 Busway 1100 ft $0.00 0 Standing Section $0.00 0 Misc Electrical Equipment $0.00 0 Transformers up to 1 kvalkw $0.00 0 ................up to 10 kvalkw $0.00 0 .................up to 50 kvalkw $0.00 0 .................up to 100 kvalkw $0.00 0 ....over 100 kvatkw $0.00 0 Low Voltage Equipment $0.00 0 Low Volt Wiring System 1 Ckt $0.00 0 Misc. Conduit $16.25 1 Misc. Conductor $0.00 0 Circus ( gen or ride) $0.00 0 Circus (mech ride or lights) $0.00 0 Christmas Tree Stand $0.00 0 Fireworks Stand $0.00 0 Other Electrical Fee $0.00 Investigation Fee $0.00 Plan Check Fee $0.00 Reinspection Fee $0.00 TOTAL CALCULATED FEES $40.25 EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 160 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 DECLARATIONS WdRKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ l have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. ❑ 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My work s' compensatio Ins rance carrier and policy number are: Carrier: f� Policy Number: (This section nebd not be clnplated if the permit is valued at one hundred dollars (310x?) or less.) ❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisions. Applicant Signature: _ Date: _ (WARNING: FAILURE TO S$CURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALT. SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I ant licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic. # Class # Contractor's Signature: Date: D/ q9 CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a Construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: T _ Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, after, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors license Law (Chapter 9 (Commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant tq a civ,I penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. It, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License taws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Da te: Owner ID verified by drivers license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUST41AL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feel in depth into which a person Is required to descend, will be made in Connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 Of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). Will ...---.--.................................................... 2 Does or will the applicant or present or future building occupant need to rile a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater then a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure), ..... ... ......................... ................. ........................................................--.--............................---.--.........................................---......................................... 3 Does or will the applicant or present or future building occupant need to prepare an RM PP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and fiting with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ..............................................................................•---•.......I........I.................. 4 If an RMPP is regent) re ulrod, has Section 25534 of the California Health and Safe Cade been full com lied with? p y q' ty y p ©Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a rmit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes IpeNo (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). .......................................................................................................................................................................................................................................................................... 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (ri't'es", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code), ....................................................................................... . .....................................'Ir,-P-0 ­1 . 0.1'1 - " "'c- ............. ir,ic"............................................t'h'e ..............-.......... h ....... ject......this. .F Ii a permit from tfie South Coast Air Quality Management Distric! or other air pollution control district or, agenc�r is required for the work which is the subject of this application, have fill of the disclosures prescribed by California Health and Safety Code Section 42303 been made. ❑ Yes ❑ No .............................................................................................................................................................................................................................................................. 8 (If fres", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all slate laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Dale: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is Correct. I agree to cornply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. I ature df Legal Owner(s)/ Date And/Or Authorized Applicant D T CGDE t. INSPECTION TYR: CODE INSPECTION TYPE DATE 1fiIIIlAL$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final Y 208 Final Plumbing 200 Final Re -Root 210 Final Electrical 201 Final Final Block/Retainfng Wag 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site _ 204 Final Demolition 250 Final Building/Occupancy 2446-46 MF CITY OF COSTA MESA BUILDIMG DIVISION DEVELOPMENT SERVICES DEPARTMENT PERMIT PERMIT NUMBER B98-02161 (714) 754.5273 Fax (714) 754.4856 77 FAIR DRIVE, COSTA MESA, CA 92626 BUILDING PERMIT Job Address: 3333 BRISTOL ST Suite: ROBM Vicinity: ROOF Parcel Nunmber: 41250103 Zoning: PDC PDC Applicant: YSLAS, THOMAS Address: Phone: 909-694-4114 Zip: Status: ISSUED Applied: 12/02/1998 Issued: 01 /1 411 999 Owner: CMF INC Address WAY DEPT STORES CO ST LOUIS,MO Phone: 611 OLIVE ST #1300 Zip: 63101 Contractor: BROOKSTONE TELECOM INC Address: 27450 YNEZ ROAD 300 Phone: 90-6944114 TEMECULA Zip: 92531 License: 711591 Arch Eng: Address: Address: Phone: Phone: Zip: License: License: o SCOPE OF PERMIT 2ND BTS INSTALLATION (4 X 6 X 6 FT. HIGH) FULLY SCREENED, AS APPROVED PER ZA 97-26. ISNTALL ONE ADDITION& PHONE EQUIPMENT UNIT AT ROOF AT E INSTALLATION. r THE 1ST INSTALLATION WAS COMPLETED UNDER PC#5035-97A. - FEE SUMMARY Plan Check: $146.09 Calc Valuation: $15,000.00 Permit: $224.75 Claim Valuation: $15,000.00 SMTP Res: $0.00 SMIP Com: $3.15 Other: $0.00 Inspection: $0.00 Total: $373.99 PLANNING & ZONING SETBACKS MAIN STRUCTURE Front 0-0 Rear 0-0 Left 0-0 Right 0-0 ACCESSORY Front 0-0 Rear 0-0 Left 0-0 Right 0-0 EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 A + • r. WORKERS' COMPENSATION DECLARATION: f hereby affirm under ponafty of perjury one of the foffowing deciarefions: 1 have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued, ❑ 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My work rs' tom ensation Ins nce carrier and policy number are: Carrier. L Poffcy Number: (This section need not be conip'lettid if the permit is valued at one hundred dollars ($ f 00) or less.) ❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply_with these provisions. rl_ Applicant Signature: Date: i WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER 70 CRIMINAL PENALTIES AND GVIL FINES UP TO ONE HUNDRED THIDUSAND DOLLARE (5100,000). IN ADOMON TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST. AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) o1 Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic. #Class a - Contractors Signature: y A t _ Date: . . � j ,1 _ 9_� CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is Issued. (Sec. 3087, Civil Code). Lenders Name: Lender's Address: SignAture: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that 1 am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to Its issuance, also requires the applicant for such permit to fila a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt lherefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sale compensation, WILL DO THE WORK, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or Improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. 11, however, the building or Improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). 0 I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of properly who builds or improves thereon, and who contracts for Such project with a contractors) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner f0 verified by drivers license. ❑ Yes ❑ No Drivor's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or dead): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION; ❑ 1 hereby certify that no excavation live (5) or more feet in depth into which a person is required to descend, will be made In connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) loot high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 6, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .....---�....................................... e. d' ..--,---..........is.t'r.........-.......................... z.a...............................................................-............................... 2 Does or will the applicant or present ar future building occupant need to fila a registration form for acutely hazardous materials? ❑ Yas ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ..............................................................................................'c'_c...-........-.-...........................-........,..................-..r'n..........................................................'1'y.' ....................... d. a. i...... 3 Does ar will the applicant or present or future building occupant need to prepare en RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the Cafifomia Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the fire Department. .... ..................................................................................... .... ....... ................... ....... ........................ .......................................................................... ........ a If an RMPP is presently required, has Section 25534 of the California Health and Safety Cade been fully complied with? ❑ Yes ❑ No ........................................................................................................................................................................•---....................................................................---"---........................ 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? [] Yes E No (Sectlon 65950.2 of the California Government Code requires that the requested information be fumished on applications for non-residentlal building permits). ---'*-"*,"*,is,",*''""----- .............is",..-m------.......-..................-...................................-----....-............................................................................................ .. 6 Will any part of the facility to ba constructed under this permit be within 1000 feet f:om the outer boundaries of a school? ❑ Yes ❑ No (If 'yes'. the facility must meet the requirement of Sections 25534 and 42303 of the Califomia Health and Safety Code). ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency Is required for the work which Is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 boon made? ❑ Yes ❑ No ................................................. ................................. ..................................................... ....... 8 (ff yes', attach certiftCste of compliance from the appropriate air pollution control cifioer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Data: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that 1 have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Sign ur Legal Owners)1& /�� ate dlOr Authorized Applicant f pDate G911" IHSPEMQN TYPE DM INTITA 5 CODE INSPECTIGHTYPE QAIE tNTMALS 161 B Fixed Systom Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 206 Final Plumbing 200 Final tae-Roof 210 Final Electrical 201 Finai Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site W 204 Final Demolition 250 Final Building/Occupancy PT z44e.46 M CITY OF COSTA MESA o BUILDING DIVISION >; DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER ''• PERMIT B99-01405 (714) 754-5273 Fax (714) 754-4856 77 FAIR DRIVE, COSTA MESA, CA 92626 BUILDING PERMIT Job Address: 3333 BRISTOL ST Status: ISSUED Suite: ROBM Applied: 09/02/1999 Vicinity: WHOLE STORE Issued: 12/28/1999 Parcel Number: 41250103 Zoning: PDC PDC Applicant: GARCIA, DAVE ISSUED BY: C� Address: 950 S. ARROYO PARKWAY CA Phone: (626) 578-1115 PASADENA Zip: 91105 Owner: CMF INC. $8,969.58 Address %MAY DEPT STORES CO , $13,799.35 ST LOUIS, MO- - Phone: 611 OLIVE ST #.1300 Zip: 63101 Contractor: DAY CONSTRUCTION CO $0.00 Address: 3188 AIRWAY #C f l Phone: (714)885-8950 COSTA MESA Zip: 92626 License: 610643 Arch : AP & T ARCHITECTS Eng: Address: 950 S. ARROYO PARKWAY- ', Address: CA Phone: (626) 578-1115 Phone: PASADENA Zip: 91105 License: License: SCOPE OF.PERMIT 223,404 SF STORE TENANT IMPROVEMENT FOR "ROBINSONS MAY" - INCLUDES INTERIOR PARTITIONS, CEILINGS, LIGHTING, ETC. REF: B99-00701 FOR SHELL BUILDING, Plan Check: $8,969.58 Permit: $13,799.35 SMIP Res: $0.00 SMIP Com: $681.20 Other: $0.00 Inspection: $0.00 Total: $23,450.13 SETBACKS MAIN STRUCTURE Front 0-0 ACCESSORY Front 0-0 FEE SUMMARY PLANNING & ZONING Rear 0-0 Leff 0-0 Rear 0-0 Left 0-0 Calc Valuation: $3,243,826.08 Claim Valuation: $0.00 Right 0-0 Right 0-0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92.28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 DECLARATIONS WORKERS' COMPENSATION DECLARATION: 1 hereby affirm under penalty of perjury one of the following declarations: VIve and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performanceof the rk for which this permit is issued. ave and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issuad. workers' compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed if the permit is valued at one hundred dollars ($100) or less.) ❑ I certify that in the performance of the work for which this permit Is Issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Califomla, and agree that if I should become subject to the workers' compo p ns of Section 3700 of the Labor Code, 1 shall forthwith It visions. Applicant Signatur - Date: WARNING: FAIL ORKER ' COMGENSA ON COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EM OY CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOU ($100,000}, IN DITION TO THE OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 37060E THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. [11h ICENS CONTRACTORS DECLARATION - affirm that I am licen d and r pr ions of Chapter 9 (commencing with Section 7000) of Di n 3 of the Business nd Professions Code, and my license is in full nd effoct. Lic. tt Class p Lctor's SignatureDate: CONSTRP21fOEN LENDING AGENCY: ereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lenders Name: _ Lenders Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption, Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors license Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her qwn employees, providod that such improvements are not intended or offered for sale. It, however, the building or improvement is sold within one year of comptebon, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Data: Owner ID verified by drivers license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of documerit, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation live (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high, (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division, Signature: Date: Division of Industrial Safety Permit Number: _ HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I Will the applicant or present or future building occupant need 10 file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be fled with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of Compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or f4ture building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or ftiture building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the Califomla Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses Which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required, has Section 25534 of the Calitomia Health and Safety Code been fully complied with? ❑ Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification from the South Coast Air Quallty Management District or from any other air pollution control district or agency? rU Yes M No (Section 65850.2 of the California GOverhment Code requires that the requested information be fumished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes', the facility must meet the requirement of Sections 25534 and 42303 of the Calitomia Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency Is required for the work which is the subject of this application, have all of the disclosures proscribed by California Health and Safety Code Secfion 42303 been made? ❑ Yes ❑ No 8 (if "yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature Of ner(sDate j Au nze "plica ate CODE 9. INSPECTIj2H 9AH INTITIALS CODE! INSPECTION 1XP INMIAL 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 f=inal Demolition 250 Final Building/Occupancy 2446-46 (714) 754-5273 • Fax (714) 754-4856 77 FAIR DRIVE, COSTA MESA, CA 92626 SIGN PERMIT ,lob Address: 3333 BRISTOL ST Plan Check: $117.81 Calc Valuation: $10,000.00 Suite: ROBM Permit: $181.25 Claimed Valuation: $10,000.00 Vicinity: $2.10 Other: $0.00 ' Parcel Nunmber: 41250103 Zoning: PDC PDC Applicant: SQUEAK KOSSNER $0.00 Address: $301.16 Phone: (949)975-8367 Zip: Owner: CMF INC Address %MAY DEPT STORES CO ST LOUIS, MO Phone: 611 OLIVE ST #1300 Zip: 63101 Contractor: CAREY SIGN GRAPHICS Address: 1274 N GROVE Phone: 714-630-8414 ANAHEIM CA Zip: 92806 License: 376085 Arch 1 Eng: Address: Phone: Zip: License: Status: ISSUED Applied: 05/23/2000 Issued: 05/23/2000 ISSUED BY: i�T SCOPE OF PERMIT INSTALL 3 SIGNS - EACH 5' HIGH BY 50.5' LONG - ONE EACH ON THREE FRONTAGES (SOUTH, EAST, WEST) FOR ROBINSONS/MAY. PLANNING & ZONING NOTES: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754.5626 FEE SUMMARY Plan Check: $117.81 Calc Valuation: $10,000.00 $0.00 Permit: $181.25 Claimed Valuation: $10,000.00 SMIP Com: $2.10 Other: $0.00 $0.00 Inspection: $0.00 $0.00 $0.00 Total: $301.16 PLANNING & ZONING NOTES: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754.5626 DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by section 3700 o1 the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy number are: r` Carrier. t� LJr Z) Policy Number: ly?6 V ID (This section need not be completed if the permit is valued at one hundred dollars ($100) or less.) ❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws ofCal omia, and rea that it I should become subject to the workers' compensation provisions of action 3700 of the Labor Code, I shall forthwith comply with these provisi s. Applicant Signature: Date: WARNING: FAILURE TO SECURE MPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE {$100,000), IN 171 TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic. If O 2r Class # 0—V Contractor's Signature: Date: 7db CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation at Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑. I, as owner of the property, of my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title B, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Data: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight o1 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one lime has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 --Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk M _,na--------------------------------------------------------- d � - �enti. �� � o a for acutely -------------------------------------- �� za d --..-.-� -. materials)? -------- . -- - -------------._.--- anagement and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No _ -- _-- _—.--- ----------------- ------ - -- -- _ _ ---_ _..--- -,__ ---- _ _--- - __ - - - ,_ _ _- - - _,_----...----_------------------------------------ 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication aermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes )� No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). --.---------- ..,.., _ _,_,-., - - ----.-..,---------- --------------------- -,a-,n-,-y - .,....-- 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if "yes', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). - - — - - _ --.._- - -- — --- -- _.. - _ -e-r _-_------------ ---------------- 7 If a permit from the South Coast Air Quality Management District or othair pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No a (If 'fres", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-describf property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Sig tura Oi Legal Owner(s) Date And/Or Authorized Applicant Data CODE INSPECTION TYPE D jg IMirrIAL5 CODE INSPECTION TYPE DATE INTMALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Finai Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy 2446-46 4 (714) 754-5273 • Fax (714) 754-4856 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT Job Address: 3333 BRISTOL ST Suite No ROBM Vicinity: WALL SIGNS Parcel Nunmber: 41250103 Applicant: SQUEAK KOSSNER Address: 1274 N GROVE Phone: 714-630-8414 ANAHEIM CA Zip: 92806 Owner: CMF INC Address %MAY DEPT STORES CO ST LOUIS, MO Phone: 611 OLIVE ST #1300 Zip: 63101 Contractor: CAREY SIGN GRAPHICS Address: 1274 N GROVE Phone: 714-630-8414 ANAHEIM CA Zip: 92806 License: 376085 SCOPE OF PERMIT ELECTRICAL FOR THREE iLLUMINATED WALL SIGNS FOR ROBINSONSIMAY, REF:SB00-00057 ISSUED BY: Status: ISSUED Applied: 05/23/2000 Issued: 05/23/2000 COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or it work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5628 FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 Temp Dist System I Lighting $0.00 0 Temp service test $0.00 Busway 1100 ft $0.00 0 Res. a/c package $0.00 Standing Section $0.00 0 New Res (1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0 New Res (3+units) $0.00 0 Transformers up to 1 kvalkw $0.00 0 Pool I Spa $0.00 0 ................up to 10 kvalkw $0.00 0 Lighting Fixts $0.00 0 .................up to 50 kvalkw $0.00 0 Recept Outlets $0.00 0 .................up to 100 kvalkw $0.00 0 Switches $0.00 0 ..................over 100 kvalkw $0.00 0 Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0 Res Appl ' $0.00 0 Low Volt Wiring System I Ckt $0.00 0 Service to 200a $0.00 0 Misc. Conduit $0.00 0 Service to 1000a $0.00 0 Misc. Conductor $0.00 0 Service over 1000a $0.00 0 Circus ( gen or ride) $0.00 0 Motors to 1 hp $0.00 0 Circus (mech ride or lights) $0.00 0 Motors to 10hp $0.00 0 Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 0 Fireworks Stand $0.00 0 Motors to 100hp $0.00 0 Other Electrical Fee $0.00 Motors over 100hp $0.00 0 Communication drops $0.00 0 Investigation Fee $0.00 Sub panel to 200a $0.00 0 Plan Check Fee $0.00 Palo Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $73.80 3 Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $97.30 Intermed Pole $0.00 0 COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or it work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5628 DECLARATIONS *OkERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance o1 the work for which this permit is issued. My ars' compensation Insurance carrier and policy number are: '12e-00 Carrier. Policy Number: ' (This section need not be complera4l if the permit is valued at one hundred dollars ($100) or less.) ❑ 1 certify that in the performance of the work for which this permit Is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Cali rnia, and agree that If I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these pro Ass s. �� Applicant Signature: Date: � _ WARNING: FAILURE TO SECURE O E S' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN DDITI N TO THE CAST OF COMPENSATION, DAMAGES AS PROWDED FOR IN SECTION 3705 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed underprovisions of hapten 9 mmencing with Section 7000) of Division 3 of the Businessand Professions Code, and my license is in full force and effect. Lic. #__3'1b0 k _ Class 4 C Contractor's Signature: Date: 3 CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a Construction lending agency for the performance o1 the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: _ Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he of she is licensed pursuant to the provisions o1 the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. It, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who Contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license, ❑ Yes ❑ No Driver's Ucensa No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation live (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, talsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Adminigtrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure), 2 Does or will the applicant or prgsent or future building occupant need to file a registration form for acutely hazardous materials? .0 Yes _❑ No uW w l (Section 25533 of the California Health and Safety Coda, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight o1 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or prgsent or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and tiling with the Fire Department of an RMPP by buginesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5 Does Or will the applicant or present or future building occupant require for the work which is the subject of thisa plication a emlit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? 8 Yes a No (Section 65850.2 of the Califomia Government Code requires that the requested Information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if -yes ", the facility must meet the requirement of Sections 25534 and 42303 of the CaMomla Health and Safety Code) 7 It'a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No S (If "yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-describ d property for inspegtion purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection, Sig lure Of Legal Owner(s) GD Date LZ AndlOr Authorized Applicant Date CODE 8• INSPEGT10H7YPE )&U iNTmALS gQDE INSPECTION TYPE ,pM )NTMALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical Q 201 • Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy 2446-46 rr(.4 :(�.i (714)754-5273 • Fax(714)754-4856 CITY OF COSTA MESA 19r, BUILDING DIVISION DEVELOPMENT SERVICES DEPARTMENT PERMIT Job Address: '3333 BRISTOL ST Suite: ROBM Vicinity: Parcel Nunmber: , 41250103 . BUILDING PERMIT Zoning: PDC PDC PERMIT NUMBER B99-01229 77 FAIR DRIVE, COSTA MESA, CA 92626 Status: ISSUED Applied: 08/06/1999 Issued: 08/06/1999 Applicant: TURLEY, PAUL • ISSUED BY: Address: 3188 AIRWAY ` #C Phone: 714-885-8950 COSTA MESA, %� ` f Zip: 92626 Owner. CMF'I C� ti Address %MAY•DEP,T STORES'CO ST LOUIS;.MO "Phone'.' :_. �. • �� J fit 1 OLZip: 63101 IVE ST -#1300.' ' ` r ~ \� �_ _ Contractor: DAY CONSTRUCTION CO /r , dd� . � Aress: 3988 AIRWAY \ Phone:. 714-885-8930 COSTESA p• 9262 License: 610643 Arch , �i;;/ �� Eng. - Address: 1 r _ ", Address: Phone: �� Phone: �; i License: License: f r SCOPE OF PERMIT DEMOLISH EXIST NON BEARING WALLS; EXTERIOR WALL"COVERING AND ROOF SHEET METAL IN PREPARATION FOR FUTURE,ADDITION TO R06INSON MAY.'" FEE SUMMARY f: Plan Cl ecEc '.' $0.00 Calc Valuation: $so;000.oti r Permit .%, , $923.75 _ - — Claim Valuation: $90,000,00 1 SMiP Res:' $0.00 f i l ti. ,. '�SMIP Com: ,,`\�� $18.90 1 Other: `Inspection: \$0.00 ' Notal: $94265 - PLANNING_ & ZONING SETBACKS'.\ �. MAIN STRUCTURE Front 0-0 ACCESSORY Front; `0- 0 PARKING Existing: .0 NOTES: Rear '0-'0 Left 0-0 Rear0-0 Left 0-0 R. squired: 0 Proposed: Right 0- 0, ! ' i Right . 0-o"', o. NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord, No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 DECLARAVONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent 10 self -insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed if the permit is valued at one hundred dollars ($100) or less.) ❑ I certify that in the performance of the work for which this permit is issued, i shall not employ any person in any manner so as to became subject to the workers' compensation laws of i rnia, and agree that if I sh ecome subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith Corr) hese pr ' ' I nt Sign e: IECI AMPENSATION COVERAGE NLAWFUL AND SMALL SUBJECT AN IMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENWMON, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I here d under provisi ns of Chapter 9 ommencing with Section 7000) of Div[ s ss�andPmlassjons S,,pd nd my licens�fn rce and e L C. # lass* [- Contracto s Signature: Data: ON LENDING AGENCY: rLendores I hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is Issued. (Sec. 3097, Civil Code). Name: Lender's Address: ature: Datw OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Coda: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a coniractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or dead): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that n0 building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Data: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater then a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or wilt the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may requiro the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materialswith the Fire Department. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully compiled with? ❑ Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? jJ Yes H No (Section 65850.2 of the California Government Code requires that the requested information be fumishad on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (It yee, the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 It a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (if'yW, attach certificate of Compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above Is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: t certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. S' to s} � a r Authorized Appllca t CODE t INSPECTION TYPE PATE v lNTITIA CODE a INSPECTION TYP(NTMA 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Butlding/Occupancy ^ 2446-46 (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 BUILDING PERMIT Job Address: 3333 BRISTOL ST Suite: ROBIVI Vicinity: ROB -MAY ROOF TOP Parcel Number: 41250103 Applicant: JONES, BILL Address: Owner: CMF INC- .• , 0 Zoning: PDC PDC ISSUED BY: Phone: 909-232-3686 Zip: l Address /oMAY DEPT S10RE5 CO- - - _ ST LOUIS, MO Phone: 611 OLIVE ST #1300 Zip: 63101 Contractor: BROOKSTONE TELECOM INC Address: • 27450 YNEZ ROAD #300 Phone: (909)694-4114 TEMECUTA. CA �. Zip: t " 92531 --License: ' 71.1591. Status: ISSUED Applied: 04110/2001 Issued: 04/10/2001 Arch Eng:. , Address: Address: Phone: .Phone: Zip: License: License: -- • SCOPE OF PERMIT; —' INSTALLATION OF THE 4TH SASE TRANSCEIVER -STATION (3 ALREADY INSTALLED) ON AN EXISTING ROOF, \ (ROB -MAY) FOR "PAC BELL." REF: B00-00779, 898-02161 E01-00242, E00-00835, E88099924 + ZA-97-26' FEE SUMMARY Plan Check: $0.00 _ Calc Valuation: ;� $30,000.00 Permit: \$442,25 Claim Valuation:'•' $30,000.00 SMIP Res: $0.00l�f�j SMIP Com: $6.30 Other: $0.00 Inspection: $0.00,,�V Tota l:. \$ 448.55 PLAN NING"&ZONING SETBACKS MAIN STRUCTURE Front '0-0 Rear,' -0-0' Left D-0 �) '! Right/0 0� ACCESSORY Front 0-0 Rear 0-0 _ Left 0- 0 . r.. -Right 0-0 PARKING Existing]: 0 Required: 0 Proposed:_" 0 NOTES: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12.21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration.of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2x46-46 (6100) 11/ WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the labor Code, for the performance of the work for which this permit is Issued. 1 have and will maintain workers' compensation insurance, as required by section 3700 of file Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and polka number are: Carrier; Policy Number: (This section need not be completed if the permit 1s valued of one hundred dollars ($ too) or less.) ❑ I certify that in the performance of the work for which this permit Is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and ag that It I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisions. Applicant Signature:_ Data: WARNNG: FAILURE TO SECURE WORKERS' COMPENS -ri UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE F PENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is In full force and effect. Lic. # Class # Contractor's Signature: Data: =i . I b - a S CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a Construction lending agency for the -performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lenders Neme: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or Improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Dew Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.9. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-slx (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec, 341, Title 6, California Administrative Coda). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and ceriity a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume at 55 gallons, or 200 cubic foot of compressed gas at standard temperature and pressure). ............................._...........................- _ ._.... _ .................. -....................... _..................... ..................... ................ ........................................................ .-.............................. ................ —_........ _ - 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 o1 the Calilomia Health and Safety Code, with same exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ......... . ......................................................... — _ _^.....--......-.............._.._....................... ...................... _............................................................................................................................ ....-.............. _ . ............... _.._ 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials}'i ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ............................................I..............._..........................._...........................................................••....................-,.....................................................................................................••,..•_...................................................................__.......--. 4 If en RMPP is presently required, has Section 25534 of the Calitomia Health and Safety Code been fully Complied with? ❑ Yes ❑ No ....... ............... .... .................................................. ------........... -----...---..................................... ........................-................................................................................. ...................................... ................................ ............... ...................... ............... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes � No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any parr of the facitiry to be constructed under this permit be within 1000 feet from the outer boundaries of a school? 0 .Yes ❑ No (If yes the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Coda). _..--.-.. _...--- ......... - ..... ----.....---._....._..............._—........................................_. __._....... ----- ....... - --- 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and SafetyCode Section 42303 been made? ❑ Yes ❑ No _ ...._._...- ................_...._..--- ........_.... .._..........-_......................... ..........-................................ ........................ ..--..... ............ --.................. — ........... ---..._. 6 (If yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certily that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION. OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit unfit final inspection. Si nat Of Legal Owner(s) Date :A- .A ) And/Or At z ate CODE R. INSPECnoN TYPISL$ CODE It INSPECTION TYPE Qf INIMA 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 BUILDING PERMIT .Job Address: 3333 BRISTOL ST Status: ISSUED Suite: ROBM Applied: 06/01/2000 Vicinity: ROOF Issued: 08/23/2000 Parcel Number: 412501c3--, zoning: PDC PDC Applicant: SIMPSON, GERI - - - Calc Valuation: ' Address: 27450 YNEZ RD Claim Valuation: SMIP Res: SUITE 300 Phone: (909) 694-4114 SMIP Com: TEMECULA, CA Zip: 92591 Owner: CMF INC Address %MAY DEPT STORES CO Total: ST LOUIS, MO Phone: . 611 OLIVE ST #1300 Zip: 63101 Contractor: BROOKSTONE TELECOM INC PLANNING & ZONING Address: 27450 YNEZ ROAD #300 MAIN STRUCTURE Front 0-0 Rear 0-0 Left -0-0 Phone:, (909)694-4114 Front . 0- 0 TEMECULA, CA Right. 0-0 PARKING Zip: 92531 License: 711591 a . ISSUED BY: Arch : Eng: BOJORQUEZ & ANDERSON Address: Address: 3185 AIRWAY AVE Phone: COSTA MESA, CA Phone: (714) 444-3030 SUITE H Zip: License: 92626 License: SCOPE OF PERMIT INSTALL ONE NEW BTS CABINET FOR "PACIFIC BELL WIRELESS" FOR CELL SITE. -ALL SCREENED BY EXISTING AND FUTURE MECHANICAL SCREEN. $30,000.00 $30,000.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, an -a required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this perm'L FOR INSPECTIONS CALL: (714) 754-5626 t r Maas -as (rrao) FEE SUMMARY Plan Check: $287.46 - - - Calc Valuation: Permit: $442.25 Claim Valuation: SMIP Res: $0.00 SMIP Com: $6.30 Other: $0.00 Inspection: $0.00 Total: $736.01 . • PLANNING & ZONING SETBACKS MAIN STRUCTURE Front 0-0 Rear 0-0 Left -0-0 Right 0- 0 . ACCESSORY Front . 0- 0 Rear 0-0 Left 0-0 Right. 0-0 PARKING Existing: 0 Required: 0 Proposed: 0, NOTES: $30,000.00 $30,000.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, an -a required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this perm'L FOR INSPECTIONS CALL: (714) 754-5626 t r Maas -as (rrao) DECLARATIONS WORKERS' COMPENSATION DECLARATION: ' I hereby affirm under penalty of perjury one of the following declarations: © i have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Coda, for the performance of the ®,Zwvfk for which this permit is issued. .1 and will maintain workers' componsation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My rkers' compen tin Insur rtce er and oltcy umb are: Carrier: Policy Number:_Y�7 (This section need not be completed it the permit Is valued at one hundred dollar 100) or less.) ❑ 1 certify that in the performance of the work for which this permit is issued. I shall not employ any person in any manner so as to become subject to the workers' compensation taws of California, and agree that if I should become subject to the workers' compensation provision012 00 of the Labor Code, I shall forthwith comply with these 'sions. Applicant SignatureDate: WARNING: FAILURE T SECURE WORKERS' COMPENSATION COVE E IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Cade, and my license is In full force and effect. Lic. p Class a Contractor's Signature Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance o1 the work for which this permit Is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Data: OWNER -BUILDER DECLARATIONS: hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, after, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt lherelrom and the basis for the alleged exemption. Any violation of Sectlon 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Driver's License No, Expires: Verification of Ownership by (type of document, I.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Coda). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Masa Fire Department by every business which has at any one time during a reported year a quantity o1 hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure),_ J ...... _-11-111111111111111 .......................-"""""""""""-..... _............ --- ....... ----- 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of Compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need io prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No {Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ....................".."""..............................................................................................................................................................".....""............. ...................................................................................._ .. 4 If en RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No ................................e-n-...."rf'...................."............"."....."""....I,'r,'......"ir,"...'o-'r -....""'w" "r'k' "...."""".h' i'...........s'u' ..................."is'......p.5'.a'..............."--""•"""...................."""....""""....._..................._............._...—. 5 floes or will the appticanl or present or future building occupant require for fila work which is the subject of, this a�pfcation a�ermil for such Construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). _...................... ..........-..................—_....."".............—........................................................................".....""""".....""""""..."" 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ............."""_""""........._...__...__._.............""""""...... ._.....................................""•"•""""""---...................................................................._.........."""""............................. _ ........_ _.......... 7 If "" a permit from the South Coast Air Quality Management Distdcl or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No -."""••"""""......................................I•""""..._........ .................... .................... ....- ...................................... ........................... _."."""""""""".."""--- 8 (tf yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify udder penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Ignature Of Legal Owner(s) I Date �Q U And!O uthorized Applica Qat 01gy L INSPECTION TYPE 26M IMMIAL§ CODE INSPECTION TYPE DIE ItMALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Well 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final BuildinglOCcupancy CITY OF COSTA MESA _" y ' F _ BUILDING DIVISION PERMIT NUMBER DEVELOPMENT SERVICES DEPARTMENT J•; PERMIT B99-00701 (714) 754-5273 Fax(714)754-4856 77 FAIR DRIVE, COSTA MESA, CA 92626 BUILDING PERMIT Job Address: 3333 BRISTOL ST Suite: ROBM Vicinity: NEW ADDITION Status: ISSUED Applied: 0511811999 Issued: 09/22/1999 Parcel Number: 41250103 Zoning: PDC PDC Applicant: DAVID GARCIA ISSUED BY: Address: _ a' -,,Phone: 626=578=11.15-` w Zip` '/% �-- Owner: CMF ING./ -. Address %MAY DEPT STORES -601 ST,LOUIS, MO i ---'Phone, �J611 OLIVE ST #1300 j'y = ,{ c Zip: Contractor DAY CONSTRUCTION CO X /� \\ Address: \3188 AIRWAY #C Phone: (714)885-8950 COSTA:MESA i Zip 926261 License:, 610643 Arch : ABRAHAMIAN PAGLIASSOTTI & TANAKA :: ' Eng: Address: '950 SOUTH ARROYO PKWY P * /� Address: 1, --Phone: _626-578.1115 �� "�� Phone: r' PASADENA,'CA 91105 "T Zip: j i' ��... _ License: > / Cfcense: SCOPE OF PERMIT 23,603 SF LOWER LEVEL, 25,025 SF.MIDDLE LEVEL ADDITIONTO EXISTING "ROBINSON MAY" SEE PA -99-24 FEE SUMMARY `y Plan Check:$6,9$8.4$ �_ � ,. , r -�. J #_, :: _�_ Valuation: 1$3,086,968.92' _Calc Permit: $10,751.50 _ - ^ - _ -- -Claim Valuation: ,:, $0,00 SMIP Res: $0.00 SMIP Com: $648.26 Other: A""10-00 �Inspectiom , ��'�$0.00 Total: x$18,388.24 7� PLANNING & ZONING: SETBACKS !,/ �� ,���- ,T� MAIN STRUCTURE Front 450-10,, y�Rear Left ..-250-0 Right - �0-0 \ 1\', � � � ! � - -1 � `,`lam � ` E � O 4 7 ♦ `/ /� / // ACCESSORY Front 0- 0 ' ,f Rear 0-0 Left 0-0- Right` ", 6-0 PARKING Existing: 0 Required: 9499 - Proposed: 1060. .. NOTES: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, g 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 WORKERS' COMPENSATION DECLARATION: r hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I I have and wilt maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed it the permit is valued at one hundred dollars ($100) or less.) ❑ 1 certify that In the perWE nce of the wor f which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws ofnia, and a if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these ovi. Applicant Signature: Date: WARNING: FAILURE TO CURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE 100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under prov' ' sof pt 9 ommencing with Section 7000) of Division 3 of the Business and Professions Code, and my license Is in full force and effect. Lic. # Class # Contractor's Signature: Date: CONSTRUCTION LENDING AG CY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Dale: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _ 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program fo ❑Yes [I No r acutely hazardous materials)? (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. _ —..... - ----- _---.--,.---.----.,.-,.---...,-------------------- ,..., . ­ ------- ----- 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? []Yes ❑ No - -- ------- --------------------- -------- ..-------- ------ 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? IU Yes a No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If "yes', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 if a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No .---------------------------------- -- - — - 8 (if 'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. i agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. e Of Legal Owner(:) Date - And/Or Authorized Applicant Date D t- INSPECTION TYPE 2AN INTRIALS CODE = INSPECTION TYPE DATE INTITIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 206 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy � %' i 2446-46 o`�p RFs CITY OF COSTA MESA a BUILDING DIVISION DEVELOPMENT SERVICES DEPARTMENT PERMIT (714)754-5273 • Fax(714)754-4856 BUILDING PERMIT PERMIT NUMBER Boa -00269 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Status: ISSUED Suite: ROBM Applied: 03/02/2000 Vicinity: ROBINSONS MAY STORE BACKROOM AREA Issued: 03/08/2000 Parcel Number: 41250103\ Zoning: PDC PDC , Applicant: DON WALKER ISSUED BY: Address: 160 E. MONTECITO #E Phone: (626) 355-1360 SIERRA MADRE, CA Zip: 91024 Owner: CMF INC Address %MAY, DEPT STORES CO_ ST LOUIS, MOS - . _ Phone: ' 611 OLIVE ST #1300 Zip: 63101 Contractor: -.DON WALKER ENTERPRISES Address: 160 E. MONTECITO #E Phone: (800) 676-4050 SIERRA MADRE, CA . Zip: 91024 License: 772391 1 Arch Eng: SAL E FATEEN Address: _ Address: 161 ATLANTIC ST Phone: Phone: (909)869-0989 POMONA,CA Zip: License: 91768 License: SCOPE OF PERMIT INSTALLATION OF BACKROOM SHELVING FOR "ROBINSONS MAY" STORE. FEE SUMMARY Plan Check: $63.58 ` .. - - Calc Valuation: $25,000.00 Permit: $391.25 f.' Claim Valuation: $25,000.00 SMIP Res: $0.00 SMIP Com: $5.25 Other: $0.00 Inspection: $0.00 Total: $460.08 PLANNING & ZONING SETBACKS MAIN STRUCTURE Front 0-0 Rear 0-0 Left 0-0 Right 0_0 ACCESSORY Front 0-0 Rear 0-0 Left 0-0 Right 0-0 PARKING Existing: 0 Re uired: 0 Proposed: 0 NOTES: " r - NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 DECLARAMNS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of penury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the tabor Code, for the performance of the s Ework for which this permit is issued. h ve and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 1?.(rvorkers' compensation Insurance carrier and policy number are: aI ,e`i: - Icy Number j ca action need riot be completed if the pbrrhigos valued at one hundred dollars $ fOO) or fess.) ❑ 1 certify that Int the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws o1 Cafifomia, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with the rovislons. , ppticent.Signature: _� t' 1` Date1"'" �CO - It NI LUEM Tp, ECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUaIECT AN E PLIN 'IIYEATCRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARE (SiOD.000), IN ADDff1ON TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 37o6 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm th m.licensad under provisions of C ter 9 (commencing with Section 7000) of Division 3 of a 6usine and Professions Code, and my license is in full force and effect. C i ass n� omractars Slgnatuse: ate'— CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is issued. (Sec. 3097, Civil Code). Lender's Name: Lenders Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjurythal I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the properly, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her awn employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License taw does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, lalsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2. Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code), ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division at Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity o1 hazardous materials equal to Or greater than a weight of 500 pounds, or a volume o1 55 gallons, or 200 cubic feel of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration farm for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater then a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will th applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air poltution control district or agency? Yes K No (Section 65850,2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if "yes', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 It a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by Califomia Health and Safety Code Section 42303 been made? ❑ Yes ❑ No B (if -yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I cenify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Rate: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. i agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. ignature Of at Owe ] Date -.ur., r' �•_ An'd10 , RPI n ori.?:: Date CODE f. I^ ECTION Typ DATE INTfTIALS CODE INSPECTION TYPfi 2AM IML 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final BlocQRetaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy 2446.46 ya� (714)754-5273 • Fax(714)754-4856 CITY OF COSTA MESA BUILDING DIVISION DEVELOPMENT SERVICES DEPARTMENT. . PERMIT .lob Address: 3333 BRISTOL ST Suite No ROBM Vicinity: ROBINSONS MAY STORE Parcel Nunmber: 41250103 Applicant: SMITH, JIM Address: 3188 AIRWAY #C COSTA MESA, CA Owner: CMF INC Address %MAY DEPT STORES CO ST LOUIS, MO 611 OLIVE ST #1300 Contractor: DAY CONSTRUCTION CO Address: 3188 AIRWAY #C COSTA MESA ELECTRICAL PERMIT Phone: (714) 885-8950 Zip: 92626 Phone: Zip: 63101 Phone: (714)885-8950 Zip: 92626 License: 610643 SCOPE OF PERMIT AFTER HOURS ELECTRICAL INSPECTION WITH RANDY BUCK FOR 4129100. FEE SUMMARY NUMBER E00-00389 77 FAIR DRIVE, COSTA MESA, CA 92626 ISSUED BY: Status: ISSUED Applied: 04/28/2000 Issued: 04/28/2000 r Quantity ISSUE FEE $0.00 0 Temp service test $0.00 0 Res. a/c package $0.00 0 New Res (1-2 units) $0.00 0 New Res (3+units) $0.00 0 Pool 1 Spa $0.00 0 Lighting Fixts $0.00 0 Recept Outlets $0,00 0 Switches $0.00 0 Non Res Appl $0.00 0 Res Appl $0.00 0 Service to 200a $0.00 0 Service to 1000a $0.00 0 Service over 1000a $0.00 0 Motors to 1 h p $0.00 0 Motors to 10hp $0.00 0 Motors to 50hp $0.00 0 Motors to 100hp $0.00 0 Motors over 100hp $0.00 0 Communication drops $0.00 0 Sub panel to 200a $0.00 0 Pole Light Pkg $0.00 0 Sign Circuits $0.00 0 Temp Pwr Pole $0.00 0 Intermed Pole $0.00 0 FEE SUMMARY NUMBER E00-00389 77 FAIR DRIVE, COSTA MESA, CA 92626 ISSUED BY: Status: ISSUED Applied: 04/28/2000 Issued: 04/28/2000 r Quantity Temp Dist System l Lighting $0.00 0 Busway 1100 ft $0.00 0 Standing Section $0.00 0 Misc Electrical Equipment $0.00 0 Transformers up to 1 kvalkw $0.00 0 ................up to 10 kvalkw $0.00 0 .................up to 50 kvalkw $0.00 0 .................up to 100 kvalkw $0.00 0 ..................over 100 kvalkw $0.00 0 Low Voltage Equipment $0.00 0 Low Voll Wiring System I Ckt $0.00 0 Misc. Conduit $0.00 0 Misc. Conductor $0.00 0 Circus ( gen or ride) $0.00 0 Circus (mech ride or lights) $0.00 0 Christmas Tree Stand $0.00 0 Fireworks Stand $0.00 0 Other Electrical Fee $282.00 Investigation Fee $0.00 Plan Check Fee $0.00 Reinspection Fee $0.00 TOTAL CALCULATED FEES $282.00 COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Calitomia statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void it work is not commenced within 180 days, or it work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval wilt result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 / DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is Issued. ❑ I have and will maintain workers' compensation insurance, as required by section 3700 of the labor Code, for the performance of the work for which this permit Is Issued, My workers' compensation Insurance carrier and policy number are: , Carrier: Policy Number: (This section need not be completed if the permit is valued of one hundred dollars (3140) or less.) ❑ 1 certify that in the performance of the work for which this permit Is Issued. I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forlhwith comply with these provisions. Applicant Signature: Date: WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARE (5100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is In full force and effect. Lic. of Class q Contractor's Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is issued. (Sec. 3097, Civil Coda). Lenders Name: Lenders Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors license Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signelure: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more teat In depth Into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high, (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 6, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds. or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure), 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Coda provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP Is presently required, has Section 25534 of the California Health and Safety Code been fully compiled with? ❑ Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application aermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes 15 No (Section 65850.2 of the California Government Code requires that the requested Information be furnished on applications for non-residential building permits). 6 WIII any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if 'yes*, the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42,103 been made? ❑ Yes ❑ No 8 (if 'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury (he Information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Dale: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. i agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for Inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final Inspection. n Legal Owner(s)'` Date wr,? 4& ndlOr Authorized Applicant Date CODE 1, INSPECTIONTYPCQpi;.tl INSPECTIONTYPE 26M INTITAL5 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 206 Final Plumbing 200 Final Re -Roof 210 Final Electrical IRJ 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy 2446.48 r (714)754-5273 • Fax(714)754-4856 CITY OF COSTA MESA BUILDING DIVISION DEVELOPMENT SERVICES DEPARTMENT PERMIT Job Address: 3333 BRISTOL ST Suite: ROBM Vicinity: Parcel Nunmber: 41250103 GRADING PERMIT Zoning: PDC PDC f , PERMIT NUMBER . 1 999-00010 77 FAIR DRIVE, COSTA MESA, CA 92626 Status: ISSUED Applied: 05/18/1999 Issued: 08/11/1999 Applicant: DARIUS FATAKIA _ _ ISSUED BY: Address: ,Phone:' 949-472-3401 Y 1 1 Zip. Owner: CMF NCi \ - ,lig Address %MAY DEPTSTORES,CO //STLOUIS\MO` V"���f. Phone: 61.1 OLIVE ST#1300,x_ Zip: 63101 \ �\ f Contractor: �Cp+uS`RucT�0r� Ada /re ss: Phone: C7 iq Zip•f QEDp r Licenser�nlQCa43 %} En /LARRY TODD/ROBERT BEIN, WILLIAM FROST Address: I X14725 ALTON PKWY Phone:- 949-472 3505 > f}J LRVINE,CA yJ� �- _ f _ '�;;� ` /� •' ,1 �t Zi f ' •'92fi18! �' ' " License: C35569 t f P•1 �:o I 1 { � SCOPE OF PERMIT V �' ' CUBIC YARDS � GRADING FOR "ROBINSON'S MAY" ADDITION TO EXISTING BUILDING. 14000 FEE SUMMARY - . $a.00Plan-Ceck�ti' $66.00 --acauan: $0.00 i Permif. v� '%�, $348.50 Other: ��� $0.00 $0.00 lnspection:A ��` , $0.00 $0.00 Total , $44:50 ,>> v- �� vA��.���'�'" ��" PLANNING.B ZONING \' A :�.f NOTES:- U moi' Yi Jr; It NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 ! • WORKERS' COMPENSATION DECLARATION: ti I hereby affirm under penalty of perjury one of the following declarations: ` ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the tabor Code, for the performance of the rk for which this permit is Issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. My workers' Compensation Insurance carrier and policy number are: Carrier: S7, A=—Z- wo Policy Number: (This section need not be completed ff the permit is valued at one hundred dollars ($100) or less.) ❑ 1 certify that in the perfor ce of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' Corr laws of Jfo ia, and agree that if I should become subject to the workers compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these pr, is' s. Applicant Signature: Date: WARNING: FAILURE TO SECURE WORKERS' COMPENSATION OOVERJZE rS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE (5100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under.provts 04 of Chapter 9 (Commencing with Section 7000) of Divisaon 3 of the Business and Prolessions Code, and my license is in full force and effect. Lie. # 44 Class # ! - /7 - C Contractors Signature: Date: " -.2" CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a Construction lending agency lot the performance of the work for which this permit is Issued. (Sec. 3097, Civil Coda). tenders Name: Lenders Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that udder penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a penult to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sale compensation, WILL DO THE WORK, and the structure Is not intended Or offered for Salo (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or Improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Seo. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Driver's License No, Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet In depth Into which a person Is required to descend, will be made In connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feat high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: _ Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Coda requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to Or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ NO (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of Compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Coda provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire [)apartment. 4 if an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5 Does or will the gppllcant or present or future building occupant require for the work which is the subject of this a placation a mit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes 1 No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (11 'yes'. the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No B (If 'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. l agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described proparty for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. at Owner(s) Qate And/Or Authorized Poricant Date CODE t• INSPECTION TfPE PAU I(ML$ CODE INSPECTION TYPEp�,T #MAL$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Oocupancy s'i -- 244G46 (714) 754-5273 • Fax (714) 754-4856 CITY OF COSTA MESA BUILDING DIVISION DEVELOPMENT SERVICES DEPARTMENT PERMIT BUILDING PERMIT Job Address: 3333 BRISTOL ST Suite: ROBM Vicinity: BRISTOL STREET EXIT Parcel Nunmber: 41250103 Zoning: PDC PDC Applicant: BOTELLO, DEMETRIO Address: 1100 E. ORANGETHORPE AVE. PERMIT NUMBER • B99-00686 77 FAIR DRIVE, COSTA MESA, CA 92626 ISSUED BY: ANAHEIM, CA —' Phone: (714) 578-9503= SUITE 200 / j ! i Zip: 92801 Owner: CMF,"INC' Address %aMAY DEPT�STORES CO ,,ST LOUIS; M0\ Phone:' i `i /, _ -� - " dui /� ♦ � /.�— - _ ail 611.OLIVE ST.#1300 ;-�% _. � Zip: 63101 � ;"� �,`��% f X� Contractor. SULLY MILLER --CONTRACTING �• \/ ./Address: 100 E. ORANGETHORPE AVE Phone: (714) 578-9604 ANAHEIM CA ♦`��` ��' Zip: 92801 License ; 747612.0 Arch �';'!;�'- f� J� Eng:, IAddress-�� Address:, Phone: - Phone: {' Zip:_License: ��License: i 'r SCOPE OF PERMIT WIDEN EXISTING ON-SITE.DRIVEWAY,•DRIVEWAY IMPROVEMENTS FOR SOUTHERN -MOST BRISTOL STREET ENTRANCE/ � �.. �' .. EXIT FOR SOUTH COAST PLAZA:. - � ",�,- %�'%..•` `,.- � . 1 i FEE SUMMARY `ti Plan Clieck: $507.65 �`tet' .r 1%- n = ` .� ':'1� Calc Valuation: J $83,000?00 Permit. `,'; ; $781.00 _ _ Claim Valuation: ' $83,000.00r SMIPRes:' $0.00 "SMIP"Cbm: $17.43 ` Other: I nspectiori: \ ` 10.00 $9,306.08 PLANNING &ZONING MAIN STRUCTURE Front 0- 0 Rear 0 0 Left 0 0 Right - 0- 0 ACCESSORY Front -0-0 Rear 0-0 Left 0-0 Right' 0- 0 • PARKING Existing: 0" Required: 0 Proposed: 0' NOTES: Status: ISSUED Applied: 05/17/1999 Issued: 08/18/1999 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 U DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the lollowing declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. I have and wig maintain workers' compensation Insurance, as required by section 3700 of the Labor Cade, for the performance of the work for which this permit Is Issued. My wo arsD' c.o�m.�p7ensatlon Insurance l cAarrier and policy number are: Carder: . �t �L Si J(:� c RA Policy Number. f (This section need not be completed if the permit Is valued of one hundred dollars ($100) or lass.) ❑ 1 certify that in the performance of the work for which this permit is Issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shell forthwith comply with these provisions. / J p Applicant Signature: EL(___ Date: c� 1 �/ / f WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARE (5100,000), IN ADDMON TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST. AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed r provisions of Chapter 9 (commencing with Section 7000) of Division 3C $e Business and Professions Code, and my license is in full force and affect. Lie. a (� _ _ Contracloes Signature: Ls ^� Date: -7d,711m CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there Is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Data: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to Its Issuance, also requires the applicant tar such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. 11, however, the building or Improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more test In depth Into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsewnrk, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code), ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and carllty a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business flan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 5DO pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California health and Safety Code, with soma exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity o1 acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume o1 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied wIth;F ❑ Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this a pllcation a emzit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes f No (Section 65850.2 of the California Government Code requires that the requested information be fumished on applications for non-residential building permits). 6 Will any part of the facility lobe constructed under this permit be within 1000 feet from the outer boundaries of a school? [:)Yes ❑ No (if 'yes', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 It a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (If 'yes-, attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinanceg regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final Inspection. Signature Of Le at Owner(s) l(� / Date / And/Or Authorized Applicant Date CODE 1, INSPECTION TYPE 2d¢ INTMA '3 CODE I INSPECTION TYPE 2M IKITTIAL$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 126$ Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final BlockfRetaining Wall 212 Final Fire Prevention 202 Final Factory Flre Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building /Occupancy IL. 244&46 b -rte. CITY OF COSTA MESA .� BUILDING DIVISION * DEVELOPMENT SERVICES DEPARTMENT PERMIT (714)754-5273 • Fax(714)754-4856 ELECTRICAL PERMIT Job Address: 3333 BRISTOL ST Suite No ROBM Vicinity: DRIVEWAY WIDENING Parcel Nunmber: 41250103 Applicant: FRED J JOHNSON Address: 3000 E CORONADO ST Phone: (714)632-1415 ANAHEIM, CA Zip: 92806 Owner: CMF INC Address %MAY DEPT STORES CO ST LOUIS, MO Phone: 611 OLIVE ST #1300 Zip: 63101 Contractor: F J JOHNSON, INC. Address: 3000 E CORONADO ST Phone: (714)632-1415 ANAHEIM, CA Zip: 92806 License: 489328 SCOPE OF PERMIT ELECTRfCAL FOR SOUTH COAST PLAZA DRIVEWAY WIDENING. 15 PKG LIGHT POLES 1 200 AMP SERVICE AND 3 MISC. CONDUITS. REF:699-00686 I Quantity ISSUE FEE $23.50 Temp service test $0.00 Res, a/c package $0.00 0 New Res (1-2 units) $0.00 0 New Res (3+units) $0.00 0 Pool I Spa $0.00 0 Lighting Fixts $0.00 0 Recept Outlets $0.00 0 Switches $0.00 0 Non Res Appl $0.00 0 Res Appi $0.00 0 Service to 200a $30.50 1 Service to 1000a $0.00 0 Service over 1000a $0.00 0 Motors to Ihp $0.00 0 Motors to 10hp $0.00 0 Motors to 50hp $0.00 0 Motors to f 00hp $0.00 0 Motors over 100hp $0.00 0 Communication drops $0.00 0 Sub panel to 200a $0.00 0 Pole Light Pkg $502.50 15 Sign Circuits $0.00 0 Temp Pwr Pole $0.00 0 Intermed Pole $0.00 0 PERMIT NUMBER E99-01194 77 FAIR DRIVE, COSTA MESA, CA 92626 Status: ISSUED Applied: 12115/1999 Issued: 12/15/1999 ISSUED BY: 2E24 FEE SUMMARY - - Quantity Temp Dist System 1 Lighting $0.00 0 Busway 1100 ft $0.00 0 Standing Section $0.00 0 Misc Electrical Equipment $0.00 0 Transformers up to 1 kvalkw $0.00 0 ................up to 10 kvalkw $0.00 0 .................up to 50 kvalkw $0.00 0 .................up to 100 kvalkw $0.00 0 ..................over 100 kvalkw $0.00 0 Low Voltage Equipment $0.00 0 Low Volt Wiring System 1 Ckt $0.00 0 Misc. Conduit $54.60 3 Misc. Conductor $0.00 0 Circus ( gen or ride) $0.00 0 Circus (mech ride or lights) $0.00 0 Christmas Tree Stand $0.00 0 Fireworks Stand $0.00 0 Other Electrical Fee $0.00 Investigation Fee $0.00 Plan Check Fee $305.55 Reinspection Fee $0.00 TOTAL CALCULATED FEES $916.65 COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of ISO days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 DECLARATIONS WORKERS' COMPENSATION DECLARATION: hereby affirm under penalty of perjury one of the lollewing declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. My workers' compensation Insurance carrier and policy number are: Carrior: Policy Number: (This section need not be caomplefed ff the permit is valued at one hundred dollars ($100) or less.) ❑ 1 certify that in the performance of the work for which this permit is Issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws oaf nd agrea that It I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these pr s. AppfiCanlSig11 re: Date: m'y% WARMING: FAILURE TO S CURE WO PENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIM:NAL PENALTIES AND O%nL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($1(30,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. tic. p �✓ i Class a o Contractors Signature: Data: 42 - _4r6- % CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there Is a Construction lending agency for the performance of the work for which this permit Is Issued. (Sec. 3097, Civil Code), Lenders Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that i am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Cade) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors Ucense Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractors) license pursuant to the Contractors License Laws.). © 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No, Expires: Verification of Ownership by (type of document, i,e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 o1 the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 boos or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Healih and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any qne time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 Cubic feet of Compressed gas, standard temperature and pressure). 3 oes or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Masa Fire Department may require the preparation, certification and filing with the Fire apartment of an RMPP by businesses which are reQulred to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? [:)Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this gppplication aermit for such construction or modification Irom the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes 19 No _(Section 65850.2 of the California Goverment Code requires that the requested Information be fumished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1 DDO feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meat the requirement of Sections 25534 and 42303 o1 the Calliornia Health and Safety Code), 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency Is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (11 "yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the Information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. 1 agree to comply with all state taws and City ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. _:;e�Slgn r Of Legal Owner(s) — � mate „ y n&Or Autharrzed Applicant Date 00 _# INSPECTION TYPE MM INTMAL5 CODE 11 INSPECTION TYPE DATE INTITIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pod Spa Final 208 Final Plumbing G 200 Final Re -Root 210 Final Electrical 1� . - �D -T 9 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy 2446.x6 CITY OF COSTA MESA ' BUILDING DIVISION t DEVELOPMENT SERVICES DEPARTMENT P �����ER � PERMIT ors_CM02A (714) 754-5273 • Fax (714) 754-4856 FIRE SUPIRESSIeN PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Status: ISSUED Suite: ROBM Applied: 01/26/2000 Vicinity: CMF INC ` Issued: 02/14/2000 Parcel Number: 41250103 Zoning: PDC PDC % Applicant: EMANUEL SOLI ISSUED BY: Address: SCOPE OF PERMIT ADD NEW FIRE SPRINKLER FOR NEWLY ADDED AREA, ALT EXISITNG SYSTEM FOR TI AREA, RE: B99-01405. FEE SUMMARY Plan Check: 1,115.50 Calc Valuation: $229,000.0 Permit: 1,716.15 Claimed Valuation: 229,000.00 Other: $0.00 Total: $2,831.65 NOTICE: The work authorized by this permit shall comply with all applicable handicap access 'requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 Phone: 818-782-2022 Zip: Owner: CMF INC ` Address %MAY,DEPT STORES CO ' ST LOUIS, MO '• Phone: ' 611 OLIVE ST #1300 ' Zip: 63101 Contractor: METRO.FIRE PROTECTION Address: 14141 COVELLO ST Phone:- 818-782-2022 VAN-NUYS, CA Zip: 91406 License: 578097 SCOPE OF PERMIT ADD NEW FIRE SPRINKLER FOR NEWLY ADDED AREA, ALT EXISITNG SYSTEM FOR TI AREA, RE: B99-01405. FEE SUMMARY Plan Check: 1,115.50 Calc Valuation: $229,000.0 Permit: 1,716.15 Claimed Valuation: 229,000.00 Other: $0.00 Total: $2,831.65 NOTICE: The work authorized by this permit shall comply with all applicable handicap access 'requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 DECLARAMNS WORKERS' COMPENSATION DECLARATION: r I hereby affirm under penalty of perjury one of the following deciaratlons: ❑ I have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the �j work for which this permit is issued. L� I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. My workers' compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed if the permit is valued at one hundred dollars ($ 100) or less.) ❑ 1 certify that In the performance of the work for which this piprmLl €s issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should oma subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisions. Applicant Signature: Date: WARNING: FAILURE TO SECURE WORKERS' OOMPENSA COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND GVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION; I hereby affirm that I am licensed under pro sions of Chapter 9 (comm cing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic. # ��' O Class # G — ( (4=� Contractors Signature: Date: 2-- 1 Y= cro CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there Is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: _ _ Lenders Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that tinder penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than We hundred dollars (5500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her awn employees, provided that such improvements are not intended or offered for sale. 11, however, the building or improvement is sold within one year of Complel€on, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contraclor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: __ Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code), ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industriat Safety, as noted above, unless such person has a permit to do Such work from the division. Signature: Data: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 W Ill the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater then a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet cf compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous mat"ats)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Pira Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication agermit for such construclion or modification from the South Coast Air Ouality Management District or from any other air pollution control district or agency? Yes ❑ No (Section 65850,2 of the California Government Code requires that the requested information be fumishad on applications for non-residential building permits). 6 Will any part of the lac€lity to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the fao€lily must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code), 7 WIt a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ NO B (If "yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree 10 Comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final Inspection, Signature Of Legal Owner s Date And/Or Aut prized Applicant Date goDE 0. INSPECTION ME pLijE IWITIA, CODE II INSPECIlON TYPE 2AM INTM LS 1616 Fixed System Final Fire Prevention °�"( —670 L� 206 Final Mechanical 1266 Pool Spa Pinal 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final BlocVRelaining Well 212 Final Fire Prevention i a • I —0-1:Y �] 202 Final Factory Fire Piece 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Bu€ldinglOccupency 2446-46 (714)754-5273'• Fax(714)754.4856 CITY OF COSTA MESA BUILDING DIVISION :;P111T NUMBED DEVELOPMENT SERVICES DEPARTMENT PERMIT 99-00219 ,lob Address: 3333' BRISTOL ST Suite: MALL Vicinity: SOUTH COAST PLAZA ESCALATORS 77 FAIR DRIVE, COSTA MESA, CA 92626 Status: ISSUED Applied: 09/07/1999 Issued: 09/14/1999 Parcel Number: 41250107 Zoning: PDC PDC Applicant: DUFFY, BRIAN ISSUED BY: Address: 23891 VIA FABRICANTE �. MISSION VIEJO, CA ' Phone:, - �: � :_ (949) 472-3186 ,._ SUITE617 Zip: 92691 - - Owner: SOUTKCOAST PLAZA Address 1k ,j.SERGERSfOM i)COSTA MESA, CA /�,� Phone: '',� X3315 FAIRVIEVU_RD-''�_.' Zip: 92626��`, Contractor:' TRI COUNTY FIREv Address: 23881,VIA FABRICANTE CA Phone: (949) 472-3186��`;� MISSION VIEJO Zip: 92692 License: 659326 ,,-'SCOPE OF PERMIT /12 FIRE SPRINKLER. HEADS FOR NEIN �_SCALATORS IN SOUTH COAST PLAZA. - REF:699-00246`` FEE SUMMARY Plan Check:- $63.21; ' , .• Calc Valuation: $4,000.00 ' Permit'- $97.25 ` ' Claimed Valuation: $4,000.0o- '� Other:" $0.00 ' Total:,$160.46 f.� NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12.21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: , In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Faiiurs to obtain inspections and final approval Will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: © I have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensatlon insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My worke ' compensation Insurance carrier and policy number are: D Carrier, til i G >• I` Policy Number: �%C (This section need not be completed if the permit is valued at one hundred dollars ($100) or less.) ❑ 1 Certify that in the performance of the work for which this permit is Issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Califomia, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these proyjsigns. �] Applicant Signature: %rs^" _?40 Date: WARNING: FAILURE TO SECURE WORKERS' COMPENSA RAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL P&ALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOU ARE (5700,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am IlconseS under provisigins. of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license Is in full force and effect. Lic. # Class # th _- Contractor's Signature:Date: CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any qty or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (5500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or Offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose Of sale.). ❑ I, as owner Of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bili or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth Into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more then thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-buifder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Data: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION- 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume at 55 gallons, or 200 cubic foot of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to fila a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 o1 the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight at 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 Ilan RMPP is presently required, has Section 25534 of the California Health and Safely Code been fully complied with? ❑ Yes ❑ No 5 Does or will the applicant or present or future building occupent require for the work which is the subject of this application aPffrmit for such construclion or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Dyes No (Section 65850.2 of the California Government Cade requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be Constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If yes", the facility must meet the requirement Of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (I1 'yes, attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Data: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with an state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for Inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature Of Legal n') 5,./ � e34' And/Or Autho plicant Dat CODE I. INSPECTION TYPE un �1 gLDF • INSPECTION TYPE R&U IUl 1616 Fixed System Final Fire Prevention Cl - R4 _Ci E � 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention " 1 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy 2446.46 'I CITY OF COSTA MESA BUILDING DIVISION - "PERMUMBER DEVELOPMENT SERVICES DEPARTMENT �• PERMIT E99-00840 (714) 754-5273 Fax (714) 754-4856 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT Job Address: 3333 BRISTOL ST Status. ISSUED Suite No MALL Applied: 09/08/1999 Vicinity: ESCALATORS ADJACENT TO "ROBINSON'S MAY" Issued: 0910811999 Parcel Nunmber: 41250107 ISSUED BY: Applicant: WALL, CINDY _ -- - - - Address: 5655 DOVER CA(Phone: (909) 628=7187 CHINO Jl�ti C } 'Zip: 91710+ i 'COAST POwner: 'SOUTH -ti_�c� �- _�. �_ �, -• Address�-t�,6C TSE f�J COSTA MESA; CAS Phone: /3315FIRVIEW-RD� Zip: 92626 / Contrac�o D P"MURPHY CO Address��5655:DOVER '; .CA'/ Phonf,,;(909) 628-7187i \ i rJl /f HINO '/Zp:•--.'9171D.._l } l,r�•, �.� ,1 �,1 License: 536483 y A, ' , .',�h,� ' � � .���'�� � tir ate.. - <� - _ , • �-� , ti�`�'jlj � 1 SCOPE OF PERMIT .-ELECTRICAL PERMIT F�I. @ "S.C. PLAZA" -ESCALATORS ADJACENTJQ "ROBINSONS MAY'': 1 INSTALL 8 -LIGHTS, 14=OUTLETS,-& 2-MOTORS'TQ 10'HP.-` , f REF: B99-00246 .`' .4, .) �`. h \ nn `fir; FEE-SUMMARYr;�{,� y Quantity/1', / i ISSUE -FEE j 1ti $23.50 Temp Dist System! Lighting $0.00 0/"/'/' `Temp service test ,,, $0.00 Busway /100,{t x$0.00 0 } Res. alc package $4.00 Standing Section $0.00 0%, New Res (1-2 units) ` $0.00 0 Misc Electrical Equipment R $0.00 f,0 ` r� / f '• 11 New Res (3+units) \ \1 $0.00 0 `" Transformers up to 1 kvalkw . $0.00 //'o, Pool /Spay ` / \\` ;x$0.00 0 ;:� „ :`. ; '� .....up to 10 kvalkw $0.00ti, , 0 Lighting"piicts �\ .$8.80 8 ,t ✓` ;! .: ....1 :up to 50 kvalkw, $D.OD!%f D Recept Outlets \$15.40 14 . . ..up,to,100.kvaRtw _ $D.00X 0 y /' Switches \\N\ a 0:00 0 H„F.'c,y}1, ;�:; �$ \ $ � ; �.... � � ,. ....':..over..100 kvalkw=:,4�"', D.00 0 , Non Res Apply` \ $0.00���� '0�� , �' ,� '� :Low Voltage Equipment .`�' � so 00 i�� 0 Res Al / _ j pp `-`\ $0.00 10 ; r" `Low Volt Wiring;System'! Ckt ; i $0.40 / 0� Service to200a ��� '$0.00 � 0�� '=' �3 MiscrConduitr,, $0.00 Service to 1000a -. �� `� Misc. Conductor =�'�" $0 00 0 v\ ; �.' ` *_��= - ( 9'en or ride) .$0:00r /0�"� Service over 1000a $D:OD .\. 0 ` - * Circ us'( ` ` ` Motors to 1 h $D:00;,; /0; Circus (mech ride or lights) �$0.00�! /-D% DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain work rs' comps sation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. My s' comnnntiorvtm Ter and policy number are: Carrlei T Policy Number: (This sectio not be completed 1f the permit is valued at one hundred dollars ($100) or less.) ❑ 1 cortify that In the performance of the work for w ich this permit is issued, I shall not employ any person In any manner so as to become subject to the workers' Compensation laws of Ilfomia, and gree that if s ould become subject to the workers' compensation provisions of Section 3700 of the tabor Cade, I shall forthwith comply with these prov s Applicant Signature: Date:. 0,/2 WARINWG: FAILURE TO SECURE WORKERS' ;OMP E TION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS {$100,0001, IN ADDITION TO TH OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am license pro f Chapter 9 (commencing with Section 7000) of Division 3 of the Businessd` Professions Code, and my license is in full force and effect. Lic. # Class # 1 Contractor's Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is issued. (Sec. 3097, Civil Coda). Lenders Name: Lenders Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or Improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i,e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet In depth Into which a person Is required to descend, will be made In connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, 11tle 8, California Administrative Cade). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Cade, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? Cl Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required, has Section 25534 of the Calitomla Health and Safety Code been fully complied with? ❑ Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a fermi.t for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes LJ No (Section 65850.2 of the California Govemment Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If -yes-, the facility must meet the requirement of Sections 25534 and 42303 of the Califomia Health and Safety Code), 7 11 a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which Is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (If 'yes", attach certificate of compliance from the appropriate air pollution control officer), CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. l agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. ig at re Of I (i i i t And/y Auirmrizuu Applicant ate CODE 1, INSPECTION TYPE 2AIX lfj ¢ CODE f INSPECTION TYPE p&jE INTMALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical Z�"r7711p 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy 2446.46 (714) 754-5273 • Fax (714) 754-4856 FIRE SUPRESSION PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Status: ISSUED Suite: MALL Applied: 06/08/2000 Vicinity: Issued: 06/28/2000 Parcel Number: 41250107 Zoning: PDC PDC ISSUED BY: Applicant: SHEILA LOONEY Address: Phone: 714-993-2822 Zip: Owner: SOUTH COAST PLAZA Address %C J SERGERSTOM COSTA MESA, CA Phone: 3315 FAIRVIEW RD Zip: 92626 Contractor: ALERT FIRE PROTECTION INC Address: 5200 E HUNTER AV Phone: (714)993-2822 ANAHEIM, CA Zip: 92807 License: 316324 SCOPE OF PERMIT INSTALL 2 NEW HEADS IN FILL OF ESCALATOR FILL BETWEEN 1STAND 2ND FL, RE:B00-00106. FEE SUMMARY Plan Check: $25.19 Permit: $38.75 Other: $0.00 Total: $63.94 Calc Valuation: $1,000.00 Claimed Valuation: $1,000.00 NOTICE. The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and filial approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 /f Ri rI WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ElI have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. f� I have and will maintain workers' compensation insurance, as required by section 3700yyyf the Labor Code, for the performance of the work for which this permit is issued. I My workers'�campensation I urance carrier and policy number are: , aa74;,-;, Carrier: _ -Z Policy Number: Lu (This section need not be completed if the permit is valued a1 one hundred dollars ($100) or less.) ❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California,agree at if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisions. / f� v Applicant Signature: Ul Date: C 2— WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAG UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPE ATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provi ions I Chapter 9 (commencing with Section 0) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic. # Class # Contractor's Signature: Date: _ U CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -budder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - properly tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). - - - ---...-;---.,...--------.......,................,........................ ........ ,.....---: ------......-......--........ --------------------------------------......,I.............................................................. ..-...,...,.--.,...,...,.--.,...,...,...-.. .,...-..,...,.. 2 Does or will the applicant or present or future building occupant need to file a reg�strat�on form for acutely hazardous materials? [:]Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _..,----.-------------------------------- - 3 Does or wilt the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5 as or will the applicant or present or future building occupant require for the work which is the subject of this gipplication agermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes LJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (Ii 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 if a permit from the South Coast Air Ouality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (If "yes", attach certificate of compliance from the appropriate air po0uticn control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to Comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. natureLegal Owner(s) � �ate,t ;} An Or Authorized A lerant Date CODE Y, INSPECTION TYPE 2ME INTM6LS CODE 0 INSPECTION TYP INTITIAL 1616 Fixed System Final Fie Prevention ' 3 !" f 5� V 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention ! - $� IN 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy 2446-46 (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT Job Address: 3333 BRISTOL ST Suite No MALL Vicinity: SECURITY OFFICE Parcel Nunmber: 41250107 Applicant: MARTIN, LOWELL Address: 1137 E SUNFLOWER Cl ORANGE,CA Owner: SOUTH COAST PLAZA Address CIO C J SEGFRSTROM COSTA MESA, CA 3315 FAIRVIEW RD Phone: (714)538-2504 Zip: 92866 Phone: Zip: 92626 Contractor: LOWELL MARTIN ELECTRIC INC Address: 1137 E SUNFI-OWER Cl Phone: (714)538-2504 ORANGE, CA Zip: 92866 License: 775598 ISSUED BY: Status: ISSUED Applied: 01/2412001 Issued: 01/24/2001 SCOPE OF PERMIT IMPROVEMENTS TO MALL SECURITY OFFICE: 22 FIXTURES, 90 OUTLETS, 6 SWITCHES, 14 COMMUNICATION DROPS, 6 SUB PANELS TO EC EQUIPMENT 1 HEATER UP TO 1 KVAIKW, 1 HEATER UP TO 10 KVAIKW. . 00-0195 FEE SUMMARY Quantity Temp Dist System 1 Lighting $0.00 0 Quantity ISSUE FEE $23.50 $0.00 0 Temp service test $0.00 Transformers up to 1 kvalkw Res. a/c package $0.00 $12.30 1 New Res (1-2 units) $0.00 0 New Res (3+units) $0.00 0 Pool 1 Spa $0.00 0 Lighting Fixts $23.46 22 Recept Outlets $73.10 90 Switches $6.60 6 Non Res Appi $0.00 0 Res Appl $0.00 0 Service to 200a $0.00 0 Service to 1000a $0.00 0 Service over 1000a $0.00 0 Motors to 1 hp $0.00 0 Motors to 10hp $0.00 0 Motors to 50hp $0.00 0 Motors to 100hp $0.00 0 Motors over 100hp $0.00 0 Communication drops $15.40 14 Sub panel to 200a $183.00 6 Pole Light Pkg $0.00 0 Sign Circuits $0.00 0 Temp Pwr Pole $0.00 0 Intermed Pole $0.00 0 FEE SUMMARY Quantity Temp Dist System 1 Lighting $0.00 0 Busway 1100 ft $0.00 0 Standing Section $0.00 0 Misc Electrical Equipment $36.40 2 Transformers up to 1 kvalkw $4.75 1 ................up to 10 kvalkw $12.30 1 .................up to 50 kvalkw $0.00 0 .............up to 100 kvalkw $0.00 0 ..................over 100 kvalkw $0.00 0 Low Voltage Equipment $0.00 0 Low Volt Wiring System 1 Ckt $0.00 0 Misc. Conduit $0.00 0 Misc. Conductor $0.00 0 Circus ( gen or ride) $0.00 0 Circus (meth ride or lights) $0.00 0 Christmas Tree Stand $0.00 0 Fireworks Stand $0.00 0 Other Electrical Fee $0.00 Investigation Fee $0.00 Plan Check Fee $0.00 Reinspection Fee $0.00 TOTAL CALCULATED FEES $378.51 COMMENTS 1 SPECIAL. CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, g 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not Commenced within 180 days, or if work Is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754.5626 zaoc-ac taws DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ l have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work far which this permit is Issued. My workers' compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed if the permit is valued at one hundred dollars ($100) or less.) ❑ I certify that in the performance of the work for which this permit is Issued, I shall not employ any person in any manner so as to became subject to the workers' compensation laws of California and agree that if I should become sub'ect to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provislonS. �� Applicant Signature: r Date: /l L WARNING: FAILURE TO SECURE WORKERSCOMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic. a Class a Contractor's Signature: f Data: CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is Issued. (Sec. 3047, Civil Code). Lender's Name: Lender's Address: Signature: Data: OWNER-BUILDER DECLARATIONS: hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License jaw does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself Or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or improvement Is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that n0 excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more then thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, .or 200 cubic feet of compressed gas at standard temperature and pressure). .......gistra............ti.............................. ....................................................................... 2 Does or will the applicant or present or future building occupat need to nfile a reon form for acutely hazardous materials? ❑Yes ❑ No (Section 25533 of the California Health and Safety Coda, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 1111_ 1111............._.......1111............. _.......•................_......................................_—.._................... .._............................... .................. ...................... ....._....... _......... .................... ................ ...................... _........................ 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. __......_....-•--- ...................... __.... . _.__................................................ 1111 --.._......................_—...................._.._._._..._............_..... .....------....... ...._........._------..... ............... W 1 111. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No ...............�111_1.......................... ....... I................... _..................... -- ... _..... ................._ ......... ............._ _...... 1111............._........... ........_ ... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification from the South Coast Air Duality Management District or from any other air pollution control district or agency'? LJ Yes 1 No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). –......................_............................. ----.....__...............__...................----.................-.. ............._.................... ..........................._ ....................._ .......... 6 Will any part of the facility to be eonsUucted under this permit be within---...1000..feat......from....the....outer......bo..undaries..of a scho..ol? ❑Yes ❑ No (if -yes". the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ... . ....................... ........................... .............................................. ....... ............................_...........................—..............................._....._................................... __............ _._._ ............ ...... ........... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 bean made? ❑ Yes ❑ No ............................................................................................................................. .................-....................................................................................................... ....................... ........................................................................ ............................,.,....... 8 (lf yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I cenify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I conify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. 'gna eOf Oeal r(s) Date o-° Y-0 ------ AndfOr Authorized Applicant Date CODE If INSPECTION TYPE 2AX IfJIMALS CODE / INSPECTION TYPE QAIE INTITIA1� 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wail 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final BuildinglOccupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-masa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT Job Address: 3333 BRISTOL ST Status: ISSUED Suite No MALL Applied: 07/03/2001 Vicinity: Issued: 07/03/2001 Parcel Nunmber: 41250107 Applicant: MARTIN, LOWELL ISSUED BY: Address: 1137E SUNFLOWER CIR Phone: 714-538-2504 ORANGE, CA Zip: 92866 Owner: SOUTH COAST PLAZA Address %C J SERGERSTOM COSTA MESA, CA Phone: 3315 FAIRVIEW RD Zip: 92626 Contractor: LOWELL MARTIN ELECTRIC.,INC ' Address: 1137 E SUNFLOWER Cl NPhone: (714)538-2504 ORANGE, CA Zip: 92866 License: 775598 i :SCOPE OF.PERMIT REF: B01-00983. "SOUTH COAST PLAZA SECURITY OFFICE�T.I._ELECTRICAL`TO INCLUDE: 23 LIGHT FIXTS., B`OUTL•ETS, 2 SWITCHES, 6 COMMUNICATION DROPS. _ -- - FEE!SUMMARY Quantity -'.-. - ' /;4 r/ Quantity . ISSUE FEE $23.50 Temp Dist System l Lighting $0.00 0 Temp service test $0.00 Busway 1100 ft $0.00 0., ` Res. a/c package, $0.00 Standing'Section "" $0.00 1'0' , New Res (1-2 units) $0.00 0Misc Electrical Equipment $0.00 0 .�...; New Res (3+units). $0.00 0 r. ', Transformers up to 1 kvalkw $0.00 0 Pool !Spa $0.00 0 tom% '" -'up to 10 kvalkw $0.00 0 Lighting Fixts ' x$24.19 23 - " . ' .................up to 50•kvalkw $0.00/, 01 Recept Outlets $6:80 8z "'' :...F 1111.. up to:100'kvalkw ^ �" {;$0:00 0 Switches '` $2.20 .`. z 2;'" .: " r..:.......:....:over 100 kvalkw " `-- $0"00 0 Nan Res Appl $0.04 �0 c= '� °Low•Voita e Equipment 9. ,.C $0.00✓`' ' 0 % Res Appl �� ` �$0100 �01�t; -� o ; r� LOinr Volt Wiring5ystem`1 Ckt:�$0.00 . ''0 Service to 200a �$0.00�� \\\\0 � • Misc. Conduit $0.00 1 �/0 , Service to 1000a �, som r 0 Misc. Conductor'_ `$0.00,zl; 0 Service over 1000a $0.00\` i .� 0' Circus (gen or ride) ;'` t $0100 0,/ Motors to 1 hp $0.00 , Circus (meth - ride or lights) $0.00', 0 Motors to 10hp ,.$0.00 ,_ 0, ".' , ,' Christmas Tree Stand'. $0.00 0 Motors to 50hp $0.00 ~; 0 Fireworks Standx$0.00 0 Motors to 1 00h $0.00 ,~' -0 ` ` Other Electrical Fee /' $0.00 Motors over 1 00h $0.00 ``".0 Communication drops $6.60 6,_ _ Investigatio6 F e f $0.00 Sub panel to 200a $0.00 0 Plan, Check Fee $0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $0.00 0 Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $65.29 Intermed Pole $0.00 0 COMMENTS / SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446.46 (6100) DECLARATIONS j RKERS' COMPENSATION DECLARATION: reby affirm under penalty of perjury one of the following declarat€ons: I hav nd will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the for which this permit is Issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: Policy Number. (This section need not be completed if the permit Is valued of one hundred dollars ($ f 00) or less.) ❑ 1 certify that in the performance of the work for which this permit is issued. I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Cali ornia, and agree that if I should become subject to the workers' compensation provisions of Section 700 of the Labor Code, I shall forthwith --_comply with these pro vis. ns. /-& / O } Applicant Signature: 4 5 Date: l r � WARNING: FAILURE TO SECURE WORKERS COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SU&JECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic. # Class # Contractor's Signature: 7 Date: CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No, Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sac, 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be tiled with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ................................................................................................................................................................................................................................................................................................................................................................................ 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ...... ................................................................................ ."",....................................................................................................................................................................................................................................................... I .............................. 3 Does or will the applicant or present or future building occupant need to prepare an AMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Heatth and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RM PP by businesses which are required to register acutely hazardous materials with the Fire Department. 4.......f.a.R.M..P................................................... .................................................................... ....................................................... ............................................................................................................................... ..................................... is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? E] Yes El No ..................................................... . 5 goes or will the applicant or present or future building occupant require for the work which is the subject of this g2plication a Permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Witl.an art of the facilit...to be con-ir"....................e,r.....................................h-........................................u"t'...................................................................................................................................................................... ..................... . y p y strutted under this permit be within 1000 feat from the outer boundaries of a school? ❑Yes ❑ No (if 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). .... ....... ............................... ......................................................................................... .............................................................. ------------...................................................................................................................................................... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No .................................................................................................................................................................................................................................................................................................................................................................... 8 (If "yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. i a tor o f Le Owners O gate r 1 And/Or Authorized Applicant Date CODE R. INSPECTION TYPE DAM Imo$ QQ.QE INSPECTION TYPE DATE INTMAL 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical L(L 201 Final Block/Retaining Welt 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 PLUMBING PERMIT Job Address: 3333 BRISTOL ST Suite No MALL Vicinity: SECURITY OFFICE Parcel Nunmber: 41250107 Applicant: WATSON, DUSTY Address: 1260 LOGAN AVE. B-2 ISSUED BY: Phone: (714)662-7933 COSTA MESA, CA Zip: 92626 Owner: SOUTH COAST PLAZA Address %C J SERGERSTOM COSTA MESA, CA Phone: 3315 FAIRVIEW RD Zip: 92626 Contractor: WATSON CONSTRUCTION INC. Address: 1260 LOGAN AVE. B-2 Arch / Eng : Address: Phone: (714)662-7933 COSTA MESA, CA Zip: 92626 License: 705797 Phone: Zip: License: Status: ISSUED Applied: 01/22/2001 Issued: 01/22/2001 SCOPE OF PERMIT PLUMBING PERMIT FOR INTERIOR T.I. OF SECURITY OFFICE OF "SOUTH COAST PLAZA". INSTALL 1 CONNECTION, 1 FLOOR DRAIN, 1 BAR SINK, 1 TRAP PRIMER, & 1 WATER HEATER, REF: B00-01950 QTY FEE SUMMARY AMT ISSUE FEE $23.50 Backflow irrigation $0.00 Backflow Preventer $0.00 Bathtub $0.00 Clarifier System $0.00 Connect (Ice,Soda,etc) $9.80 Dental Units $0.00 Dishwasher $0.00 Drain, Floor $9.80 Drain, Rainwater $0.00 Drain, Roof $0.00 Drinking Fountain $0.00 Expansion Tank $0.00 Gas Earthquake Valve $0.00 Gas (1-4 outlets) $0.00 Gas (Over 4 outlets) $0.00 Gas Repipe $0.00 Gas Service $0.00 Interceptors (Grease, Oil) $0.00 Interceptors (Sand Auto ) $0.00 QTY FEE SUMMARY AMT QTY AMT QTY Laundry Tub 1 Washer $0.00 0 Sump Pump $0.00 0 Landscape Irrigation $0.00 0 Swimming Pool $0.00 0 P -Trap $0.00 0 Trap Primer $9.80 1 Pressure Regulator $0.00 0 Urinal $0.00 0 Process Piping (per 10 ft) $0.00 0 Vacuum Brkr Bkflow(l A) $0.00 0 Receptors $0.00 0 Vacuum Brkr Bkflow(5+) $0.00 0 Septic Tank $0.00 0 Wash Basin $0.00 0 Sewer Cap for Demo $0.00 0 Wash Basin Set $0.00 0 Sewer Connect $0.00 0 Waste and Vent System $0.00 0 Sewer Private Line $0.00 0 Water Closet (Toilet) $0.00 0 Shower $0.00 0 Water Heater/ vent $12.30 1 Sink, bar $9.80 1 Water Piping (Inst or Rep.) $0.00 0 Sink, commercial $0.00 0 Water Re -pipe $0.00 0 Sink, Floor $0.00 0 Water Service $0.00 0 Sink, kitchen $0.00 0 Water Softener $0.00 0 Sink, servicelmop $0.00 0 OTHER $0.00 Spa (private) $0.00 0 VIOLATION $0.00 Spa (public) $0.00 0 PLAN CHECK $0.00 REINSPECTION $0.00 0 TOTAL CALCULATED FEES: $75.00 NOTICE: The work authorized by this permit s�vi`8 IaSREM6 641IMMONS requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446.46 (6/00) IN DECLARATIONS WORKERS' COMPENSATION DECLARATION: hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. l have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: F,Ga�rier.. 'PolicyNumber: € {Thls section nee not be completed if the permit 1s 1ue at one hundred dollars f$100) or less.) ❑ I certify that in the performance of the work for which this p rmi ' issued, I shall not employ any person in any manner so as to become subject to the workers' compensation law Califomia, and agree that hould eco a bject to the workers' compensation provisions of Section 3700 of the Labor Code, 1 shall forthwith comply with thele pro isions. sApplicant Signature- Dater-_� WARNING -FAILURE TO SECURE WORK RS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000}, IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVi DED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that 1 am licensed under provisions of Chapter ommencing with Section 7000) of Division 3 of fhe.Susiness and Professions Code, and my License is in full �- :. force and effect. L'fc.� Class'#-•� Contractor's Signature:-- - I Data--- CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lerlding agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: T Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a coniractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e, - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division o1 Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Numbon HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ................................a' n".........................o'r' ....... r'e....... ild'................--p'a' .............d, t'......1*e*....................................................................z'a'..........................."I's"...............................................................................................,. 2 Does or will the applicant or present or future building occupant need to file a registration farm for acutely hazardous materials? ❑Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ............................................................................................................................................................................................................................................................................................................................................................ I............ 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ............................................................................................................................................................................................................................................................................................................................................................................................ 4 if an RMPP is presently required, has Section 25534 of the Califomia Health and Safety Code been fully complied with? ❑ Yes ❑ No ........ ....... .................................................. ............................................................................................................ .................. .................................................................................................................................. I ........................... .............. 5 does or will the applicant or present or future building occupant require for the work which is the subject of this a plication aggennit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes LJ No (Section 65850.2 of the Califomia Government Code requires that the requested information be furnished on applications for non-residential building permits). ....................m...... .......................................................................... ........................................................................................................... ------•--....................................................................................................................................................... 6 WIII any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (11 'fres", the facility must meet the requirement of Sections 25534 and 42303 of the Califomia Health and Safety Code). .............................................................................................................................-...............................................................-------------............................................................................................................................................................. 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safely Code Section 42303 been made? ❑ Yes ❑ No ........................................................................................................................................................................................................................................................................................................................................................ attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and cityordinances regarding Hazardous Materials and Emission4, Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORI ON OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and ity rdinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above -dost d property for inspection u ses. a e of to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature Of Legal Owner(s) Date Arid/Or Authoriied'Applicant' +Dater�� CODE /. INSPECTION TYPE PAM INTRIALS CODE f INSPECTION TYPE 1Z9IE Rm@dL$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing r 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy f CITY OF COSTA MESA BUILDING DIVISION DEVELOPMENT SERVICES DEPARTMENT;B00_01 ER T NUMBER PERMIT 950 (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.usBUILDING PERMIT Job Address: 3333 BRISTOL ST Suite: MALL Vicinity: SECURITY OFFICE Parcel Number: 41250107 zoning: PDC PDC Applicant: WATSON, DUSTY Calc Valuation: $45,000.00 Address: 1260 LOGAN AVE Claim Valuation: $45.000.00 SMIP Res: $0.00 Phone: (714) 662-7933 SMIP Com: COSTA MESA, CA zip: 92626 Owner: SOUTH COAST PLAZA Address %C J SERGERSTOM Total: COSTA MESA, CA Phone: 3315 FAIRVIEW RD Zip: 92626 Contractor: WATSON CONSTRUCTION INC. Address: 1260 LOGAN AVE. B-2 Rear 0-0 Left 0-0 Right 0-0 Phone: (714)662-7933 COSTA MESA, CA Zip: 92626 License: 705797 77 FAIR DRIVE, COSTA MESA, CA 92626 ISSUED BY: Status: ISSUED Applied: 12/04/2000 Issued: 01/2212001 Arch : OLSON, DAVID Eng: Address: 15375 BARRANCA PRKWY Address: F101 Phone: 949-450-0093 Phone: IRVINE, CA Zip: 92718 License: C19424 License: SCOPE OF PERMIT IMPROVEMENT TO MALL SECURITY OFFICE TO INCLUDE RELOCATING SECURITY SUPERVISIOR, SECURITY, BREAK ROOM, HUMAN RESOURCES AND ACCOUNTING, ENLARGE DISPATCH OFFICE. NOTES: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or it work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 / 2446.46 (6100) FEE SUMMARY Plan Check: $96.49 Calc Valuation: $45,000.00 Permit: $593.75 Claim Valuation: $45.000.00 SMIP Res: $0.00 SMIP Com: $9.45 Other: $0.00 Inspection: $0.00 Total: $699.69 PLANNING & ZONING SETBACKS MAIN STRUCTURE Front 0-0 Rear 0-0 Left 0-0 Right 0-0 ACCESSORY Front 0-0 Rear 0-0 Left 0-0 Right 0-0 PARKING Existing: 0 Required: 0 Proposed: 0 NOTES: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or it work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 / 2446.46 (6100) DECLARATIONS I WORKERS' COMPENSATION DECLARATION: I hereby affirm under penafty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the rk for which this permit is issued. I#have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: 7 Carrier: if. (NQQR �JPolicy Number:. d_ 1 (This sa on n ompleted if the ermit is valded at one hundred dollars ($ f 00) or less.) ` ❑ 1 certify that in the performance of the work for which this rmit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation la of California, and agree t f I shou ecome subject to the workers' compensation provisions of Section 3700 of the labor Code, I shall forthwith comply with these p visions. rAppli�'nt Signature: WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CNIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000}, IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that,l,am ligensed under provisions of hapter 9 ( encing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect 6C.-# Class # Contractar's'Signature: — -"� Date: �`,� 7_-� —� If CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lenders Name: Lenders Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that l am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professlons Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner o1 property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 6, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight o1 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ..........................•.................................................................................... 1-----....................................................----•-•------..................................... .............. ,............................................................... ............. -..................................... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed........................................................................................ ----•-............................................................................................................................................................................... ................................. ................... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. .....................r'e" .......... ................................................'h' a..... -lif'o, ir'.........o'e-.................... t"e"......................-- "n -•-•---- ........... Ile, ......................... .................. --..................................................................... 4 tf a.. RMPP is presently required, has Section 25534 of the California Health and Safety Cade been fully complied with? ❑Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application agermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ LJ Yes No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). .........................................................................................................................................................................................................................I................................................................................................................... 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (I1 'fires", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). .......................................................................................................................................................................................................-....................._............................................................. 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes [:] No .................................................................................................................................................................................................................................................................................................................................. 6 (I1 jres", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the Information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purpo s. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signatur Of L Date { _ And/Or Authodzed'Appticant-- — •� - L- Date CODE t• INSPECTION TYPE PMT1H�S CODE INSPECTION TYPE INTITI&$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final BuildinglOccupancy �O O i (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Suite No MALL Vicinity: MALL Parcel Number: 41250107 Applicant: SANDERS, BIL"Lr Address: 1140 RED GUM ST' ANAHEIM CA" Owner., /"",SOUTH COAST PLAZA _" Address:/ /6C J SERGERSTOM, COSTA MESA;,CA 3315 FAIRVIEW RD MECHANICAL PERMIT Status: ISSUED Applied: 01/30/2001 Issued: 01/30/2001 ISSUED BY: - cz� Phone: (714) 630-3200 Zip: 92806 Phone: Zip:. 92626 Contractor -,_/ THERMALAIR INC Address: ' A140 RED GUM ST, r' ' Phone: ^ f 'ANAHEIM CA ` Zip: License: (714) 630-3200 ' 92806 102216 Arch_1 Eng: ' Address: i -;-'Phone: Zip: License: SCOPE OF PERMIT 4 " REF THE MALL SECURITY'OFFICES. REF B00-01950. 2 FAU UNITS? 100BTU: 1 ALTER DUCT " t' SYSTEM. 7 VAV BOXES. 2 COMPRESSORS UP TO 3HP-S. ,�� � - � i'lr• i � - ;1 1 1 FEE SUMMARY Quantity �; Y Quantity ISSUE FEES $23.50 Repair! Alt Absorbticn Unit i' $0.00 0 Inst FAU�100 k BTU �`� _ $29.60 2 Repair l Alt Refrigeration Unit �: $0.00 r�0' ; Inst FAU >100 k BTU \ .$0.00 0 Ventiilation'System 11/` i �. $0.00' %/0 Repair I Alt Cooling/Heath \'Z$13.70' 4 1 ' ' _` Evaporative Coolerw+ T -"� `', �� ' $0.00/I 0 Inst 1 Rep. Recess�Wall Htr / �.$0.0Q 0 ,. l` � Commercial Incinerator �� � � $0.000 Refrig Sys <100.k BTU /� $0.00��0 = Domestic Incinerator -�/` $0.00 0 Refrig Sys >100 k, BTU "G / $0.t30�0 " Compressors 1 Absor tion stemsY S V P. _..:._ Gas Piping `�\ /,$0.00 0`��`� � ', , Up to 3 hp 1.100.k.67U' � � l $0.00 0 Facto Fireplace ` $D.DO 77 , �� Factory P ` _ 3 -To 15 hp / 500 k BTU, ,\ r% �/ /$o.00 0 Hood wlMech Exhaust `���$0.00 i •0- - - 15 To 30 hp 1 1,000 k BTU\ ;� / $0.00 0 VAV Box $74:55_ _! 7 r ,_ 30 To 50.h 1,1,750 k BTU�� ` �' > $0.00 0 Vent Fan I Single Duct \>> $0.00 0 ' J�` 1 -1 Over 50,hp 11 Over,1,750 BTU . %7� = 60.00 0 Appliance `$0.000 �J� Boilers 1 J Fire Dampers $0.00- o- % : ,--Up to 3 hp`-' $29.40 2 Smoke Dampers $0.000_ ;' 3 To 15 h rl Inst or Relocate A I Vent $0.00 0 ` 1 P $0 00 0 PP � x.15 to�30 hp �-- � $0.00 0 Air Handlers < 10000cfm $0.00 0 - - -- 30 to'50"hp $0.00 0 Air Handlers > 10000cfm $4.00 0 Over 50 hp $0.00 0 Floor Furnace $0.00 0 Other Mechanical Fee Floor or Suspend Heater $0.00 0 Investigation Fee $0,00 Plan Check Fee $0.00 Reinspection Fee $0.00 TOTAL CALCULATED FEES $170.75 COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable Codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446-46 (eros) \ \/ DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is Issued. I have and will maintain workers' compensation Insurance, as required by section 3700 of the tabor Code, for the performance o1 the work for which this permit is issued. My workers Compensation Insurance carrier and policy number are: Car r. ] .L�S2- �i�5 V,�L^T� _ Policy Number:mab –Qn (This section need not be completed If the permit is valued at one hundred dollars ($ f 00) or less.) ❑ I conity that in the performance of the work for which this permit is issued, I shall not employ any person In any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith e ions. -• pl:c-anSi FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT A1PLM7 bGvERARimiNAL PENALTIES AND CIVIL RHES UP TO ONE HUNDRED THOUSAND DOLLARE (51 00,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. INTEREST, AND ATTORNEY'S FEES. LICENSED C ON: I her m that I nsed under pro islons of Cha ler 9 (commencing with Section 7000) of' on 3of t e Business and Professions Code, and my license is in full e_and Uc. p I nap C. G ntractor•s Signature• CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is issued. (Sec. 3097, Civil Code), Lender's Name: Lender's Address: Slgnature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjecta the applicant to a civil penalty of not more than five hundred dollars (5500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors Ucense Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. It, however, the building or improvement is sold within one year o1 completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Data: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, Le. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet In depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more then thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 34., Title 8, California Administrative Code). ❑ As owner-bullder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to Elle and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic toot of compressed gas at standard temperature and pressure). .._ ... _................---........._..�_. - — .._............. _.................... ._...................... ......... .......................................... ............ .... --- .. ................ . 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _—.._.....—. — — _.._. ................ ...._....... 3 goes or will the appplicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? [I Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 It an RMPP is presently required, has Section 25534 of the California Health and Safety Cada been fully complied with? ❑ Yes Q No ..........................._�_................. _................... ___ .............._.__.................._._...................................................._....................................... _......... ---.T ................. —........... 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this a plication a ermil for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agoncyt Yes U No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits), ......... ..................................... .........................................__........................................................ ................._.................................... -...................... _.......... 8 WII1 any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes', the facility must moot the requirement of Sections 25534 and 42303 of the California Health and Safety Coda). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by Calitomia Health and Safety Code Section 42303 been made? ❑ Yes ❑ No _.....�....._._..._..---------.............. _ ................. _ ................... — __................ _— � ........ _ 6 (tt yes", altach Certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION.OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is Correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature 04 LegalOwner(s) Data And/Or Authoriz CODE f• INSPECTION -TYPE QAiE' I[iTMALS CODE! INSPECTIONTYPE ALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical )t 17 -01 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block(Retaining Well 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714)754-5273 • Fax(714)754-4856 CITY OF COSTA MESA BUILDING DIVISION DEVELOPMENT SERVICES DEPARTMENT, - PERMIT BUILDING PERMIT Job Address: 3333 BRISTOL ST Suite:) I & '- Vicinity: ESCALATOR NEXT TO ESCADA Parcel Number: 41250107 Zoning: PDC PDC Applicant: DENNIS POTTS Address: r Phone: (949)863-9434 Zip: PERMIT NU Boo=00106 T7 FAIR DRIVE, COSTA MESA, CA 92626 . 1 J ISSUED BY: Status: ISSUED Applied: 01/24/2000 Issued: 06/02/2000 Owner: SOUTH COAST PLAZA Address %C J SERGERSTOM COSTA MESA, CA Phone: 3315 FAIRVIEW RD, Zip: 92626 Contractor: _WATSON CONSTRUCTION INC. Address: 1260 LOGAN AVE. B-2 CA Phone: (714) 662-7933 COSTAW ESA Zip: 92626 License: 705797 Arch : GENSLER, Eng: Address: 4675 MACARTHUR COURT #350 Address: Phone: (714)863-9434 Phone: NEWPORT BEACH, CA Zip: 92660 License: License: SCOPE OF PERMIT STRUCTURAL FLOOR FILL 1N AT INTERIOR OF MALL OPENING, FROM FIRST TO, SECOND FLOOR. (FILLING IN FLOOR) FOR THE SCP EAST TERMINUS OF THE BEAR STREET BRIDGE. FEE SUMMARY Pian Check: $29.45 Calc Valuation: $30,000.00 Permit: $181.25 Claim Valuation: $10,000.00 SMIP Res: $0.00 SMIP Com: $2.10 Other: $0.00 Inspection: $0.00 Total:. $212.80 PLANNING & ZONING SETBACKS MAIN STRUCTURE Front 0-0 Rear 0-0 Left 0-0 Right 0-0 ACCESSORY Front 0-0 Rear 0-0 Left 0-0 Right 0-0 PARKING Exist w ' 0 Required: 0 Proposed: 0 NOTES: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: . Carrier: Policy Number: (This section need not be completed if the permit is valued at one hundred dollars ($100) or less.) ❑ I certify that in the performance of the work for wh h this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that it I uId become son provisions subject to the workers' compensation of Section 3700 of the Labor Code, I shall forthwith comply with th se visions. Applicant Signature: Date:Q= -Zi WARN:NG: FAILURE TO SECURE WC ERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CAVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and affect. Lic. #Class #Contractors Signature: Date: - _ .ri zz CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3087, Civil Code), Lenders Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter g (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sola compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date:. Owner 10 verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title B, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I Will the applicant or present or future building occupant need to fife and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with soma exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, Or 200 cubic feet of compressed gas at standard temperature and pressure). .............. ,....... .,...............,......,......,.........................,...,...,.................... ,......... ----------.............. ........ ................ ,_....................... .-... ,----------------- -.,.. ,------------------- -.,.----------------------------- 2 Does or will the applicant o present or iuture building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication afermil for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes L I No (Section 65650.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If ryes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 It a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 6 (if 'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penally of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. i to Owner(s) Date (n -- 7th- - And/Or Authorized Applicant Date CODE N, INSPECTIONTYPE 2E9 INT(T1AL5 CODE INSPECTIONTYP INTITIAL 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 f=inal Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy 2446-46 C/ �� r .. ., l•i tel•.. � J+.^ .- -. . 4... .�.'= i Jxi .�. � � � _.-. - - i -Y�,. .. f �. CI- Y OF COSTA MIF -A r■■ ""'Development Services, Division of Building and Safety CERTIFICATE OF OCCUPANCY This certificate is issued pursuant to the requirements of the 2007 California Building Code, Section 110 adopted by the City of Costa Mesa certifies that at the time of its issuance the building structure herein below described was inspected and approved for occupancy as follows: Building Address 3333 Sear Bristol St Use Commercial Bldg_ Permit NumberBC10-00393 Group M Type of Construction I_A Fire Zone Use Zone Owner of Building Sears Roebuck & Co. Tenant Forever 21 Address 3333 Beverly Road, HOffman Estates, IL 60179 � BUILDING OFFICIAL-Khanh Q. Nguyen, C.B.Q. By Date REQUIRED TO BE POSTED IN A CONSPICUOUS PLACE .•a�r_ - J 3r CITY OF COSTA MESA ��` +kF 9 BUILDING DIVISION 4 > 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 www.ci.costa-mesa.ca.us h FOR INSPECTIONS CALL: (714) 754-5626 "`��°�`� PERMIT NUMBER: SB11-00044 PERMIT TYPE B_SIGN STATUS: ISSUED DATE ISSUED: 04/28/2011 ISSUED BY: JOB ADDRESS: 3333 SEAR BRISTOL ST CM Suite/Unit: SEAR Vicinity: SQ. FT: 0 Valuation: $6,500.00 SCOPE OF WORK: INSTALLATION OF (2) EXTERIOR (1 EXT SIGN TO BE ILLUMINATED) GILDING SIGNS AND (2) INTERIOR ILLUMINTED SIGNS FOR "FOREVER 21" LOCATED INSIDE SEARS. 3 SIGN CIRCUITS. OWNER: SEARS, ROEBUCK AND CO Address: D 768TAX,B2-116A Unit:HOFFMAN ESTATES, IL PHONE: City/State/Zip: 3333 BEVERLY RD APPLICANT: HOLMES, TIM Address: Unit: PHONE: 562-690-5622 CitylStatelzZip: CONTRACTOR: D AND D SIGN SERVICE License No. 856006 Address: 1282 W LAMBERT ROUnit: PHONE: 562-690-5622 City/State: BREA, CA ZipCode: 92821 CELL: ARCHITECT: License No. PHONE: ENGINEER: License No. PHONE: SIGN PERMIT FEE SUMMARY PLAN CHECK FEE: $90.51 HOURLY PC FEE: $0.00 PERMIT FEE: $139.25 ELECTRICAL FEE: $97.30 SMIP FEE: $1.37 OTHER: $0.00 INSPECTION: $0.00 BLDG STD ADMIN FUND $1.00 TOTAL FEE: $329.43 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No, 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM HATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. OE / INSPECTION TYPE DATE INTMAL CODE t IN$Pi:CTIQN TYPE DATE INTiiIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roo( 210 Final Electrical 201 Final BlocklRetaining Wall 212 Final Fire Prevention =I 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign x o 222 Final Site 204 Final Demolition 250 Final Building/Occupancy WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' Compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: -ti !Z TXW_ 3B}t.A(? L—f rhls season need ndr be owoeled ifthe pemrR a vahted alone hundred dollars (5100) or less,) 5licy iVumber:_J' CIZ8 I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the La Code, I shall forthwith comply with these prov' ion$. F_Za^ Appruant� gnature3 Dal � WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES U( TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Z10XG Class #— -4S (CLmUauor's &gnature� Date CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Dale OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that i am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5. Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to rile a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my empfoyees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. if, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.), ❑ I am exempt under sec. Business and Professions Code for this reason: Signature 3057-46 (3107) Owner 10 verified by drir,,. license. )] Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building stnrcture. Scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Ari 2, Sec. 341, Title 8, California Administrative Code), ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Date Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened refease of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materiafs equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department, 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes 0 No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes". the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (if "yes', attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. nalure cf Lega! Owneris) Date AF I Andlor Authorized Applicant Date 'Daie- •• A CITY OF COSTA MESA BUILDING DIVISION } 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 7544856 • www.ci.costa-mesa.ca.us FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: SB10-00076 PERMIT TYPE B_SIGN STATUS: - ISSUED + DATE ISSUED 10113!2010' • ISSUED BY: BE JOB ADDRESS: 3333 BRISTOL ST CM Suite/Unit: Vicinity: So. FT: 0 k) Vaivatio$2,000.00 SCOPE OF WORK: INSTALL 2 NEW LED SIGNS F • R SEARS. CATION AT 1ST FLOOR AND FACES MALL. OWNER: SOUTH COAST PLAZA Address: 3315 FAIRVIEW RD Unit: PHONE: City/State/Zip: COSTA MESA, CA APPLICANT: JIMMY FULLER Address: 3081 E MIRLOMA AVE Unit: PHONE: 714-262-4707 CitylStatelzZip: CONTRACTOR: INSIGNIA Address: 3081 E MIRALOMA AVEUnjt: City/State: ANAHEIM, CA ZipCode: 92806 ARCHITECT: License No. ENGINEER: License No. SIGN PERMIT FEE SUMMARY PLAN CHECK FEE: $45.01 HOURLY PC FEE: $0.00 PERMIT FEE: $69.25 ELECTRICAL FEE: $72.70 SMTP FEE: $0.50 OTHER: $0.00 INSPECTION: $0.00 BLDG STD ADMIN FUND $0,00 TOTAL FEE: $187.46 License No. 872790 1� PHONE: 714-237-1600310.00076 _CELL: PHONE:•_ "..._. ',1 ..i PHONE: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be Considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE /. INSPECTION TYPE DATE INIMAL5 COOED INSPEVION TYPE PAN INTMAL 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Root 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Finat Planning Approval 203 Final Sign _ 11 222 Final Site 1 204+ Final Demolition 250 Final Building/Occupancy t WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the perfo ante of the work for which this permit is issued. Q' I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: 1 � / Carrier. ��1ti i•LVICAC J rVe�i1��WAI� (Thm section need nor be cw#eled d the peis valued at one hundred dYLirs ($100) or fess) Policy Number: -1!89 � rle) G`7 — zerfb ❑ I certify that in the performance of the work for which this permit is issued, I shaft not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisions. °� _ ., joh!Almn ----'-'7iSc�fit's Signature . Date WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 4 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. �+ `T�zor o _ t tar's Signature Dale CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm (hat there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lenders Address: Signature Dale OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion. the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature Date 705746 (31071 ft Owner ID verified by driver's license. Driver's License No. ❑ Yes ❑ No Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Set, 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division, Applicant's Signature Date Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department, 4. if an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be famished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feel from the outer boundaries of a school? ❑ Yes ❑ No (if 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If 'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature of Legal Owner(s) Date a`C,�/?� t'l- An ut onz ppicani Data CITY OF COSTA MESA "`F BUILDING DIVISION > 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 - Fax (714) 754-4856 - www,ci.costa-mesa.ca.us Je' FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BC10-00393 PERMIT TYPE: B_COMBO STATUS: ISSUED Sub Type: COM—ALT DATE ISSUED: 1011212010 ISSUED BY: r• JOB ADDRESS:�'-3:333rSEARrB_RISTOLI"ST'CM SuitelUnit: SEAR APN: 41250106 9'• Vicinity: BASEMENT AND LOWER LEVEL Primary Occ:' Const Type: I -A SO. FT: 43377 Valuation: 3,100,000.00 SCOPE OF WORK: 43,377 SF INTERIOR TI FOR "FOREVER 21" LOCATED ON BASEMENT AND LOWER LEVEL OF SEARS. WORK TO INCLUDE CONSTRUCTION OF NEW NON -LOAD BEARING WALLS TO CREAT NEW SALES AREA, NEW CHANGING ROOMS, (2) NEW RESTROOMS, NEW ESCALATORS, ELEVATOR, STAIRS, SKYLIGHTS AND A NEW EXTERIOR FACADE FOR FOR PORTION OF BUILDING, ROOF TOP MECHANICAL AND NEW SCREENING. 1 REFRIG SYST ¢ 100 K BTU, 4 REGRIG SYS > 100 K BTU, 2 RESTROOM VENT FANS, . OWNER: SEARS, ROEBUCK AND CO ESTATES, IL Phone: APPLICANT: HORTA, JENNIFER Phone: 213-763-2884 Address: D 768TAX,B2-116A City/State/Zip: 3333 BEVERLY RD Address: CitylStatelzZip: Unit: HOFFMAN IL; ry.-00393 Unit: : CONTRACTOR: J R LENNEN CONSTRUCTION License No. 798968 Phone: 209-933-9000 Address: 1136W FREMONT STUnit: Cell: City/State: STOCKTON, CA ZipCode 95203 ARCHITECT: J T NAKAOKA ASSOCIATES ARCHITECTS License No.0013089 PHONE:310-286-9375 ENGINEER: License No. PHONE: COMBINATION PERMIT FEE SUMMARY Building Plan Check: $2,156.99 Building Fees: $13,273.75 . Electrical Fees: $2,547.93 K 970 2 Mechanical Fees: .$470.40 Plumbing Fees: $229.30 SMIP Residential: $0.00 SMIP Commercial: $651.00 Bldg Std Admin Fund $124.00 TOTAL FEES: $19,453.37 'Refer to fee receipts for all fees paid for project HOURS FOR CONSTRUCTION ACTIVITY: EFFECTIVE 3/18/2010 - PER CMMC Sec. 13-279 Monday thru Friday - 7:00 am thru 7:00 pm. Saturdays- 9:00 am thru 6:00 pm. Prohibited all hours - Sundays and the following Federal holidays: New Years Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day and Christmas Day NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 HAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE 1• INSPECTION TYPE DATE INTMAL CM WSPECTION TYPE/ DST IN AL / tl "• 1616 Fixed System Final Fire Prevention 206 Final Mechanical X ry � 5, 1 : , 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final BlocWRetaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval . •"V -',' "i 203 Final Sign 222 Final Site % �h 204 Final Demolition 250 Final Building/Occupancy 4b WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code. for the performance of the work for which this permit is issued. ❑ I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: a ter--�-C f! Li` JlN✓\- �fris section nnLwl completed �eJthe pemrA is valued at one hundred ablfars (S ton) w less) ,01'" y-Pfumber:y{ I��G -- ❑ I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in any manner so as to become subject to the works 'compensation laws of California, and agree that if I should come sublet o the workers' compensation provisions of Section 3700 of th Labor Code, I hall forthwith comply with these prgvisions./� V j�jtys_`Signasure• /�,._ e j WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my IiGense i i f II r e 5 effect. C of CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that [here is a construction lending agency for the performance of the wart( for which this permit is issued. (Sec. 3097, Civil Code). Lenders Name: Lender's Address: Signature Dale OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure. prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature Date 3057.4613/07) *A Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property lax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation We (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Date Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to rite and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons. or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department, 4. It an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. if a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safely Code Section 42303 been made? ❑ Yes ❑ No 8, (If 'yes", attach certiftcale of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with ail state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purRpses. I agree not to occupy or allow occupancy of any building authorized by tth s permit until final inspection. Signal a of Legal Ownerts) Dat '�fh`ods.a.nppt�ani�Odle e, i CITY OF COSTA MESA BUILDING DIVISION > 77 FAIR DRIVE, COSTA MESA, CA 92626 - (714) 754-5273 • Fax (714) 754-4856 - www.ci.costa-mesa.ca.us r ". FOR INSPECTIONS CALL: (714) 754-5526 PERMIT NUMBER: BC10-00425 PERMIT TYPE: B_COMBO STATUS: ISSUED Sub Type: COM—ALT DATE ISSUED: 12/23/2010 ISSUED BY: RMD JOB ADDRESS: 113333 -SEAR -BRISTOL --ST CM - Suite/Unit: SEAR APN: 41250106 Zoning:PDC, , Vicinity: ROOF TOP SEARS ANNEX BLD Primary Occ: Const Type: I -A SQ. FT: 0 Valuation: - $25,000.00 SCOPE OF WORK: STRUCTURAL, ELECTRICAL AND MECHANICAL WORK FOR THE INSTALLATION OF ROOF TOP HVAC UNIT AT "SEARS". 1 NEW 50 TON CHILLER, MISC EL EQUIP FOR NEW CHILLER. OWNER: SEARS, ROEBUCK AND CO ESTATES, IL Phone: APPLICANT: THERIAULT, JOE Phone: 949-588-6300 Address: D 768TAX,B2-116A City/State/Zip: .3333 BEVERLY RD Address: Citylstatelzzip: CONTRACTOR: RAM AIR ENGINEERING INC License No. 470556 Phone: 949-588-8300 Address: 25172 ARCTIC OCEANUnit: Cell: City/State: LAKE FOREST, CA ARCHITECT: ENGINEER: PLUMP ENGINEERING, INC 10101d=3l► -A1101,11:94Ntiil�r�� 'IUt'iit'►I�.�1 Building Plan Check: Building Fees: Electrical Fees: Mechanical Fees: Plumbing Fees: SMIP Residential: SMTP Commercial: Bldg Std Admin Fund TOTAL FEES: License No. License No.0 052696 $63.58 $399.25 $41.70 $41.70 $0.00 $0.00 $5.25 $1.00 $544.48 Unit: HOFFMAN Unit: . SUITE 108 ZipCode 92630 PHONE: PHONE:714-385-1835 `Refer to fee receipts for all fees paid for project HOURS FOR CONSTRUCTION ACTIVITY: EFFECTIVE 3/18/2010 - PER CMMC Sec. 13-279 Monday thru Friday -7:00 am thru 7:00 pm. Saturdays -9:00 am thru 6:00 pm. Prohibited all hours- Sundays and the following Federal holidays: New Years Day, Memorial Day, Inde endence Day, Labor Day, Thanks ivin Da and Christmas Da NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE /. INSPECTION TYPE 1616 Fixed System Final Fire Prevention 1266 Pool Spa Final 200 Final Re -Roof 201 Final Block)Retaining Wall 202 Final Factory Fire Place 203 Final Sign 204 1 Final Demolition D_&IN INTMALS CODE IN INSPECTION TYPE 206 Final Mechanical 208 Final Plumbing 210 Final Electrical 212 Final Fire Prevention 220 Final Planning Approval 222 Final Site 250 Final BuildingfOCctipancy DATE INTITIALS X -.� q�..-L 011 l3 N by a -PJ X 3-Q -a01I y C-01 �.�n-� U01gN i�t�RD_ WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain workers' compensation insurance,- as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy fauaher are: VCa`rildf: _At7iJ i2+Sk (This section need nor be completed d th if is vahied at one hundred dollars ($100) or less_) oticy tvumber: �w4 C7533 4C� Ll_� 4 4ii --- ❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code. I shall forthwith comply with these provisions. -17- -)-3'16 l U jjpljca 9t 61g ature Dartrt WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. -- 12 cag�gnjurerr8�e�� CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption, Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (5500),): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided [hat such improvements are not intended or offered for sale. if, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature 3057.46 (3107) Date Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure. scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8. California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Dale Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed- by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If 'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penally of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of pedury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature or Leo Owner(s) Date n7 1 CITY OF COSTA MESA • 77 FAIR DRIVE, COSTA MESA. CA 92626 - (714) 754-5273 - Fax (714) 754-4856 - www.ci.costa-mesa.ca.us FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BC10-00126 PERMIT TYPE: B_COMBO STATUS: ISSUED Sub Type: COM—ALT DATE ISSUED: 06/25/201A ISSUED BY: IZ� JOB ADDRESS: 3333 SEAR BRISTOL ST CM Suite/Unit: SEAR APN: 41250106 • Zoning:PDC, , Vicinity: BASEMENT GROUND AND 2ND LEVEL Primary Occ: Const Type: I -A SQ. FT: 150000 Valuation: 2,750,000.00 SCOPE OF WORK: 207,600SF INTERIOR SHELL IMPROVEMENTS TO BASEMENT GROUND LEVEL_ AND 2ND LEVEL LOCATED INSIDE "SEARS" FOR FUTURE TENANT SPACE. BASEMENT LEVEL WORK INCLUDES THE REMOVAL OF NON -LOAD BEARING PARTITION WALLS, DEMOLITION OF 2 SETS OF MENS AND WOMENS RESTROOMS, CAP PLUMBING, CONSTRUCTION OF NON -LOAD BEARING WALLS TO CREATE NEW MALL ENTERANCE, SALES AREA, NEW CEILINGS, RECEIVING AREA, NEW PARTITION TO CREATE A NEW FUTURE TENANT SPACE. 2ND LEVEL WORK INCLUDES REMOVAL OF NON -LOAD BEARING PARTITION WALLS, CONSTRUCTION OF NEW NON -LOAD BEARING WALLS TO CREATE CORRIDORS, NEW OFFICE AREAS, LOSS PREVENTION AREAS, COMPUTER, ELECTRICAL ROOMS, FITTING ROOMS, NEW CEILINGS, NEW MENS AND WOMENS RESTROOMS AND NEW PARTITION WALL TO CREATE FUTURE TENAT SPACE. ALTER/REPAIR COOUHEAT IN 2 ZONES, 1 VENT FAN, 6 SMOKE DAMPERS, 149 LIGHT FIXTS, 74 OUTLETS, 13 SWITCHES, 1 SVC OVER 600A, 2 FLOOR DRAIN, 3 DRINKING FOUNT, 2 TRAP PRIMER, 3 URINALS, 7 WASH BASINS, 1 WASTE AND VENT, 11 WATER CLOSETS, 1 WATER REPIPE. OWNER: SEARS, ROEBUCK AND CO ESTATES, IL Phone: APPLICANT: MORRISSETTE, RON Phone: 714-491-1317 CONTRACTOR: i C E BUILDERS INC Phone: 714-491-1317 Cell: ARCHITECT: RIVER, COLLEEN ENGINEER: Address: D 768TAX,B2-116A City/State/Zip: 3333 BEVERLY RD Address: City/State/zZip: License No. 775947 Address: 421 E CERRITOS AVUnIt: City/State: ANAHEIM, CA License No.C23579 License No. Unit: HOFFMAN Unit: . ZipCode 92805 PHONE:714-979-3904 PHONE: COMBINATION PERMIT FEE SUMMARY INSPECTION TYPE QAU INTn1AL$ Building Plan Check: $1,949.39 Building Fees: $11,996.25 Electrical Fees: $339.69 Mechanical Fees: $101.65 Plumbing Fees: $317.50 SMIP Residential: $0.00 SMIP Commercial: $577.50 Bldg Std Admin Fund $110.00 A FES: 115 391.98 t 'r . fe gVaf94f8YM6$r 1�Yf81r�9Vit sha cdmply with all applicable handicap access requirements under California statutes and related regulations. (Ord. o. 92-28, § , 12-2 9 ) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval +Arill result in the expiration of this permit. CODE I INSPECTION TYPE QAU INTn1AL$ CODU INSPECTION TYPE DATE INTITIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing off —16 —10 200 Final Re -Roof 210 Final Electrical 201 Final Block/Rewining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final BuildinglOccupancy • WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' mpensation, as provided for by section 3700 of the Labor Code, for the pe ce of the work for which this permit is issued. have and will maintain workers' compensation insurance, as required by s n 3700 of the Labor Code, for the performance of the work for which this permit is issued. ni rrr���yyyeeers' compensation Insurance carrier and policy number : re t� Carrier: � "1 (This sectimneed+Wis iuedattonehurxlreddafJs51001less-) Policy Numberc�'V ;.�� ❑ I certify that in the performance of the work for which this permit is issued. I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the r Code, f hall fo��!e se provisions._ -J0 ocr WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (S100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. 7 1 5 T "Ctass ' RatUre '� CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code), Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5. Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business -and Professions Code) or that he or she is exempt therefrom and them basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature 3057-4643/07) Owner ID verified by driver s license. ❑ YA ❑ Noy Driver's License No, Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (35) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Division of Industrial Safety Permit Number: Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1, Will the applicant or present or future building occupant need to file and certify a Business Pian for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed wilh the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the Califomia Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? []Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Oualily Management District or from any other air pollution control district or agency? []Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? []Yes ❑ No (If yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Dale CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: l certify under penally of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. ale ZSn ,-1 CITY OF COSTA MESA BUILDING DIVISION r77 FAIR DRIVE, COSTA MESA, CA 92626 - (714) 754-5273 - Fax (714) 754-4856 - www.ci.costa-mesa.ca.us �• FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BC10-00126 PERMIT TYPE: B_COMBO STATUS: ISSUED Sub Type: COM_ALT DATE ISSUED: 06/25/2010 ISSUED BY: RMD JOB ADDRESS: 3333 SEAR BRISTOL ST CM Suite/Unit: SEAR APN: 41250106 Zoning:PDC, , Vicinity: BASEMENT GROUND AND 2ND LEVEL Primary Occ: Const Type: I -A SO. FT: 150000 Valuation: 2,750,460.00 SCOPE OF WORK: REVISION TO PERMIT ON 08/18/10 TO INCLUDE 5 NEW ROOF MOUNT SPLIT SYST AND CURBS FOR COMPUTER AND CAMERA ROOMS, REV TO INTERIOR MALL ELEVATIONS, OFFICE AREAS, CEILINGS, ADDED PWR FOR ENTERANCE LIGHT. 207,600SF INTERIOR SHELL IMPROVEMENTS TO BASEMENT GROUND LEVEL AND 2ND LEVEL LOCATED INSIDE "SEARS" FOR FUTURE TENANT SPACE. BASEMENT LEVEL WORK INCLUDES THE REMOVAL OF NON -LOAD BEARING PARTITION WALLS, DEMOLITION OF 2 SETS OF MENS AND WOMENS RESTROOMS, CAP PLUMBING, CONSTRUCTION OF NON -LOAD BEARING WALLS TO CREATE NEW MALL ENTERANCE, SALES AREA, NEW CEILINGS, RECEIVING AREA, NEW PARTITION TO CREATE A NEW FUTURE TENANT SPACE. 2ND LEVEL WORK INCLUDES REMOVAL OF NON -LOAD BEARING PARTITION WALLS, CONSTRUCTION OF NEW NON -LOAD BEARING WALLS TO CREATE CORRIDORS, NEW OFFICE AREAS, LOSS PREVENTION AREAS, COMPUTER, ELECTRICAL ROOMS, FITTING ROOMS, NEW CEILINGS, NEW MENS AND WOMENS RESTROOMS AND NEW PARTITION WALL TO CREATE FUTURE TENAT SPACE. ALTER/REPAIR COOLIHEAT IN 2 ZONES, 1 VENT FAN, 6 SMOKE DAMPERS, 149 LIGHT FIXTS, 74 OUTLETS, 13 SWITCHES, 1 SVC OVER 600A, 2 FLOOR DRAIN, 3 DRINKING FOUNT, 2 TRAP PRIMER, 3 URINALS, 7 WASH BASINS, 1 WASTE AND VENT, 11 WATER CLOSETS, 1 WATER REPIPE. OWNER: SEARS, ROEBUCK AND CO ESTATES, IL Phone: APPLICANT: MORRISSETTE, RON Phone: 714-491-1317 CONTRACTOR I C E BUILDERS INC Phone: 714-491-1317 Cell: ARCHITECT: RIVER, COLLEEN ENGINEER: Address: D 768TAX,B2-116A CitylState/Zip: 3333 BEVERLY RD Address: CitylStatelzZip: License No. 775947 Address: 421 E CERRITOS AVUnIt: City/State: ANAHEIM, CA License No.C23579 License No. Unit: HOFFMAN Unit: : ZipCode 92805 PHONE:714-979-3904 PHONE: COMBINATION PERMIT FEE SUMMARY Building Plan Check: $1,949.99 1 Building Fees: $11,999.90 _I Fixed System Final Fire Prevention Electrical Fees: $434.27 ,6V Final Re -Roof Mechanical Fees: Plumbing Fees: $155.95 $317.50 `1�SED SMIP Residential: $0.00 ��— SMIP Commercial: $577.60 AdfnWpFsU�ijthorized by this permit shall cq"gI Wh all applicable handicap access re irements under Califomia sta es and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE t. INSPEC11ON TYPE 1616 Fixed System Final Fire Prevention 1266 Pool Spa Final 200 Final Re -Roof 201 Final Block/Retaining Wall 202 Final Factory Fire Place 203 Final Sign 204 Final Demolition DATE INTMALS CODE t INSPECTION TYPE 206 Final Mechanical 208 Final Plumbing 210 Final Electrical 212 Final Fire Prevention 220 Final Planning Approval 222 Final Site 250 Final Building/Occupancy DATE INTMAL WORKERS' COMPENSATION DECLARATION: I hereby affirm under penally of perjury one of (he following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are:, terrier: L -J b &r_�`faL4_Ai[/CC LG�Yf%d� x/_ole (This section need not be completed C the pent is valued at one hundred dollars (S 100) of less.) Policy Number: WA -7 —,� 5_0 " 9F_ 4 0 S — 4'r Q ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become sub'ect to the workers' compensation provisions of Section 3700 of the 11 h f rt ' comply with these provisio a v s S' a Dater WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. U,�.� 5' Cla s # L 13 --r------ Co actor' ign ur CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER-81,1ILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption, Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License taws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature 3057-46 (3107) Date Owner ID verified by drivers license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Date Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safely Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will (he applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be fumished on applications for tion -residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? []Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution Control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If 'yes". attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and slate that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final. inspection. CITY OF COSTA MESA 4 Sol "'�9 BUILDING DIVISION } 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 - www.ci.costa-mesa.ca.us �. FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: E10-00157 PERMIT TYPE ELEC STATUS: ISSUED APN: 41250106 DATE ISSUED: 06/2912010 ISSUED BY: RMD JOB ADDRESS:• 33 SEAR.BRIS%WL!TS! Suite/ unit: SEAR Vicinity: SECOND—FLOOR AND BASEMENT � SCOPE OF WORK: ELECTRICAL PERMIT FOR THE INSTALLATION OF 20 COMMUNICATION DROPS IN CONJUNCTION WITH 2O7,600SF INTERIOR SHELL IMPROVEMENTS TO BASEMENT GROUND LEVEL AND 2ND LEVEL LOCATED INSIDE "SEARS" FOR FUTURE TENANT SPACE. REF;# BC10-00126 OWNER: SEARS, ROEBUCK AND CO Address: D 768TAX,B2-116A Unit:HOFFMAN ESTATES, IL PHONE: CitylStatelZip: 3333 BEVERLY RD APPLICANT: NIE. JASON Address: P 0 BOX 3824 Unit: PHONE: 877-783-2448 CitylStatelzZip: HUNTINGTON BEACH, CA CONTRACTOR: POWER DATACOM INC License No. 891907 Address: P O BOX 382411nit: PHONE: 877-783-2448 , City/State: HUNTINGTON BEACH, CA ZipCode: 92605 CELL: ELECTRICAL PERMIT FEES Electrical Plan Check Fee: $0.00 Electrical Permit Fee: $45.50 Reinspection Fee $0.00 TOTAL FEES $45.50 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE /. INSPECTIONTYPE DATE IRTMACQDER INSPECTION TYPE DATE IN11T1ALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1265 Pool Spa Final 208 Final Plumbing f 200 Final Re -Roof 210 Final Electrical�� 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Fina$ Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy WORKERS' COMPENSATION DECLARATION: hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: (This sedan need not be completed d rhe pemut u valued at one hundred dollars (5700) or less.) Policy Number: 1 1 certify that in the performance of the work for which this permit is l ed, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Califomia, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of t e Labor Code,I s all forthwith comply with these provision . 75 -- lir - _ _ 2 Appti�g , sureDale WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. CIa'ss # 7 liTtracia' Signature CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: 1 hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant'for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will, have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professioris Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractbr(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature Date 3057.46(3!47) qP Owner ID verified by driver a license. []Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Tille 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Division of Industrial Safety Permit Number: Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons. or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the Califomia Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agericy? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? []Yes ❑ No (If 'yes the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If 'Yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury (hat I have read this application and state that the information given is Correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature f Legal Owner(s) Date Andlor Authortx AppFa_n e� (714)754-5273 • Fax(714)754-4856 CITY OF COSTA MESA BUILDING DIVISION DEVELOPMENT SERVICES DEPARTMENT PERMIT ELECTRICAL PERMIT .lob Address: 3333 BRISTOL ST Suite No Vicinity: SE(�QS Parcel Nunmber: 41250106 Applicant: MEIXNER, WILLIAM Address: Owner. - SEARS, ROEBUCK & CO Address D1768TAX,B2-116A $22.00 HOFFMAN ESTATES,. IL Temp service test 3333 BEVERLY RD Contractor:' WILLIAM R MEIXNER & SONS Address: 5316 CLIFFSIDE CIR VENTURA,CA Phone: (805)647-7008 Zip: Phone: Zip: 60179 Phone: (805)647-7008 Zip: 93003 License: 701134 SCOPE OF PERMIT 18 LIGHTS, 12 OUTLETS & 4 SWITCHES FOR GARY'S TUX. B99-00387. FEE SUMMARY Temp Dist System / Lighting Busway 1100 ft Standing Section Misc Electrical Equipment Transformers up to 1 kvalkw ................up to 10 kvalkw .................up to 50 kva/kw :................up to 100 kvalkw ..................over 100 kvalkw Low Voltage Equipment Low Volt Wiring System / Ckt Misc. Conduit Misc. Conductor Circus ( gen or ride) Circus (mech ride or lights) Christmas Tree Stand Fireworks Stand Other Electrical Fee Investigation Fee Plan Check Fee Reinspection Fee PERMIT NUMBER E99-00345 77 FAIR DRIVE, COSTA MESA, CA 92626 status: ISSUED Applied: 04/27/1999 Issued: 04/27/1999 ISSUED BY: Quantity $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 $0.00 $0.00 $0.00 TOTAL CALCULATED FEES $56.00 COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 Quantity ISSUE FEE $22.00 Temp service test $0.00 Res. a/c package $0.00 New Res (1-2 units) $0.00 0 New Res (3+units) $0.00 0 Pool / Spa $0.00 0 Lighting Fixts $18.00 18 Recept Outlets $12.00 12 Switches $4.00 4 Non Res Appl $0.00 0 Res Appl $0.00 0 Service to 200a $0.00 0 Service to 1000a $0.00 0 Service over 1000a $0.00 0 Motors to 1hp $0.00 0 Motors to 10hp $0.00 0 Motors to 50hp $0.00 0 Motors to 1 00h $0.00 0 Motors over 100hp $0.00 0 Communication drops $0.00 0 Sub panel to 200a $0.00 0 Pole Light Pkg $0.00 0 Sign Circuits $0.00 0 Temp Pwr Pole $0.00 0 Intermed Pole $0.00 0 FEE SUMMARY Temp Dist System / Lighting Busway 1100 ft Standing Section Misc Electrical Equipment Transformers up to 1 kvalkw ................up to 10 kvalkw .................up to 50 kva/kw :................up to 100 kvalkw ..................over 100 kvalkw Low Voltage Equipment Low Volt Wiring System / Ckt Misc. Conduit Misc. Conductor Circus ( gen or ride) Circus (mech ride or lights) Christmas Tree Stand Fireworks Stand Other Electrical Fee Investigation Fee Plan Check Fee Reinspection Fee PERMIT NUMBER E99-00345 77 FAIR DRIVE, COSTA MESA, CA 92626 status: ISSUED Applied: 04/27/1999 Issued: 04/27/1999 ISSUED BY: Quantity $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 $0.00 $0.00 $0.00 TOTAL CALCULATED FEES $56.00 COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 DECLARATiONS WORKERS' COMPENSATION DECLARATION: c I hereby affirm under penalty of perjury one of the following declarations: ❑ l have and will maintain a certificate of consent to setf-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. have and will maintain workers' compensation insurance, as required by section 3700 of the tabor Code, for the performance of the work for which this permit Is issued. My workers' compensation insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed if the permit is val at one hundred dollars ($100) or less.) ❑ 1 certify that in the performance of th ric which this permit is Issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Celifo ia, a gre should become subject to the workers' compensation provisions of Sectlon 3700 of the Labor Code, I shall forthwith comply with these pr e — 4 Applicant Signature: Date: WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLIARE (Si 00,0W). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am lice.,;e jpviblp f Chapter 9 (commencing with Section 7000) o1 Division 3 of the Bus a :s on yd yd my J�ens� i� in full force and effect. Lic. p 'i Class �j ! (w Contractors Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is Issued. (Sec. 3097, Civil Code). Lenders Name: Lenders Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to Its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Coda) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031,5 by any applicant for a permit subjects the applicant to a civil penalty o1 net more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner a1 property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden o1 proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who Contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sac. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more foot in depth into which a person Is required to descend, will be made In connection wlth work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Tl90 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted stove, unless such person has a permit to do such work from the division. Signature: Date: Division of industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Pian for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 Of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Liepartment of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 Ilan RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a�ermit for such construction or modification from the South Coast Alt Quality Management District or from any other air pollution control district or agency! BY L -I No (Section 65850.2 of the California Govemment Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'fres", the facility must meet the requirement of Sections 25534 and 42303 o1 the California Health and Safety Code). 7 It a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑Yes ❑ No 8 (it yes", attach Certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to Comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: +Jets: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for Inspection purposes, I agree not to occupy or allow occupancy of any building authorized by this permit until final Inspection. lure Of Legal Owners _Sl_ rim Date And/Or Authorized Applicant Date' CODE #• INSPECTIONTYPE li6IE lid CODE! INSPE0110NTYPE 2&H INTMALS 1616 Fixed System Flnat Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Flo -Roof 210 Final Electrical �rf -74? 201 Final Biock(Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy 244648 CITY OF COSTA MESA f _ BUILDING DIVISION DEVELOPMENT SERVICES DEPARTMENT PERMIT (714)754-5273 • Fax(714)754-4856 BUILDING PERMIT PERMIT NUMBER ✓699-00387 77 FAIR DRIVE, COSTA MESA, CA 92626 .lob Address: 3333 BRISTOL ST Status: ISSUED Suite: SEAR `'` =F Applied: 03/22/1999 Vicinity: Issued: 04/27/1999 Parcel'Nunmber: I "-41250106Zoning: PDC PDC Applicant: MEIXNER, WILLIAM -am ISSUED BY: Address: Phone: (805)6677008 Zip: Owner: SEARS, ROEBUCK & CO Address D1768TAX,62-116A HOFFMAN ESTATES, IL Phone: 3333 BEVERLY. RD Zip: 60179 i Contractor. `,,WILLIAM1,R MEIXNER & SONS ' Address: 5316 CLIFFSIDE CIR Phone: (805)647-7008 VENTURA,CA Zip: 93003 License: 701134 Arch Eng: Address: Address: Phone: Phone: Zip License: Zip: License: SCOPE OF PERMIT INTERIOR ALTERATION TO CATALOG SALES BUILDING TO INCLUDE TUXEDO RENTALS, FEE SUMMARY Plan Check: $233.19 Calc Valuation: $26,000.00 Permit: $358.75 Claim Valuation: $26,000.00 SMIP Res: $0.00 SMIP Com: $5.46 Other: $0.00 Inspection: $0.00 Total: $597.40 PLANNING & ZONING SETBACKS MAIN STRUCTURE Front 0-0 Rear 0= 0 Left 0-0 Right 0- 0 ACCESSORY Front 0-0 Rear 0-0 Left 0-0 Right 0-0 PARKING Existing: 0 Required: 0 Proposed: 0 NOTES: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void it work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: in order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval wlll result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 DECLARATIONS WORKERS' COMPENSATION DECLARATION: ro I hereby affirm under penalty of perjury one of the following declarations: ' ;,irk ve andwillmaintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the forwhich this permit Is Issued. ve and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed It the permit is valued at one hundred dollars ($ 100) or fess,) ❑ 1 certify that In the performance of the wo r ich this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Callfo , and a uld become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these pro Applicant Signature: Date: WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERA E IS UNLAWFUL AND SHALL SUEUECT AN EMPLOYER 70 CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS (Sm00.000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed �unAder provl Ions o ter 9 (commencing with Section 7000) of Division 3 of the Busi and Pro ions e, nd m tae Is in full force and affect. Lic. N e t/l ie Class M � C � � �� Contractor's Signature: � - — Date: CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there Is a construction lending agency for the performance of the work for which this permit Is issued. (Sec. 30137, Civil Code). Lender's Name: Lenders Address: Signature: Deme: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that i am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to Its Issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit Subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property. or my employees with wages as their sole compensation, WILL OO THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not Intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or Improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors license Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Drivees License No. Expires: Verification Of Ownership by (type of document, i.e, - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ r hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made In connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Data: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the Calltomla Health and Safety Code provldas that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP Is presently required, has Section 25534 of the California Health and Safety Code boon fully compiled with? ❑ Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication afermil for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes LJ No (Section 65850.2 of the California Govemment Code requires that the requested Information be fumishad on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'fres', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by Califomla Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (If 'yes", attach certificate of compliance from the appropriate air pollution control officer). _ CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. i agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final Inspection. 001- egal ner(s) Date And/Or Authorized Applicant Date CODE !. INSPECTION TYPCODEN INSPECTION TYPE 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final BlocklRetaining Wali 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy 4i il 2448.46 Job Address: 3333 BRISTOL ST Status: ISSUED Suite: SEAR Applied: 03/08/2007 Vicinity: CANOPY Issued: 03/08/2007 Primary Occ: Type of Construction: Parcef Number: 41250106 Zoning: PDC Applicant: RICHARD EVES Address: 2121 ATLANTA AVE SUITE 1 Phone:_ 951.781.4441 _ _ _ RIVERSIDE, CA Zip: - 92507 ISSUEQ BY: Owner: SEARS, ROEBUCK -&;CO' ' .4 Address D1768TAX;B2-116A ✓` -� � HOFFMAN.ESTATES, IL— +, tl ? 'Phoned 3333:BEVERLY R6'1 .1�_` .__ - W_= = _ ,Zip: ---fi0179C Contractor F 7 M CONSTRUCTION~INC=; Address:'%; 2121 ATLANTA AVE'% SUITE 1/ �✓ / RIVERSIDE -CA Zip:, 92507�� �:�,� Phone: 951.781.4441 License: 771109 �\ �� ✓ ���`� BArch %SEng; Address: > , ' Address: Phone: ° :. c+ Phone: \' V, Zip: / License r _ _ ` "1' �� _ - LiGB' ; nse:" `- ':Jf • ��� � ,f _ -- -- - moi:_ � �' t •,s • - ' \� SCOPE OF PERMIT DEMOLISH WATER DAMAGE CAUSED,T,O STUCCO AND LATHING OF CANOPY ADJACENT TO "SEARS AUTOMQTIVE" BY A TRUCK. --FEE SUMMARY- Plan UMMARY Plan Check:. $0.00 i .r1'� �'r` %� '! �/ r(��+, r r -,IV VCalc Valuation: t,' $3,000:00 Permit: . $83.25 `�Glaim Valuation: _ $;3,000:00 . SMIP Res: $0.00 SMIP Com:.,,$0.63 €- � Other: $0.00 Inspection: $0.00 Total: $83.88 ` PLANNING & ZONING�'� SETBACKS�� �` • :t, ��q. MAIN STRUCTURE. Front ` 0- 0 ' Rear .;,0= 0 Left '0= 0'=" Right 070,,' ACCESSORY. Frons, 0-.0 �, `'` Reay 0_0 Cei1 0 -"Right /✓j 0; 0 �� ' .� �, PARKING_ Existing:/ 0 "�<; � Required:' 0 �? ° Propose%:' 0. NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446-46 (sroo) DECLARATIONS WORKERS' COMPENSATION DECLARATION: - I hereby affirm under penalty of perjury one of the following declarations: ` ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the for which this permit is issued. I le and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. M, w rk rs' compensation Insur nce carrier and policy number are: /� rr ert Policy Numb7f0 2 a - (This se Aced not b completed if the permit is valued atone hundred dollars ($100) or less.) ❑ I certify that in the performance of the work for which this permit is Issued, I shall not employ any person in any manner so as to become subject to the workers' compensation law alifo la, and agree that i should become subject to the workers' compensation provisions of Section 3700 of the Labor Cade, I shall forthwith tom es visio zoopliCantSignature:• _ Data: AILURE 7 SECURE WORKERS' COMPENSATION COVERAGE: IS UNLAWFUL AND SHALL SUaJECT AN EM R TO CRIMINAL PENALTIES AND CAVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: nder ovisions of Chapter 9 (commencing with Section 7000) of Divisio u Mess and Profes ions Code, and my license is in full fort a d effect. Liiit� Class q7 �a Gontractor s Signature:,= _ Date: CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DEC � ,, bra,., hereby affirm thatriynder perky of perjury thaf.f-*rt EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or cdunty wt ca h requires permit to catiatr eFil�lter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement th the or sfi_e1i;-AJ6eaSoU:p!rrsuanMo the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Prof e n9Pron ''tha4he.or slie ici6 mDLIherefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjests.the applica penalty of no m`ore'than l ndred dollars ($500).): ❑ I, as owner of the with wages es their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business andr� Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through hi o r o employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the o nor -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). r, ❑ I, as owner of the property, am EXCL"USLVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more then thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division o1 Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any on time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .....................................................................................................••------................................................................................................--------------.............................................................. ........................................................... 2 Does or wi11 tha applicant or present or future building occupant need to file a registration farm for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 Cubic feet Of compressed gas at standard temperature and pressure). ---• • ................................. I'll ........................------------................................................................................. ................................................ ....................................................................................................................................... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ......................................................................................•----•------•------........................................... 4 It an RMPP is presently required, has Section 25534 of the California Health and Safety Code boon fully complied with? ❑ Yes ❑ No --............................................................-............................................................................................... .............................................. ........................... .... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Ll Yes 1 No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ........l ....... .............. ..................................._-------.. ----------•--...........................................................----------------............................................. ....... - ....................-........................................................ ❑ ........... 6 Wilany part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? Yes ❑ No (it'yee, the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ................................................................................................................................................................................................................................................................................... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ..................................................................................................................................................................................,..................................................................---..................... ............. 8 (If "yes", attach certificate of compliance from the appropriate air pollution control officer), CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-describod property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. natu g Owners)Data 22 O w 1 - `� _ ridl07Auttio zed=. -pl'scant CODE #, INSPECTION TYPE 21AM INTITIAL CODE INSPECnONTYPE QAIE f 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 206 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Btock/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 • Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy C ito f Costa 211 �a Development Services, Division of Building and Safety CERTIFICATE OF OCCUPANCY This certificate is issued pursuant to,, the requiremen"ts of7the`Uniform Building Code, Section 308 adopted by the City of Costa Mesa certifiesthat:at-the time of,its,issuance the building structure herein rr i - � v - i�� r wti� below described was inspected and - q%e, _ occup�anGy4as'follows:1 Building Address 3333 $tt'Ys7im .iTRxET SRnRs Use GARDENING BETA` I S'iORE Group R-2 Type 4,Co' istruction 1 _ FR .RP Fine,: Owner of Building SRARS- `�a Tena Address 3333 BRISTOL ftigH •SRARS, COSTA. -144 �CA-`'! � By BUII.DfNG OFFICIAL- Nth Baca V- Date REQUIRED TO BE POSTED IN A CON .. .G. ,,. •-fes. .•-7 .... .. i' ,.. .-. ._,i..rin ., .9'. ..d 6r,i' , .. i r.. .. :•.•'C : ..,. Permit No.- B70641 _ - Use Zone C1-5 US PLACE i°1 0 'I N\ City of Costa Mesa Development services Department CERTIFICATE OF OCCUPANCY No. 0C � ",'17 D, Building Safety Division P. O. Box 1200 Costa Mesa, California The Building located at 3,133 Ar•;.ahnl St•rent has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group R2 Occupancy. Use of Building_ rnt-nlrtn "Ie%Q Legal Description A1?_9;()1-04 (See reverse side for Metes and Boundo Building Permit No 13 30938 Electrical Permit No. F. 1%1(11*4 Plumbing Permit No. Mechanical Permit No. ISSUED TO: Sears Rc*buck 3333 Bristol street Costa Masa, CA 92626 Number of apartments and/or guest rooms Building Official Tony C'I)a Baca by Date April 2, 1991 This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. CMF 1015.46 rev. 1/83 White - Owner; Canary - Numerical File; Pink - Bldg. Permit File (714) 754-5273 • Fax (714) 764-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 BUILDING PERMIT Job Address: 3333 BRISTOL ST Suite: SEAR Vicinity: ROOF Parcel Number: 41250106 Applicant: MOONEY, DARRELL Address: 3491 ORANGE GROVE AV SMIP Res: SUITE G SMIP Com: NORTH HIGHLANDS, CA Owner: SEARS, ROEBUCK & CO Address Dl768TAX,B2-116A Total: .HOFFMAN ESTATES, IL - 3333 BEVERLY RD Contractor: WATSON ROOFING INC Address: 3491 ORANGE GROVE AV SUITE G NORTH HIGHLANDS, CA Zip: 95660 Zoning: PDC PDC Phone: 916-481-6293 Zip: 95660 Phone: Zip: 60179 Phone: 916-481-6293 License: 602298 Status: ISSUED Applied: 09/11/2002 Issued: 09/11/2002 0 N W 0-2602 Arch Eng: Address: Address: Phone: Phone: Zip: License: License: SCOPE OF PERMIT REMOVE ROCK FROM EXISTING ROOF. INSTALL NEW SINGLE PLY, PVC, GAF ROOF. "SEARS" 100,000 S.F. FEE SUMMARY Plan Check: $0.00 Permit: $1,049.75 - - SMIP Res: $0.00 SMIP Com: $23.10 Other: $0.00 Inspection: $0.00 Total: $1,072.85 SETBACKS MAIN STRUCTURE Front 0-0 ACCESSORY Front 0-0 PARKING Existing: 0 NOTES: PLANNING & ZONING Rear 0-0 Left 0-0 Rear 0-0 Left 0-0 Required: 0 Proposed: 0 Calc Valuation: Claim Valuation: Right , 0-0 Right 0-0 $110,000.00 $110,000.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 t446-46 (sroa) WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the fallowing declarations: e and will maintain a certificate of consent to salt -Ensure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the for which this permit is Issued. I have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. My workers' compensation Insurance carrier and policy number are: / - /� c»``me ':,'�I LL s�k F wt> �i.TPolicl+,Numbar l0 107,'- (Th)s'sectron need not be completed if the permit is valued at one hundred dollars {$100) or less.) ❑ I certitythat in the performance of thew for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of,' ' mi re that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith Comply with these pr isions. g -/1_a Applicant Sigiletu�e:� Date: WAANING. FAIWRE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUEUFCT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: hereby affirm that I am licensed under r isions of Chapter 9 (commencing with Section 7000) of Division 3 of•Ihe-Business and Professions Cade, and my license is in full '., force and'effect. LIc sf r'.� Class d_6 5 c'`Contractors SfgnaEti 4: ,_,,,�,_.____ et�- CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lenders Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole Compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not Intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Cade: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ............................................................................................................................................................................................................................................................................................................................................................................................ 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ....................................................................................................................................................................................................................................................... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ........................................................................................................................................................................................................................... ............................................................................................. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safely Code boon fully compiled with? ❑ Yes ❑ No .................................................................... ..................................................................................................................................................................................................................................................... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ILJ Yes No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). -- ................................................................................................................................................................... 6 Will any part of rho facility to be constructed undar this permit be within 1000 feat from the outer boundaries of a school? ❑ Yes ❑ No (If 'fres", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ............................................. ............................. ..............--.............................................................................................................................._.....................................................................................- ...... ...................................... 7 if a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ...........1.............................................._.................................................................................................................................................................................................................................................................................................. 6 (It yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating 10 building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Si tur f Legal Owner(s) Date Ar!gL lApplicaht CODE ►. INSPECTION -U11 QAC INTI IALS CQQE_I INSPECTION TYPE PALE INTTML$ 1616 Fixed System Final Fire Prevention A 206 Final Mechanical 1266 Pool Spa Final 2013 Final Plumbing 200 Final Re Roof 210 Final Electrical 201 Final SlocktRataining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 PLUMBING PERMIT .lob Address: 3333 BRISTOL ST Status: ISSUED Suite No SEAR Applied: 06/17/2002 Issued: 06/17/2002 Vicinity: Parcel Nunmber: 41250106 ISSUED BY: Applicant: LYNDES, MIKE Address: Phone: 714-491-1317 Zip: Owner: SEARS, ROEQUCK & CO Address D1768TAX,82-116A HOFFMAN ESTATES, IL Phone: 3333 BEVERLY RD Zip: 60179 Contractor: I C E BUILDERS INC Address: 421 E CERRITOS AV Phone: 714-491-1317 ANAHEIM, CA Zip: 92805 License: 775947 Arch / Eng Address: Phone: Zip: License: SCOPE OF PERMIT REF: B02-00558. REWORK MAIN BATHROOM PLUMBING AND SINKS FOR OPTOMETRY, HEARING AID, ETC. REF: 3 FLOOR DRAINS, 1 DRINKING FOUNTAIN, 5 SINKS, 11 WASH BASINS, 2 TRAP PRIMERS, 2 URINALS, 11 TOILETS. 0 0 AMT ISSUE FEE $23.50 Backflow irrigation $0.00 Backflow Preventer $0,00 Bathtub $0.00 Clarifier System $0.00 Connect (Ice,Soda,etc) $0.00 Dental Units $0.00 Dishwasher $0.00 Drain, Floor $29.40 Drain, Rainwater $0.00 Drain, Roof $0.00 Drinking Fountain $9.80 Expansion Tank $0.00 Gas Earthquake Valve $0.00 Gas (1-4 outlets) $0.00 Gas (Over 4 outlets) $0.00 Gas Repipe $0.00 Gas Service $0.00 Interceptors (Grease, Oil) $0.00 Interceptors (Sand Auto ) _ $0.00 0 0 FEE SUMMARY QTY QTY $0.00 AMT QTY $0.00 Laundry Tub / Washer $0.00 0 0 Landscape Irrigation $0.00 0 0 P -Trap $0.00 0 0 Pressure Regulator $0.00 0 0 Process Piping (per 10 ft) $0.00 0 0 Receptors $0.00. 0 0 Septic Tank $0.00 0 0 Sewer Cap for Demo '$0A0 0 3 • _ Sewer Connect $0.00 0 0 Sewer Private Line $0.00 0 0 Shower $0.00 0 1 Sink, bar $49.00 5 0 Sink, commercial $0.00 0 0 Sink, Floor $0.00 0 0 Sink, kitchen $0.00 0 0 Sink, service/mop $0.00 0 0 Spa (private) $0.00 0 0 Spa (public) $0.00 0 0 0 TOTAL CALCULATED FEES: $366.50 GU11fIMLN I b I bli LLAAL GUNUI I IUNb NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION! This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. ' INSPECTIONS: to order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Fatlure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 244646 (15M) 0 AMT QTY Sump Pump $0.00 0 Swimming Pool $0.00 0 Trap Primer $19.60 2 Urinal $19.60 2 Vacuum Brkr Bkflow(1-4) $0.00 0 Vacuum Brkr Bkflow(5+) $0.00 0 Wash Basin $107.80 11 Wash Basin Set $0.00 0 Waste and Vent System $0.00 0 Water Closet (Toilet) $107.80 11 Water Heater / vent $0.00 0 Water Piping (Inst or Rep.) $0.00 0 Water Re -pipe $0.00 0 Water Service $0.00 0 Water Softener $0.00 0 OTHER $0.00 VIOLATION $0.00 PLAN CHECK $0.00 REINSPECTION $0.00 0 TOTAL CALCULATED FEES: $366.50 GU11fIMLN I b I bli LLAAL GUNUI I IUNb NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION! This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. ' INSPECTIONS: to order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Fatlure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 244646 (15M) 0 DECLARATIONS WORKERS' COMPENSATION DECLA iATION: Pf hereby affirm under penalty of perjury one of the following declarations: ❑ have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is Issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed If rhe pormif is valued of one hundred dollars ($100) or less.} ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation taws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these proo Applicant Signature: /'�K-rC �C-C-�Yr C�� Date: WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVE GE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADOMON TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION3706OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. LIc. # Class # Contractor's Signature: Data: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or County which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031,5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License tow does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not Intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts tot such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under see. Business and Professions Coda for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, Le. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Numtior: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: T Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to retease or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gat at standard temperature and pressure). ............._...................................... ........_......,........................................................,,,,................................................................................................................................................................ I ...................................................... _............. 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Hegllh and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). - ........................... ... ..........._._--..................... _.,..... __._... _........................... ................................... ---.... _........................_................... ----..................................................... ............... -............. --.................................... -.......... 1111..... 3 boas or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. _ ............................... ........................................................................................................................................................................................................................................ .............................................................................. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Ye....s ❑ No ....... .................................. _..... .................................. ,........................... ..................... ..................................................................................... ............... -----....................................... ............... ..........................1111.................... 5 Goes or will the applicant or present or future building occupant require for the work which Is the subject of this application a permft for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency! Yes IJ NO (Section 65650.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). _— ..................... _ _ .�-1111----................. — ........................................ --- ................. ---_........................._.._.. 1111...---111.........1 1111... 6 Will any part of the facility to be consMtructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if "yes", the facility must meet the requirement of Sections 25534 and 42303 of the Califomia Health and Safety Code). ---.............................................................................................._...............................-........................... _........................_ . -...................... _........................ -- 7 If a perm it from the South Coast Air Quality Management District or other air pollution control district or agency Is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No _...........................................................................................-.................................-..............................._.............................-........................................................... 1111.......... ..... _................ 6 (it yes-, attach certificate of Compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the Information given above is correct. I agree to comply with all state laws and City ordinances regarding Hazardous Materials and Emissions. Signature: _ Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Sre f Legal CCne s) (�� .-} —}Zat jGIl tom/ And/Or Authorized Applicant [ (Date CODE t• INSPECTION TYPE QM 1NIMA1.$ CODEi INSPECTIONIM DTE INTITIA4i 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Poo( Spa Final 206 Final Plumbing -� 200 Final Ro-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Piece 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 .lob Address: 3333 BRISTOL ST Suite No SEAR Vicinity: SEARS AUTO CENTER Parcel Nunmber: 41250106 Applicant: LYNDES, MIKE Address: 421 E CERRITOS AV ANAHEIM, CA Owner: SEARS, ROEBUCK & CO Address D/768TAX,B2-116A HOFFMAN ESTATES, IL 3333 BEVERLY RD Contractor: DE PAUL, DANIEL Address: Arch / Eng : Address: PLUMBING PERMIT Status: ISSUED Applied: 09/16/2002 Issued: 09/16/2002 ISSUED BY: �& Phone: 714-491-1317 Zip: 92805 Phone: Zip: 60179 Phone: Zip: License: 775947 Phone: Zip: License: SCOPE OF PERMIT PLUMBING PERMIT FOR INTERIOR STORE TI FOR "SEARS AUTO CENTER" FOR THE ENTIRE AUTO CENTER STORE AREA (BASEMENT AND 1ST FLOOR), 1 URINAL, 2 WASH BASINS, I WASTE & VENT SYSTEM, 2 WATER CLOSETS, 1 WATER REPIPE, REF: B02-00559 NOTICE: The work authorized by this permit stQ0Mj A18IMIDfAV& -pQM requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 244848 (6100) FEE SUMMARY AMT QTY AMT QTY AMT QTY ISSUE FEE $23.50 Laundry Tub / Washer $0.00 0 Sump Pump $0.00 0 Backflow irrigation $0.00 0 Landscape Irrigation moo 0 Swimming Pool $0.00 0 Backflow Preventer $0.00 0 P -Trap $0.00, 0 Trap Primer $0.00 0 Bathtub $0.00 0 Pressure Regulator $0.00 0 Urinal $9.80 1 Clarifier System $0.00 0 Process Piping (per 10 ft) $0.00 0 Vacuum Brkr Bkflow(1-4) $0.00 0 Connect (Ice,Soda,etc) $0.00 0 Receptors $0.00 0 Vacuum Brkr Bkflow(5+) $0.00 0 Dental Units $0.00 0 Septic Tank $0.00 0 Wash Basin $19.60 2 Dishwasher $0.00 0 Sewer Cap for Demo $0.00 0 Wash Basin Set $0.00 0 Drain, Floor $0.00 0 Sewer Connect $0.00 0 Waste and Vent System $9.80 1 Drain, Rainwater $0.00 0 Sewer Private Line $0.00 0 Water Closet (Toilet) $19.60 2 Drain, Roof $0.00 0 Shower $0.00 0 Water Heater / vent $0.00 0 Drinking Fountain $0.00 0 Sink, bar $0.00 0 Water Piping (Inst or Rep.) $0.00 0 Expansion Tank $0.00 0 Sink, commercial $0.00 0 Water Re -pipe $9.80 1 Gas Earthquake Valve $0.a0 0 Sink, Floor $0.00 0 Water Service $0.00 0 Gas (1-4 outlets) $0.00 0 Sink, kitchen $0.00 0 Water Softener $0.00 0 Gas (Over 4 outlets) $0.00 0 Sink, service/mop $0.00 0 OTHER $0.00 Gas Repipe $0.00 0 Spa (private) $0.00 0 VIOLATION $0.00 Gas Service $0.00 0 Spa (public) $0.00 0 PLAN CHECK $0.00 Interceptors (Grease, Oil) $0.00 0 REINSPECTION $0.00 0 Interceptors (Sand Auto ) $0.00 0 TOTAL CALCULATED FEES: $92.10 NOTICE: The work authorized by this permit stQ0Mj A18IMIDfAV& -pQM requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 244848 (6100) DECLARATIONS WORKERS' COMPENSATION DECLARATION: - I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' c1ompen tion I surance mer and policy number are: OO Z� Z Carrier: �T A�-� L r&e- f-' _01.&1--tom Policy Number. LJ V K L41 (This section r ed not be completed if the pertnit is valued at one hundred dollars ($100) or lass.) ❑ I certify that in the performance of the work for which this permit is issued. I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that ii I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these pro ' i ns. !-- Applicant Signature: Date: • e/�' Z WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COV RAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIvtL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed un provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Businesd Professions Code, and my license is in full force and effect. Lic. # 7 Class If G' G Contractor's Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he Or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sale compensation, WILL DO THE WORK, and the structure Is not intended Or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. tf, however, the building or Improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. Zt. ❑ NO Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax Nil or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health find Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ........ ................................... .................................. .................................... .......................................................................................................... ..........................................................................._.......................... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous malerials7 ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or wili the applicant or present or future building occupant need to, prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire •.. Department of an RMPP by businesses Which are required to register acutely hazardous materials with the Fire Department. .................................................................................,................................................................-----........................ ........................;..............................................................................................-•----.................................................. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code boon fully complied with? ❑ Yes ❑ No ......................-............................................................... ........................................................ .-....................................................................................................................................... ................................. .................................................. 5 Does or will the applicant or present or future building occupant require for the work which is the subject of thisa plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? N Yes U No (Section 65850.2 of the California Govemment Code requires that the requested information be furnished on applications for non-residential building permits). ...................................................................................................................................................................................................................... ................................................................................ fi Will any pan of the facility to be constructed under this permit be within 1000 feat from the outer boundaries of a school? ❑ Yes ❑ No (if 'fres", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Coda). .............................................................................•----•-••-----------...............................................---.......................................................................................................,................................................................................................ ........ .. 7 If a permit from the South Coast Air Qlaallty Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No .B .......(..f.y................................................................................•...................................................................................................................................................................................................... , ........... attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: _ _ Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature�0 gal Owner(s) Date And/Or AuthorizgoppllcanT Date CODE 0, INSPECTION TYPE DAM INTITIALS CODE 3 INSPECTION TYPE 2&U IKMIAL$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical n 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.cl.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 .lob Address: 3333 BRISTOL ST Suite No SEAR Vicinity: SEARS ANNEX Parcel Nunmber: 41250106 Applicant: LYNDES, MIKE Address: 421 E CERRITOS AV ANAHEIM, CA Owner: SEARS, ROEBUCK & CO Address D1768TAX,132-116A HOFFMAN ESTATES, IL 3333 BEVERLY RD Contractor: DE PAUL, DANIEL Address: Arch / Eng : Address: PLUMBING PERMIT Phone: 714-491-1317 Zip: 92805 Phone: Zip: 60179 Phone: Zip: License: 775947 Phone: Zip: License: Status: ISSUED Applied: 09/16/2002 Issued: 09/16/2002 ISSUED BY: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 Z' 2446-46 (6=) SCOPE OF PERMIT PLUMBING PERMIT FOR INTERIOR STORE TI FOR "SEARS ANNEX BLDG." 1 WASH BASIN, 1 WATER CLOSET REF: B02-00782 FEE SUMMARY AMT QTY AMT QTY AMT QTY ISSUE FEE $23.50 Laundry Tub / Washer $0.00 0 Sump Pump $0.00 0 Backflow irrigation $0.00 0 Landscape Irrigation $0.00 0 Swimming Pool $0.00 0 Backflow Preventer $0.00 0 P -Trap $0.00 0 Trap Primer $0.00 0 Bathtub $0.00 0 Pressure Regulator $0.00 0 Urinal $0.00 0 Clarifier System $0.00 0 Process Piping (per 10 ft) $0.00 0 Vacuum Brkr Bkflow(1-4) $0.00 0 Connect (Ice,Soda,etc) $0.00 0 Receptors $0.00 0 Vacuum Brkr Bkflow(5+) $0.00 0 Dental Units $0.00 0 Septic Tank $0.00 0 Wash Basin $9.80 1 Dishwasher $0.00 0 Sewer Cap for Demo $0.00 0 Wash Basin Set $0.00 0 Drain, Floor $0.00 0 Sewer Connect $0.00 0 Waste and Vent System $0.00 0 Drain, Rainwater $0.00 0 Sewer Private Line $0.00 0 Water Closet (Toilet) $9.80 1 Drain, Roof $0.00 0 Shower $0.00 0 Water Heater / vent $0.00 0 Drinking Fountain $0.00 0 Sink, bar $0.00 0 Water Piping (Inst or Rep.) $0.00 0 Expansion Tank $0.00 0 Sink, commercial $0.00 0 Water Re -pipe $0.00 0 Gas Earthquake Valve $0.00 0 Sink, Floor $0.00 0 Water Service $0.00 0 Gas (1-4 outlets) $0.00 0 Sink, kitchen $0.00 0 Water Softener $0.00 0 Gas (Over 4 outlets) $0.00 0 Sink, service/mop $0.00 0 OTHER $0.00 Gas Repipe $0.00 0 Spa (private) $0.00 0 VIOLATION $0.00 Gas Service $0.00 0 Spa (public) $0.00 0 PLAN CHECK $0.00 Interceptors (Grease, Oil) $0.00 0 REINSPECTION $0.00 0 Interceptors (Sand Auto ) $0.00 0 TOTAL CALCULATED FEES: $43.10 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 Z' 2446-46 (6=) DECLARAVONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation Insurance, as required by section 3700 of the labor Code, for the performance of the work for which this permit is issued. My workers' compo ation In uranc�.caatmer and policy number are: -_ r�c e � Q le ryr.c1 e Policy Number: Carrier: 51( 24= (This section need not be completed it the permit is valued of one hundred dollars ($100) or fess.) ❑ I certify that In the performance of the work for which this permit Is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these pro''sons. Applicant Signature: . _ Z �s�l�e ��r� Date: WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVE GE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF OOMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lie. q Class ff C S Contractor's Signature: �G'-�n Date: CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lenders Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant far such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Data: Owner ID verified by drivers license. Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work aulhorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec, 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I W III the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the Caiifornia Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .................................................................................................................................................................................. 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .................................................•..........................................................................................................-............................................... ....................... .......................................................................................... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑Yes ❑ Nc ......._...................... ......................... ._............_..................._.—._................_..__......_....1.............�._._.................... _......_ _ _...._ ............_ _......... .... _ 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this ,application a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? []Yes ENO (Section 65850.2 of the California Government Code requires that the requested Information be furnished on applications for non-residential building permits). ................................................................_..........................................................................................................---..............................._._......... ........ ........................ .............................._ .............._............ 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ......................................................_..._.................................-.......... ................................ _............................................................. ..,.................................................. ............................................ .................................. ......... ......... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency Is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ........................................................................................................................................................................................................................................................................................................................................................... 8 (If fres", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the Information given Is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. A� Si K- ur Of Legal Owner(s) — / O a Date And/Or Aidhorized Applicant / Date CODE 11, INSPECTION TYPE 2M IflILl8L3 CODE A INSPECTION TYPE 9AM Ifs 1616 Fixed System Final Fire Prevention 206 Final Mechanical /� 1266 Pool Spa Final 208 Final Plumbing - `00, 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wail 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 - Fax (714) 754-4856 - www.ci.costa-mesa.ca.us COSTA MESA, CA MECHANICAL PERMIT .lob Address: 3333 BRISTOL ST Suite No SEAR Vicinity.- ". SEARS AUTO ANNEX Address: Dl768TAX',B2-116A ' . " Parcel Number: 41250106 Applicant: FOSTER, GERALD Address: 3183 AIRWAY,AVE Zip: 60179 BLDG'F ' Phone: (714)145-0200 77 FAIR DRIVE, COSTA MESA, CA 92626 Status: ISSUED Applied: 06/19/2002 Issued: 06/19/2002 ISSUED BY: COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545628 A$-46 (sroo) / COSTA MESA, CA Zip: 92626 SCOPE OF PERMIT Owner: SEARS,•ROEBUCk & CO Address: Dl768TAX',B2-116A ' . " HOFFMAN ESTATES, IL Phone: 3333 BEVERLY RD Zip: 60179 Contractor: ENCOMPASS MECHANICAL SERVICES Address: 3183 AIRWAY AVE FEE SUMMARY BLDG F Phone: (714)445-0200 COSTA MESA, CA Zip: 92626 License: 513014 COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545628 A$-46 (sroo) / SCOPE OF PERMIT INTERIOR STORE TI FOR THE `SEARS' MAIN STORE. 1 VENT FAN/SINGLE DUCT. REF: B02-00782 FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 _ Repair / Alt Absorbtion Unit $0.00 0 Inst FAU <100 k BTU $0.00 0 Repair / Alt Refrigeration Unit $0.00 0 Inst FAU >100 k BTU $0.00 0 Ventiliation System $0.00 0 Repair 1 Alt Cooling/Heat $0.00 0 Evaporative Cooler $0.00 0 Inst 1 Rep. Recess Wall Htr $0.00 0 Commercial Incinerator $0.00 0 Refrig Sys <100 k BTU $0.00 0 Domestic incinerator $0.00 0 Refrig Sys >100 k BTU $0.00 0 Compressors / Absorption Systems Gas Piping $0.00 0 Up to 3 hp / 100 k BTU $0.00 0 Factory Fireplace $0.00 0 3 To 15 hp,/ 500 k BTU $0.00 0 Hood w/Mech Exhaust $0.00 0 15 To 30 hp / 1,000 k BTU $0.00 0 VAV Box $0.00 0.- 30 To 50 hp / 1,750 k BTU $0.00 0 Vent Fan / Single Duct $7,25 1 Over 50 hp 1 Over 1,750 BTU $0.00, 0 Appliance $0.00 0 Boilers Fire Dampers $0.00 0 Up to 3 hp $0.00 0 Smoke Dampers $0.00 0 3 To 15 hp $0.00 0 Inst or Relocate Appl Vent $0.00 0 15 to 30 hp $0.00 0 Air Handlers < 10000cfm $0.00 0 30 to 50 hp $0.00 0 Air Handlers > 10000cfm $0.00 0 Over 50 hp $0.00 0 Floor Furnace $0.00 0 Other Mechanical Fee Floor or Suspend Heater $0.00 0 Investigation Fee $0.00 Plan Check Fee $0.00 Reinspection Fee $0.00 TOTAL CALCULATED FEES $30.75 COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545628 A$-46 (sroo) / DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the � work for which this permit Is issued. ,lfhave and will maintain workers' compensation insurance, as required by section 3700 a Labor Code, for the performance of the work for which this permit is issued. 11 M ars' pensa0 urance carrier a pot number re: r / .Cafpier Pof* Number. C A- �(Thls secrlon n ed not ba completed if the permit Is value at one jlfundrod dollars (3100) or less.) - ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person In any manner so as to become subject to the workers' compensation laws of f6r e t If I should become subject to the workers' compensation provisions of Seel] gn 37 1 the Labor Code, I shall forthwith fply_wlth•these p o [App6/vp lanu, e WAININ`G:FAILURE TO SE RE WORKERS' COMPF-NSAT40N COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER'TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THgUSAND DOU ARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR ODDS, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am lice ad under p 'sions of Chapter 9 (commencing wlth Section 7000) of Division 3 of the Busin nd P 2 a d nsa is In full force and effect: L cwt 1—e� G7a'ss�pC�i" CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is Issued. (Sec. 3097, Civil Code). Lenders Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to Its issuance, also requires the applicant for such permit to tile a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a clvll penalty o1 not more then five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sale 000mpensatfon, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or Improves thereon, and who does such work himself or herself or through his Cr her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who bUlds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Drivers Lloenso No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certity that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsawork, or demolition or dismantling theraol, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, Califomia Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and Certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity o1 hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, _ or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration farm far acutely hazardous materials? ❑Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Piro Dapartment by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). . ............................................................................................................................................................................................................................................................................................................................... 3 Does or will theaappplicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes 11No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. —.......... —.._._.._................................................................................................. ....... ....... — _................... ._.............................. _.................. 4 It an RMPP is presently required, has Suction 25534 of the Califomia Health and Safety Code been fully complied with? ❑Yes ❑ No ._...,......._ _................_....................,.............................. --....... ................ $ Does or wi)) the applicant or present or future buftrig occupant require for the work which Is the subject of this a piloation a rmlt for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? jJ Yes ff No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the f _. .......a aclfitytobe __.._............_...� ....---permit be within 1000 feel from [h..._. -h ..... e outer ._.__...................................................- ....— _.........---•---•---•--....................... constructed under this boundaries of a school? ❑Yes Q Na (If 'yes', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). -..._......... _...... . ................................................................-- - - --- -- _ ..... - _..... .._...... ... _.._... --_.............. .._ 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency Is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No _.. ... ----.............._.................................... _ �...._._---------- -......................................., ..._._.�—_....................._...__...... _.........................................._........ 8 (ff jres-, atlach Certificate of compliance fro.m the..eppropdate air pollution control officer). CERTIFICATE OF COMPLIANCE.: I certify that under penalty of perjury the information given above is correct. I agree to Comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CI=RTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the Information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection, Authortzed.Appiicant_Jt Date QDE 1. INSPECDONTYPE 2M NTMALS o&M INSPECTIONTYPE 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Poo( Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Buitding/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.cl.costa-mesa.ca.us MECHANICAL PERMIT Job Address: 3333 BRISTOL ST Suite No SEAR .. Vicinity: SEARS AUTO CENTER Parcel Number: 41250106 Applicant: FOSTER, GERALD, Address: 3183 AIRWAY AVE- BLDG F Phone: (714)445-0200 COSTA MESA, CA" Zip: 92626 Owner: SEARS,�ROEBUCK & CO Address: 01768TAX,B2-116A HOFFMAN'ESTATES, IL Phone: 3333 BEVERLY RD Zip: 60179 Contractor. ENCOMPASS MECHANICAL SERVICES Address: 3183 AIRWAY AVE 77 FAIR DRIVE, COSTA MESA, CA 92626 Status: ISSUED Applied: 0611912002 Issued: 06/1912002 ISSUED BY: BLDG F Phone: (714)445-0200 COSTA MESA, CA Zip: 92626 License: 513014 SCOPE OF PERMIT INTERIOR STORE TI FOR THE "SEARS" AUTO CENTER. 3 VENT FANSISINGLE DUCT. REF: 802-00559 i FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 _ _ _ Repair! Alt Absorbtion Unit $0.00 0 Inst FAU <100 k BTU $0.00 0 Repair 1 Alt Refrigeration Unit $0.00 0 Inst FAU >100 k BTU $0.00 0 Ventillation System $0.00 0 Repair I Alt Cooling/Heat $0.00 0 Evaporative Cooler $0.00 0 Inst! Rep. Recess Wall Htr $0.00 0 Commercial Incinerator $0.00 0 Refrig Sys <100 k BTU $0.00 0 Domestic Incinerator $0.00 0 Refrig Sys >100 k BTU $0.00 0 Compressors ! Absorption Systems Gas Piping $0.00 0 Up to 3 hp 1100 k BTU $0.00 0 Factory Fireplace $0.00 0 3 To 15 hp ! 500 k BTU $0.00 0 Hood w/Meth Exhaust $0.00 0 15 To 30 hp 1 1,000 k BTU $0.00 0 VAV Box $0.00 0 30 To 50 hp 11;750 k BTU $0.00 . 0 Vent Fan I Single Duct $21,75 3 Over 50 hp /Over 1,750 BTU $0.00 0 Appliance $0.00 0 Boilers Fire Dampers $0.00 0 ' Up to 3 hp $0.00 0 Smoke Dampers $0.00 0 3 To 15 hp $0.00 0 Inst or Relocate Appl Vent $0.00 0 15 to 30 hp $0.00 0 Air Handlers < 10000cfm $0.00 0 30 to 50 hp $0.00 0 Air Handlers > 10000cfm $0.00 0 Over 50 hp $0.00 0 Floor Furnace $0.00 0 Other Mechanical Fee Floor or Suspend Heater $0.00 0 Investigation Fee ' $0.00 Plan Check Fee $0.00 Reinspection Fee $0.00 TOTAL CALCULATED FEES $45.25 COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work Is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Faiture to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL. (714) 7545626 W&M t6Mi - DECLARAMNS WORKERS' COMPENSATION DECLARATION: I hereby affirm unser penalty of perjury one of the following declarations: ❑ t have and will maintain a certificate of consent to sell -Insure for workers' compensadon, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. have and will maintain workers' compensation Insurance, as -'re37 of the Labor Code, for the performance of" workfor which this perml uad. My rke pensai]p� Insurance carrier an li um ter Carrier: / r Policy Number: L� J (This section neect not be completad if the permit 1s valued of on hundred dollars ($100) or less.) ❑ I Certify that In the performance of th rk for which thl permit is Issued, I shall not employ any person In any manner so as to become subject to the workers' compensation laws al Cali a Wet t II I uId becroma subject to the workers' OOmpensatlon provisions of Sectla 3700 d the Labor Code, I shall forthwith comply with these provlsl Q Applicant Signature: Date: WARNING: FAILURE TO SECU W(;RKERS' PENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO C IMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter oommen ' with Section 7000) o1 Division 3 of the Bus$rl P o io e, an my license is in full force and effect. Lic. N Class #9 Contractors Signature: Date: —2— CONSTRUCTION CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there Is a construction lending agency for the performance o1 the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: _ _ Lender's Address: Signature: _ _ _ Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the fotlowing reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to Its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than live hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors Ucense Law does not apply to an owner of property who builds or Improves thereon, and who does such work himself or horseff or through his or her own employees, provided that such improvements are not intended or offered for We. ft. however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner bf the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds Or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec, Business and Professions Code for this reason: Signature: Data: Owner ID verllled by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, Le. - property tax bill Or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby Certify that no excavation five (5) or more feet in depth Into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, talsework, or demolition or dismantling thereof, will be more than thlay-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Tille 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: I) Msfon of indusirfal Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ NO (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet, of compressed, gas at standard temperature and pressure). _ .............................. . ............. __.............w„ 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time ha4 on hand a quantity of acutely hazardous materials equal to or greater then a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). �......__ _ ...._ _..r . .. ............. .. .._... ......................,...._.......................__.._................-............................_..........................................__..........--•--...._�.-.................-.—.......................................... 3 Does or will the applicant ar present or future building occupant need to prepare an an (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the Califorte Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire bepartment of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. _ ........_...._. _ __......................................................................... __........ ry............,............... ................p.......................„. ..... .........,........... _.........................._........................................... 4 If an RMPP le presently required, has Section 25534 of the California Health and Safe Code been full compiled with? []Yes ❑ No ........_._.__...........�.......... ............................................................................................................................................................................................................................ 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this implication amr it for such construction or modification ge from the SOuth Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes LJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). .......... ... ............................. .�---............................. .................. ............................. _.._................................................... ..................................... ..............._..... .-.._........ ........................................................................... 6 WIII any part o1 the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes 0 No (If yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). __..._.........._..— _ __ _ ................. 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures proscribed by California Health and Safety Code Section 42303 been made? ❑Yes ❑ No 8 (If yes', attach Certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OP COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the Information given Is correct. I agree to comply with all state taws and city ordinances relating to building Construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for Inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection, e al Owner(s) / D And/Or Authorized Applicant !/ Data CODE I INSPEOQN TYPE PAR INIfI A CODE # INSPECTION TYPE 2&3 1 LA 1616 Fixed System Final Fire Prevention 206 Final Mechanical�� 1266 Pool Spe Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT Job Address: 3333 BRISTOL ST Suite No SEAR Vicinity: INTERIOR STORE Parcel Nunmber: 41250106 Applicant: LARSON, KEVIN Address: 5415 INDUSTRIAL DR Phone: 714-895-458 HUNTINGTON BEACH, CA Zip: 92649 Owner:/,SEARS, ROEBUCK & CO Address D1768TAX,B2-1.16A'. ♦ HOFFMAN.ESTATES, IL Phone: 3333 BEVERLY RD Zip: 60179 A .. Contractor: R L DOUGLASS ELECTRIC Address: 5415 INDUSTRIAL DR HUNTINGTON BEACH, CA e 8 --Phone: 714-895-4588 Zip: "92649 License: 452070 Status: ISSUED Applied: 06118!2002 Issued: 06/18/2002 ISSUED BY: SCOPE OF PERMIT - - INSTALL LIGHTING FIXTURES, OUTLETS;,SWITCHES, SUB -PANELS TO 200A AND COMMUNICATION DROPS. "SEARS BUILDING" REF: B02-00558 COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 244"13 f61001 �J _FEE SUMMARY = Quantity Quantity ISSUE FEE $23.50 Temp Dist System / Lighting $0.00 0 Temp service test $0.00 Busway 1100 ft $0.00 0 Res. a/c package $0.00 Standing Section $0.00 0 New Res (1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0 New Res (3+units) $0.00 0 Transformers up to 1 kvalkw $0.00 0 Pool 1 Spa $0.00 0 ................ up,to 10 kvalkw $0.00 0 Lighting Fixts 038.89 1413 .................up to 50 kvalkw $0.00 0 Recept Outlets , $149.02 r 194 - .................up to 100 kva/kw,• . $0.00 0 Switches $13.20 _ 12 ..................over 100 kvalkw $0.00 0 Non Res Appl $0.00 0 Low Voltage Equipment $0:00 0 Res Appl $0.00 0 Low Volt Wiring System ! Ckt $0.00 0, Service to 200a $0.00 0 Misc. Conduit $0.00 0 Service to 1000a $0.00 0 Misc. Conductor $0,00 0 Service over 1000a $0.00 0 Circus ( gen or ride) $0.00 0 Motors to 1 hp $0.00 0 Circus (mech ride or lights) $0.00. 0 Motors to 10hp $0.00 0 Christmas Tree Stand $0.00 ". 'D Motors to 50hp $0.00 0 Fireworks Stand , $0.00- 0 Motors to 100hp $0.00 0 Other Electrical Fee $0.00 Motors over I00hp $0.00 0 Communication drops $38.98 46 Investigation Fee $0.00 Sub panel to 200a $122.00 4 Plan Check Fee $0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $0.00 0 Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $1,365.59 Intermed Pale $0.00 0 COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 244"13 f61001 �J DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will ftintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. have and will maintQin workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compeNsatioon Insurance carrier and policy number are: Carrier �33� 7 Policy Nti _be 4Oq�'-0 k lJll�)�'�' -0 0_Z0`(77ris section need not be compla d if permit is valued atone hundred dollars ($100) or less.) ❑ I certify that in the perfo ante of the w rk r which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of lifomia, and hat if I should become subject fo the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these pr ions ,*,.�+ Appllcan t Signiture: Date:---� [Y `Q — U Z tom:. WARNING: FAILURE TO SEC RE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,1))0), IN ADDnION TO THE DOST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed in provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Businessa d Professions Code, and my license is in full -forCeland eiieot.,Llc..p ZC7 C ClassdrY�. Co`htractors,Signatur� Date: CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lenders Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter -9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. 11, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason; Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires; Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certity that no excavation five (5) or more feet In depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, t will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: bate: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? O Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materia€. equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ........... ............................. _........................................................................................................................ .......-----..................................................... .................................................. .......................................................- ........................ 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. .............................................................................................................................................................................................................................................................. ............................................ ............................... 4 If an RMPP is presently required, has Section 25534 of the Califomia Health and Safety Cade been fully complied with? ❑ Yes ❑ No .................................................................................................................................................................................................................................................................................................................................................................. 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a PPermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency/? LJ Yes t l No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). .............................................. .... .........................------................................................... ..-----.......---..................................................... _..............................................................................................I....................... 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? Cl Yes ❑ No (If 'fres", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). iFW..............._---------.............................................................------...-------................................................ ........................................................................................................................ ..................................................................... 7 ................... permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed byCalifornia Health and Safety Code Section 42303 been made? ❑ Yes ❑ No (11 ........................................................................................................................................................................................................................................................................_---..........................................................................................------. B "yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all ah laws and city or inances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspect n purposes. I agr not to occupy or allow occupancy of any building authorized by this permit until final inspection. S' atura Of Lega! = i� _Z rid/Or;Asithoriie Applicant CODE 0. INSPECTIONTYPE DATE INTMALS CODE INSPECTIONTYPE I R If1AL$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Root 210 Final Electrical Qp�� 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT Job Address: 3333 BRISTOL ST Suite No SEAR Vicinity: ANNEX BUILDING Parcel Nunmber: 41250106 Applicant: LARSON, KEVIN Address! 5415 INDUSTRIAL DR- ISSUED Applied: Phone: 714-895-4588 HUNTINGTON BEACH, CA Zip: 92649 Owner: SEARS, ROEBUCK "& CO $0.00 Address DtT68TAX,B2-i 16A ' Res. a/c package HOFFMAN ESTATES; IL Phone: 3333 BEVERLY RD Zip: 60179 Contractor: R L DOUGLASS ELECTRIC Address: 5415 INDUSTRIAL DR HUNTINGTON BEACH, CA Phone: 714-895-4588 Zip: 92649 License: 452070 Status: ISSUED Applied: 06118/2002 Issued: 06118/2002 SCOPE OF PERMIT - : INSTALL LIGHTING FIXTURES, OUTLETS AND COMMUNICATION DROPS. "SEARS ANNEX BUILDING' REF: B02-00782 FEE SUMMARY Quantity ISSUE FEE $23.50 Quantity Temp service test $0.00 0 Res. a/c package $0.00 0 New Res (1-2 units) $0.00 0 New Res (3+units) $0.00 0 Pool / Spa $0.00 0 Lighting Fixts $29.30 30 Recept Outlets $22.73 21 Switches $0.00 0. Non Res Appl -$0-00, 0 Res Appl $0.00 - 0 , Service to 200a " " $0.00-, 0, Service to 1000a $0.00 0 Service over 1000a $0.00. 0 Motors to 1 h $0.00 0 Motors to 10hp $0.00 0 Motors to 50hp $0.00 0 Motors to 100hp $0.00 0 Motors over 100hp $0.00 0 Communication drops $12.10 11 Sub panel to 200a $0.00 0 Pole Light Pkg $0.00 0 Sign Circuits $0.00 0 Temp Pwr Pole $0.00 0 Intermed Pole $0.00 0 FEE SUMMARY Quantity Temp Dist System 1 Lighting $0.00 0 Busway 1100 ft $0.00 0 Standing Section $0.00 0 Misc Electrical Equipment $0.00 0 Transformers up to 1 kva/kw $0.00 0 ................ up. to 10 kvalkw $0.00 0 .................up to 50 kvalkw $0.00 0 .................up to 100 kvalkw - _ . $0.00 0 .........over 100 kvalkw $0.00 0 Low Voltage Equipment $0.00 0 Low Voll Wiring System 1 Ckt $0.00 ' 0 Misc. Conduit $0.00 0 Misc. Conductor $0.00 0 Circus ( gen or ride) $0.00 0 Circus (mech ride or lights) $0.00 0 Christmas Tree Stand $0.00 '0 Fireworks, Stand $0.00 0 Other Electrical Fee $0.00 Investigation Fee $0.00 Plan Check Fee $0.00 Reinspection Fee $0.00 TOTAL CALCULATED FEES $87.63 COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 2446.46 (SM) % DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the `fl1 � ,work for which this permit is Issued. I have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ,,,work workers' Compensation Insurance carrier and policy number are: Carrier— Poli�ber, ---l.CAt9l /30-ZO` 6 (T1ifs'sea1ion need not be completed it the penrtit Its valued at one hundred dollars ($ f 00) or less.) ❑ 1 certify that in the perform oce of the work for ptich this permit Is issued, I shall not employ any person In any manner so as to become subject to the workers' compensation laws of C ' omia, and agree th if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these pro Ions. Applicant Signature:_77 Date: v -d L ."W_ARN�If1G'-*AILURE'TO SE RE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED 'THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED POR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: hereby affirm that I am licensed under provisions of Chap er 9 (commending with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full �vrctiatid:e)7gcL.l:ic�d Class•ff�7 L' ( � MTracid-r's.S_ignature CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: – _ Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or County which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more then five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sale compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement Is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's license No. Expires: Verification of Ownership by (type of document, i,e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation live (5) or more feet in depth Into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, talsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 WIII the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has a1 any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .........................•--.........................._........................................................................................................................ ............................... _....... .............. ..........................._...................._................._ 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _.. ............ ....... ................................._........................................................................... ........................................ ......................----•-•--•--------................................................................................................................__. 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ............................................................... .... .... ............,.,.................................... ............. •......................................................................................................................................................................................................................................... 4 Ef an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes IJ No .. __............... _.............................--.................... __................................ _.................................. I'll ............................ ... ....... ................................................................................................................................................... . 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes IT No (Section 65650.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). .............................................................................................................................................................................................................................................................................................................................................................................. 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? []Yes C]No (If yes', the facility must meet the requirement o1 Sections 25534 and 42303 o1 the California Health and Safety Code). .... __.......... ...................... _.._,.................................. �.............................. __....................... --.._................................ ............................... ............................. ................-... -.- ...... — ... _.......... _. 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency Is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No _ ... _....._........ ..............................................................._—....................... ...... .............._.__.......................... ........... ............._ ......................... -- ................. _ 8 (If 'yes-, attach certificate at compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the Information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-clescribed property for inspectio purposes. I agra not to occupy or allow occupancy of any building authorized by this permit until final inspection. Sigh1fure Of Legal n (s) 4M Or.Av orfze ;Appttcail(. �pafe CODE ;. SECTION TYPE j AN INTMALS CORE / INSPECTION TYPE 2M ItUIDALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT Job Address: 3333 BRISTOL ST Suite No SEAR Vicinity: AUTO CENTER Parcel Nunmber: 41250106 Applicant: LARSON, KEVIN Address: 5415 INDUSTRIAL DR. HUNTINGTON BEACH, CA Owner: ' SEARS, ROEBUCK & CO Address D/768TAX,B2-1.16A-" ,' HOFFMAN ESTATES, IL 3333 BEVERLY RD Contractor: R L DOUGLASS ELECTRIC Address: 5415 INDUSTRIAL DR HUNTINGTON BEACH, CA Phone: 714-895-4588 Zip: 92649 Phone: Zip: 60179 Phone: 714-895-4588 Zip: 92649 License: 452070 Status: ISSUED Applied: 06118!2002 Issued: 06/18/2002 - SCOPE OF PERMIT , - INSTALL LIGHTING"FIXTURES, OUTLETS. -SWITCHES, A",SIGN CIRCUIT, AND COMMUNICATION DROPS. 'SEARS AUTO CENTER' REF: B02-00559 COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 2"6-46 (6r00► •• FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 Temp Dist System ! Lighting $0.00 0 . Temp service test $0.00 Busway 1100 ft $0.00 0 Res. a/c package $0.00 Standing Section $0.00 0 New Res (1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0 New Res (3+units) $0.00 0 Transformers up to 1 kvalkw $0.00 0 Pool 1 Spa $0.00 0 ................up to 10 kvalkw $0.00 0 Lighting Fixts $66.53 81 .................up to 50 kvalkw $0.00 - 0 Recept Outlets $8.80 8 .................up to 100 kvalkw. - $0.00 0 Switches $2.20 2 ..................over 100 kvalkw $0.00 0 Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0 Res Appl $0.00 0 Low Volt Wiring System ! Ckt $0.00 0 Service to 200a $0.00 0 Misc. Conduit $0.00 0 Service to 1000a $0.00 0 Misc. Conductor $0.00 0 Service over 1000a $0.00 0 Circus ( gen or ride) $0.00 0 Motors to 1hp $0.00 0 Circus (mech ride or lights) $0.00 0 Motors to 10hp $0.00 0 Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 0 Fireworks Stand $0.00 0 Motors to 100hp $0.00 0 Other Electrical Fee $0.00 Motors over 100hp $0.00 0 Communication drops $3.30 3 Investigation Fee $0.00 Sub panel to 200a $0.00 0 Plan Check Fee $0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $24.60 1 Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $128.93 Intermed Pole $0.00 0 COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 2"6-46 (6r00► •• DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. -my workers' compensation Insurance carrier and policy number are: .� Cartlarti S 1-% f�� Fi-�.1�7vi� - - - _ PtSffcy Number.- O qq-i ( { AJ:9:Il t',/�L&?� FThts action need not be completed it the permit 1s valued atone hundred dollars ($100) or less.) ❑ 1 certify that In the performanCyr of the work whlch this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Callfo la, and agr at if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these prm si / ,.AppkmnI'SignatuJe:-� Dater 6 / e O z r� - �WARNING: FAILURE TO SECU ERS' COMPENSATION COVERAGE IS UNLAWFUL ANO SHALL SUBJECT AN EMPLOYER— TO CRIMINAL P A NALT4E5 AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE (S100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THrr LABOR CODE, INTEREST, ANO ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affi fgLthat.i.am licensed under provisions o1 Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license Is In full efdreL8ffect,Lia c,--- e �Cfas i " C;;iC al's Slgpalura:> ��aie!- _ tO a 144 CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason {Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or She is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature. Date: Owner ID verified by driver's license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby conity that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: -- _ -- _ - _ _ _ Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, Or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ............................................................................................................................................................................................................................................•---..----•--.........................................................................................-_................ 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet o1 compressed gas at standard temperature and pressure). ......................... ..................... ........................................ ......................._._._.......................................... ................................................ ................ ................... ................................................................. 3 Does or will the applicant or present or future building occupant need to prepare an RM PP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ... - -........................................-............. _................................................................................................... -................. — ................ - ... _....... _ 4 If aM n RPP is presentl_.......y required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes [J No _....... _...................................... _........................ ............................................................. _....... _..... ................... -_............... -...-........... -..-._... ......... .... 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this a12plication a�ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? C]Yes No (Section 65850.2 of the California Government Cafe requires that the requested information be furnished on applications for non-residential building permits). 6 Will any pan o1 the tadlity to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 o1 the California Health and Safety Code). ...................... ..................... ---._............. ---..................................... .....-........................... -....................... .............-................................................................................. -.............................................. _ ............... -- ............ ... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by Califomia Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ...8...... (li,'yeS", •attach certificate of compliance from the appr­­­111­11111111-111 priate air pollution control officer) .....................................................................................................................-•-------••.._••...••••..•.••....•••-----•••---••••.»• CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. l agree to comply with all state laws and dry ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given Is correct. I agree to comply with all state laws and city ordina ces relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspecti purposes. 1 agree n 10 occupy or allow occupancy of any building authorized by this permit until final inspection. S at L al 71 Da�� v At13/0r uthonzad.Ap t� �fldt CODE r. INSPECTIOPAR IUMALS CODE SPF RriiE 1tluIlALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Root 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Oocupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92526 BUILDING PERMIT Job Address: 3333 BRISTOL ST Status: ISSUED Suite: SEAR Applied: 06/05/2002 Vicinity: SEARS AUTO CENTER ANNEX BLDG Issued: 06/13/2002 Parcel Number: 41250106 Zoning: PDC PDC Applicant: LIEDERMAN, .TEFF ISSUED BY: Address: Phone: 818-222-2288 Zin SETBACKS MAIN STRUCTURE Front 0- 0 ACCESSORY Front 0-0 PARKING Existing: 0 PLANNING & ZONING Rear 0-0 Left 0-0 Rear 0-0 Left 0.0 Required: 0 Proposed: 0 Right 0-0 Right 0- 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under/California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) / EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days, or If work Is suspended or abandoned for a period of 180 days. i/ INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codas, and all required Inspections and itnat approval roust be obtained. Failure to obtain inspections and final approval witi result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 244046 (SM) Owner: SEARS ROEBUCK & CO Address ,� D176BTAX,B2-116A, HOFFMAN ESTATES, IL Phone: 3333 BEVERLY RD Zip: 60179 Contractor: I C E BUILDERS INC , Address: 421 E CERRITOS AV Phone: 714-491-1317 ANAHEIM, CA Zip: 92805 License:' 775947 - Arch : BLAKE SHELTERS ARCHITECTS - - Eng: Address: 4764 PARK GRANADA Address: STE 101 Phone: 818-222-2288 Phone: CALABASAS,CA Zip: 91302 License: 11101 License: SCOPE OF PERMIT 10,976 SF ANNEX BUILDING INTERIOR STORE TI AT "SEARS AUTO CENTER.- WORK TO INCLUDE NEW DOORS AND DISABLED ACCESSIBLE RESTROOM COMPLIANCE. REF: 802-00558 AND B02-00559 FEE SUMMARY Plan Check: $208.81 Calc Valuation: $20,000.00 Permit: $321.25 Claim Valuation: $20,000.00 SMIP Res: $0.00 SMIP Com: $4.20 Other: $0.00 Inspection: $0.00 Total: $534.26 SETBACKS MAIN STRUCTURE Front 0- 0 ACCESSORY Front 0-0 PARKING Existing: 0 PLANNING & ZONING Rear 0-0 Left 0-0 Rear 0-0 Left 0.0 Required: 0 Proposed: 0 Right 0-0 Right 0- 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under/California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) / EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days, or If work Is suspended or abandoned for a period of 180 days. i/ INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codas, and all required Inspections and itnat approval roust be obtained. Failure to obtain inspections and final approval witi result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 244046 (SM) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. have and will maintain workers' compensation insurance, as required by section 3700 of the tabor Code, for the performance of the work for which this pamltt is Issued. wo ars°pe sa Insurance ca or an policy number era: r I I r p-� arrior t`Gi J J'C Q G Poli V V Y Z 1 Z U 4 section need not be completed 1t the permit is valued at one hundred dollars ($ f 00) or less.) ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person In any manner so as to become subject to the workers' compensation laws of California, and agree that if should become subject to the workers' compensation provisions of Section 3700 of the Labor Coda, I shall forthwith Ih these f n Ignai WARM URE TO RE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SttB1ECT AN �,RIMINpL PFJW4LTtFS ANp pV[L RNF a^ Up TO ONE HLWDREA D DOLLARE (S100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTOMErs FEES. LICENSED CO ACTORS DECLARATION: I a m licensed under pr visions of Chapter 9 (commencing with Section 7000) of Dlvis n i13 Business nd Professions Cade, and my I1Cense is in full �. a 7 '-�� f3 Con o's Slgnat a: �� 4, A �Z7 CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is Issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sac. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, altar, improve, demolish, or repair any structure, prior to Its Issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Dhrlslon 3 of the Business and Professions Coda) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or Improves thereon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not Intended or offered for sale. If, however, the building or Improvement is sold within one year of Completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors Ligense law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contracfor(s) license pursuant to the Contractors License Laws.). ❑ i am exempt under W. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth Into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no buildieig structure, scaffolding, faisework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 6, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number. HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release Or threatened release of a hazardous material? ❑ Yes Q No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure), 2 Does or will the applicant Or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions. requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 201 cubic feet of compressed gas at standard temperature and pressure). _............._.._.._ .._.,._ ... _ - --.......... _.—.................... ................ _................... 3Does or will th❑e applicant Or prosont or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? 0 Yes (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire partment of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. -""'i"' .......... _ ..._ .. _- .........................._� ......................................... -.._............................ .... _...,...........----.— ............. _.—.. ..........—_..._. _ ._m 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied wilh? ❑ Yes ❑ No -----......... _.........---.� _.......--.................. _... _.._............... ........ _---.......................... ..... .... ........ --- ......... ............�._ .......—_._ . _.__ 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this application aQermit for such Construction or modification from the South Coast Air quality Management District or from any other air pollution control district or agency? 0 Yes ❑ No (Section 65850.2 of the California Goverment Code requires that the requested Information be furnished on applications for non-residential building permits). -- ... .. — _......._...................................................... . _...........� 6 WIII any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ©Yes ❑ Na (If yes", the facility must meet the requirement of Sections 25534 and 42303 of the Califoria Health and Safety Code). —._...... _ — --_....... ....—._........................�....................-_................_.._. 7 If a permit from the South Coast Air Ouality Management District or other air pollution control district or agency ..en is required for the work which is the subject of this application, have all of the disclosures proscribed by Califomia Health and Safely Code Section 42303 been made? ❑ Yes ❑ No ..........(it................................rlitica'..................................._.....................--e air .....-uuonc ............._._.r)..-......................................................... .._......... _... _............... —...--...�--- - 8 (If yes', attach certificate of oompllamCe from the appropriate air pol]ution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final Inspection. S ature Of Legal Owner(s) Date Authors p cant ate copE P. INSPECTION TYPE UM IKUTIAL CODE INSPECTION -TYPE Qct]$ Imo$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 BUILDING PERMIT Job Address: 3333 BRISTOL ST Status: ISSUED Suite: SEAR Applied: 04/26/2002 Vicinity: SEARS (MAIN STORE) Issued: 06/1312002 Parcel Number: 41250106 Zoning: PDC PDC Applicant: LIEDERMAN, JEFF ISSUED EY: Address: Phone: 818-222-2288 Zip: Owner: SEARS, ROEBUCK & CO Address D1768TAX,B2-116A. ' HOFFMAN ESTATES,_IL :✓ Phone: v ` _ 3333 BEVERLY -RD'. - Zip: 60179 Contractor: Address: Phone:, Zip: License: Arch : BLAKE SMELTERS ARCHITECTS ;_� Eng: Address: 4764 PARK GRANADA Address: STE 101 Phone: 818-222-2288 Phone: r CALABASAS, CA Zip: 91302 License: 11101 License: SCOPE OF -PERMIT, -, 274,517 SF INTERIOR STORE TI FOR "SEARS" TO INCLUDE THE,ENTIRE STORE (BASEMENT, 1ST AND 2ND FLOORS). WORK TO INCLUDE: CONSTRUCTION OF NEW PARTITIONS, FLOORING, RESTROOMS AND FINISHES WITH MINOR CEILING WORK AND DISABLED ACCESSIBILITY SITE WORK. REF: DEMO PERMIT AND RELATED PERMITS B02-00559 AND B02-00782 ._FEE SUMMARY Plan Check: $3,645.69 Calc Valuation: $1,000,000.00 Permit: $5,608.75 Claim Valuation:. $1,000,000.00 SMTP Res: $0.00 SMIP Com: $210.00 Other: $0.00 Inspection: $0.00 Total: $9,464.44 PLANNING & ZONING SETBACKS MAIN STRUCTURE Front0= 0 �. Rear 0- 0 Left 070 Right 0- 0 - -ACCESSORY ACCESSORY Front 0-0 Rear 0-0 Left 0-0 Right 0-0 PARKING Existing: 0 Required:' 0 Proposed: 0 NOTES: NOTICE: The work authorized by this permit shall comply with,ali applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) / EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7S4-5626 A6.46 (8104) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Coda, for the performance of the ,, work for which this permit is issued. J&_ I have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code - nos of the work for which this permit is Issued. ED s' oomponsation Insurance carrier and policy number are: r. a L FI a rr vl e r' Policy Numbe 1�l/Vki i d b 2$Z ed not be completed It the permit is valued st one hundred dollars (S 100) or less.) t in the performanco of the work for which this permit Is issued, I shall not employ any person in any manner so as to become subject to the workers ' laws of California, and agree that i should become subject to the workers' co=AN._._ f Section 3700 of the Labor Code, I shall forthwith h hese si re: , .e7 U _ E RE WORKERS, ENSAT10N COVERAGE IS UNLAWFUL AND SWILL SUBJEC_SAND CML PINES UP TOONE HUNDRED RE (SIOD,000), IN ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN SECTION VW OF THE LABOR OODE, INTEREST, AND ATTORNEY'S FEES. SED CO ATION: hereby affi hat I am licensed undo ions of Chapter 9 (commencing with Section 7 of Olvisio D,,1he Buslne nd Professions Code, and my license is in full force and a act. LIC. qasstiContractor's Signature:te: U TION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL 00 THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or Improvement is sold within one year of completion, the owner -builder will have the burden of proving that he Or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who wntracis for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, i will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to fila and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). - i'o.......................................................... . .• c, u-... rit,.......................................................f'o"r......,......,.... '1'e.........a'z"..................................................................................................,................................. 2 Does orwill the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic foot of compressed gas at standard temperature and pressure). 3 Does or will the appplicant or present or future building occupant need to prepare an RMPP (Risk Management end Prevention Program for acutely hazardous materials)? ❑ Yes ElNo (Section 25534 of the California Health and Safety Code provides that the Costs Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. _...................................................... _.._.............................................. _....... ......,..... . �............ ................._............................................._................................................................................... ...................... . ..................... _........ 4 N an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 6................................................................................................................................................................................................................................................"I',"", ................... 5 Doss or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? El Yes IT NO (Section 65850.2 of the California Government Code requires that the requested Information be furnished on applications for non-residential building permits). .................................................................................................................................................................................................................__................................I....... ...................................................................................... 6 Will any part of the facility to be constructed under this permit be within 1000 fest from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ................................................................................................................................................................................................................................................................................................................................. 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this pp................................................................_p........................y.......lifo----.......................................ry...........--..................................................................[: ••---...... ❑ No application, have all of the disclosures proscribed PP California Health and Sate Code Section 42303 been made? Yes..,_..,.._....................................................•.•___•_•••_••....,,,,,••...•.•.. 6 (If es", attach certificate of corn Bance from the a ro nota air, ollution control officer . CERTIFICATE OF COMPLIANCE: I certify that under penalty of parjury the information given above Is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have road this application and state that the information given Is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. S• ature egal Owner Date 3 a Z_ r Au riled" p scan Date CQDE N, INSPECTION TYPE )M INTRGLS CODE 1 INSPECTION TYPE 2M INTMALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Root 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy `� (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 BUILDING PERMIT Job Address: 3333 BRISTOL ST Status: ISSUED Suite: SEAR Applied: 04/26/2002 Vicinity: SEARS AUTO CENTER Issued: 06/13/2002 Parcel Number: 41250106 Zoning: PDC PDC Applicant: LIEDERMAN, JEFF ISSUED 6Y: CA_�� Address: Phone: 818-222-2288 Zip: Owner: SEARS,:ROEBUCK & CO _ Address 'D/768TAX,B2-116A - r i HOFFMAN ESTATES; IL Phone: 3333 BEVERLY RD' � � Zip: 60179 Contractor: I -C E BUILDERS INC Address: 421 E CERRITOS AV Phone:` 714-491-1317 ANAHEIM, CA Zip: 92805" License:' 775947 Arch : BLAKE SHELTERS ARCHITECTS. _. Eng: Address: 4764 PARK GRANADA Address: STE 101 Phone: 818-222-2288 Phone: CALABASAS, CA Zip: 91302 License: 11101 License: SCOPE OF PERMIT -- 25,326 SF INTERIOR STORE TI FOR 'SEARS AUTO CENTER" FOR THE ENTIRE AUTO CENTER STORE AREA (BASEMENT AND 1ST FLOOR). WORK TO INCLUDE CONSTRUCTION OF NEW PARTITIONS, FLOORING, RESTROOMS AND FINISHES WITH MINOR CEILING WORK AND DISABLED ACCESSIBILITY SITE WORK. REF: B02-00558 AND B02-00782 - -FEE SUMMARY - Plan Check: $418.76 Calc Valuation: $50,000.00 Permit: $644.25 Claim Valuation: $50,000.00 SMIP Res: $0.00 SMIP Com: $10.50 Other: $0.00 _ Inspection: $0.00 Total: $1,073.51 PLANNING & ZONING SETBACKS MAIN STRUCTURE Front 0-0 Rear 0-0 Left 0-0 Right 0-0 ACCESSORY Front 0-0 Rear 0-0 Left .0-0 Right 0-0 PARKING Existing: 0 Required: 0 Proposed: - 0 NOTES: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days, INSPECTIONS: in order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL. (714) 7545626 244646 (6W) r� DECLARATIOMS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following doclerations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. gt ave and will maintain workers' compensation insurance, as required by sed lon 3700 of the Labor Code, for the performance of the work for which this permit is Issued. _orlfers' comp nsa11 Insurance carrier and policy number are:`, Gi L) G N A Policy N bar, W 1�ction need not be completed It the permit is valued at ane hundred dollars ($100) or less.) ❑ 1 SorgLty that in the performance of the work for which this permit is Issued, I shall not employ any person In any manner so as to become subject to the workers' corn ensat o 01 California, and agree that i should become subject to the workers' compensation provisions of Section 3700 of the labor Code, I shall forthwith pywl e s / Applicant Signature: Dat WARNING; FAILURE TO SECU WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUaIE O CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLA4RE (5700,000), IN ADDITION TO THE COST OF COMPENSATfON, DAMAGES AS PROVIDED FOR W SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: irm I'Icensed under revisions of Chapter 9 (commencing with Section 7000) on 3 of the Business and Professions Code, and my license is in full fo # "7 4 fr - ure: CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lander's Address; Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, atter, Improve, demolish, or repair any structure, prior to Its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she !s exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any appticani for a permit subjects the applicant to a civil penalty of not more than Ove hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement Is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet In depth Into which a person is required to descend, will be made In connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec, 341, Title B, California Administrative Coda). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division a1 Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous materiel? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be tiled with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form tar acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic fast of compressed gas at standard temperature and pressure). --- ........................... _.............................................................. ....................._.....................-........................... ..................... _.......................... _........................................ _....................... --......................................... .......................... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Sectlon 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ...... .......................................................................................................... .................................................................................................................................. ............... -......... _..............-......................................................................... 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code boon fully complied with? ❑ Yes ❑ No ........................... ---................... ........... .............................................................................................................................................................................. _........................... .... .... _.................................................................................................... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication agermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ........ .............. ................ _...................................................... ..............-----------......................... ................................ -.................................................... ..... -........................................ ............................................ _............................................... 6 will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). --- .................. _.__....... ........................ _............. _................................................................................................................................................................................................. .................. ............... ........ I................... 7 !f a ermit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 6 (If yes", attach certificate of compliance from the appropriate air pollution control officer), CERTIFICATE OF COMPLIANCE: I certify that under penalty of penury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for Inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. nature Of Legal Owner(s) Q Z Date A orizad Applica t Date CODE N. IN5FECTIONTYPE gbh 1NTnI8LS CODE INSPECTION TYPE QAC NTITIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wali 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4656 • www.cl-costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92526 BUILDING PERMIT Job Address: 3333 BRISTOL ST Suite: SEAR Vicinity: SEARS LOADING HOCK Parcel Number: 41250106 Applicant: AMROFELL, IRV Address: 1854 S SANTA CRUZ ANAHEIM. CA zoning: PDC PDC Phone: 714-978-7530 Zip: 92805 Owner: SEARS, ROEBUCK & CO Address D1768TAX,B2-116A HOFFMAN ESTATES, IL Phone: 3333 BEVERLY RD Zip: 60179 Contractor: AMROFELL MORGAN CONTRUCTORS INC Address: 1854 S SANTA CRUZ ST ANAHEIM, CA Zip: 92805 Arch : Address: Phone: 714-978-7530 License: 391230 Status: ISSUED Applied: 02/07/2003 Issued: 03/27/2003 ISSUED BY: Eng: S B BARNES ASSOCIATES Address: 2236 BEVERLY SL Phone: • I Phone: 213-382-2385. LOS ANGELES, CA Zip: License: 90057 License: S1003 SCOPE OF PERMIT _ REMODEL TO THE EXISTING BUILDING. NEW NON-BEARING WALL AT OUTER EDGE OF THE EXISTING COVERED LOADING DOCK. RELOCATE EXISTING ROLL -UP DOORS TO THE"NEW WALL ENCLOSURE. ENCLOSED AREA IS APPROX 1016 SQ. FT. AREA WILL BE USED FOR STORAGE/STOCK ROOM PURPOSES. NO MODIFICATIONS OR ADDITIONS TO EXISTING ELECTRICAL, LIGHTING, MECHANICAL OR PLUMBING ARE INVOLVED PER APPLICANT SEE DR -03-01 Total: $719.12 PLANNING & ZONING SETBACKS MAIN STRUCTURE Front 0-0 Rear 0- 0 Left 0- 0 Right 0-0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void it work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 :"0-40 tWWJ FEE SUMMARY Plan Check: $280.90 Calc Valuation: $28,900.00 Permit: $432.15 Claim Valuation: $28,900.00 SMIP Res: $0.00 SMIP Com: $6.07 Other: $0.00 Inspection: $0.00 Total: $719.12 PLANNING & ZONING SETBACKS MAIN STRUCTURE Front 0-0 Rear 0- 0 Left 0- 0 Right 0-0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void it work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 :"0-40 tWWJ 7- I PENSATION DECLARATION: f der penalty of perjury one of the following declarations: will maintain a Certificate of consent tc self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the ich this permit is issued. have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. S My workers' comppnsallon Insurance carrier and policy number are: Carrier: S'Ti$;TE LIND Policy Number: _ _ 1 (This section need not be completed if the permit is valued at one hundred dollars ($100) or less.) a ❑ 1 certify that in the performance of the work for which this permit is Issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California nd agree that if 3 should become,§�b act to the workers' ompensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisions f d�.r1 L� Applicant Signature: ! . Date: �'2��—� _ WARNING: FAILURE TO SECURE WORKERS' COMPEN ATI COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that i am licensed under provisions of Chapter 9 (commencing with Section 00) c Division 3 of the Business andplofessions Code, and my license is in full force and effect. Lica# Class # Contractor's Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Cade). Lenders Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031 .5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation e1 Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or improvement I$ sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date'. Owner ID verified by driver's license. Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bili or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, l will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity o1 hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ......... ........ .................................................................................... .............•----.......................................----................................................................. ---�-----......,.-----------.................................................................................. 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ N0 (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .........................................................................................................................................................................................._------------.................................................................................................... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ...p:,........................... _................................. _...... .................................................................................................................. ..... ...........------------.................................................................................................... 4 It an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No ....................................................................................................................................................................................................................................... ................................ ............................................................................. 5 Gas or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency! U Yes No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ...................................................................................................................................................................................................................�-�--�-�-.................................—-...............................---.......................................................... 6 WIII any parr of the facility to be constructed under this permit be within 1000 feet from the outer boundaries 0f a school? ❑ Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ............. ........................................................................... .................................................. .................................................. ......................................................................... ................................. ................................................................ 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? [_1 Yes ❑ No .......................................------------....................................--............................................................................................................................................................... B (It yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. to 'rJCot� n re f IO,yrtns i d< r Authorized Applicant Date ti CODE INSPECTION TYPE QAC INTrrLALS CODE I INSPECTION TYPE 2AT1 ltfli[ LSA 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy v (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.uUILDING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Suite: SEAR Vicinity: 1ST FLOOR SEARS Parcel Number: 41250106 Zoning: PDC PDC Applicant: TODD BUYNAK Permit: Address: 4848 COLT ST SMIP Res: $0.00 SUITE 3 Phone: 805-658-6996 Other: VENTURA, CA Zip: 93003 Owner: SEARS, ROEBUCK & CO Total: $534.26 Address Dl168TAX,B2-116A PLANNING & ZONING SETBACKS HOFFMAN ESTATES, -IL -, Phone: MAIN STRUCTURE Front 0'0 Rear 0-0 Left 0-0 3333 BEVERLY RD Zip: 60179 Contractor: I C E BUILDERS INC Required: , 0 Proposed: 0 Address: 421 E CERRITOS AV Phone: 714-491-1317 ANAHEIM, CA Zip: 92805 License: 775947 ISSUED BY: Status: ISSUED Applied: 07/25/2003 Issued: 07/31/2003 Arch : Eng: PLUMP ENGINEERING, INC. Address: Address: 914 E KATELL4 Phone: Phone: 714-385-1835 ANAHEIM, CA Zip: License: License: 52696 SCOPE OF PERMIT CONSTRUCT NEW 6' HIGH GLASS PARTITION WALL ON IN RETAIL ARE OF THE FIRST FLOOR AT 'SEARS'. J4M&III11T4L41-1:V Plan Check: $208.81 Permit: $321.25 SMIP Res: $0.00 SMIP Com: $4.20 Other: $0.00 Inspection: $0.00 Total: $534.26 PLANNING & ZONING SETBACKS MAIN STRUCTURE Front 0'0 Rear 0-0 Left 0-0 ACCESSORY Front 0-0 Rear 0-0 Left 0-0 PARKING Existing:, 01 Required: , 0 Proposed: 0 NOTES: Calc Valuation: $20,000.00 Claim Valuation: $20,000.00 Right 0-0 Right 0-0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2"6-46 (6=) DECLARATiONS WORKERS' COMPENSATION DECLARATION: hereby affirm under penalty of perjury one of the following declarations: r ❑ I have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which Ibis permit is issued. I have and will malntain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued, My worlyprs' compensation Insure ce carrier and policy number are: f .� Q Carrier: ? 71�1���r�q>1 tri C_� Policy Number: "`pc- "6 5 -5 o (This section need not be completed if the permit is valued at one hundred dollars ($100) or fess.) ❑ I certify that in the performance of th to which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California. a a as th if f should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provision4. Applicant Signature- Date:. WARNING: FAILURE T SECURE W RS' COMPEN ON COVERAGE IS UNLAWFUL AND SHALL SUELIECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN AgDfFION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE: LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am hconsiTTr v' ions Chapter 9 (commencing with Section 7000) of Division 3 of the Busine an.g,Professio, s Code and my license Is In full force and effect. Lic. It Class p C_' Z1 C Contractor's Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more then five hundred dollars (SSW).): ❑ 1, as owner of the property, 4r my employees with wages as thelr sole compensation, WILL DO THE WORK, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. It, however, the building or Improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). - ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Cade: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signatdro: , Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Explres: Verification o1 Ownership by (type of document, Le, . property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth Into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, An 2, Sec. 341, Title 6, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: _ Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater then a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ...................pp"t.._.................... ..............'1'u..--bu1i-•----.........................'e-ed..........o.**a.............................................. u,"I.---- hie, -a'rd............................_.....,................................. ........ 2 Does or will the applicant or present or future building occupant need to file a regisiratlon form for acutely hazardous materials? ❑Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _.— ............. _...............----..............,....................................... —......_—...................... ----.......... - ................ ....._.... —-....................__.............. —--................—_..................._. ::F.16­ Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No {Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, cartification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ........................................................................................................................................................................................................................................................................................................................................111-1-­.I..,.................... 4 li en RMPP is presently required, has Section 25534 of the California Health end 5atety Code been fully complied with? ❑ Yes ❑ No ....................._....................._-----._...............,.........'e"*n.......................b"u-................._'u'-pn't,...--------..._._.....................__.... i'c"h,i'..-,h—o........................t'h"i'..................ifo'....._.........................................---------..........................-R'i"'a"l.._n, 5 Does or will rhe applicant or present or future building occupant require for the work which is the subject of chis a plication a germit for such cOnStruCllon or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes LJ No (Section 66850.2 of the Califomia Government Code requires that the requested information be furnished on applications for non-residential building permits). .............................._.......... .....,.......................................................................... ................................. ................................................................................... ,.......................................................................------................................ fi Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes ❑ No (If 'yes", the facility must meat the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ...................................... ............. ..,...................................._................................. .... ..................................... .............................................................................. .............................................................. .................. _.............................. .. 7 If a permit from the South Coast Air ouality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No .1.........111.1111........................... ......................................................................................-,.............. ................................................................................ ............... _..................................... ............................................................. yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the Information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that i have read this application and state that the information given is correct. I agree to Comply with al to laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property far in ecli I purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. rlatu Of Legal Owner{s} to nd/O uthorized Applicant Date CODE 0. IHSPECnOH�PE f)✓i[E fHIQi81$ ' CODE r tNSPECTIONSYPE - DAM II�LBL$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 206 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 Fax (714) 754-4856 • www.ci.costa-nrktaftPRESSION PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Status: ISSUED Suite: SEAR Applied: 11/06/2002 Vicinity: SEARS SHOE STORAGE AREA Issued: 11/20/2002 Parcel Number: 41250106 Zoning: PDC PDC (��& ISSUED BY: Applicant: GUTIERREZ, JOSE Address: 13941 NAUTILUS DR Phone: (714)554-6132 GARDEN GROVE, CA Zip: 92643 Owner: SEARS, ROEBUCK & CO Address D/768TAX,B2-116A HOFFMAN ESTATES, IL Phone:. 3333 BEVERLY RD Zip: 60179 Contractor: X L FIRE PROTECTION COMPANY Address: 3022 HESPERIAN WAY Phone:_ (714)554-6132 SANTA ANA, CA Zip: 92607 License: 311681 SCOPE OF PERMIT RELOCATION OF 14 SPRINKLER HEADS AND ADDITION OF 1 HEAD FOR THE "SEARS" SHOE STORAGE AREA AS PART OF THE INTERIOR STORE TI FOR "SEARS." REF: B02-00558 FEE SUMMARY Plan Check: $35.10 J Calc Valuation: $1,500.00 Permit: $54.00 Claimed Valuation: $1,5oo.00 Other: $0.00 Total: $89.10 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work Is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 Aas4e (6=) DECLARATiONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of paqury one of the following declarations: ❑ I have and will maintain a Certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Coda, for the performance of the work for which this permit Is issued. My workers' compensation In ran carrier d policy umber are: Carrier; 7 `]�Policy Number:- 5C "'�2 (This section need not be completed if the permit is valued at one hundred dollars ($100) or less.) ❑ I certify that in the performance of the work for which this permit is Issued. I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and that if I sh�bbject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisions. Applicant Signature: Date: '-pO — O WARNING: FAILURE TO SEC U ORKERS' COMPENSATION COVERA IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100, I, IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that 1 am licensed under provisionChapter 9 { comm cin Ith Section 7000) of Division 3 of the Business and Professions Cade, and my license is in full force and effect. LIc. # 6s 9f Class # Contractor's Signature: Date: !/ - 25+_-0Z_ _ dzz CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there Is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Landers Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty o1 not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL 00 THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement Is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sac. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Explres: Verification of Ownership by (type of document, i.e. - property tax bill or dead): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth Into which a person Is required to descend, will be made In connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, Califomia Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature; Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to fila and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the Califomia Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure), ............................................................................................................................................................................................................................................................................................................................................................................ 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the Callfomia Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will tha aPplicant or presant or future building occupant nead to prepero an R M P P (Risk Management and Prevention Program for acutely hazardous materials)? Cl Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materiels with the Fire Department. .............................................................................................................................................�................................................................................................................................................................................................... ............ ................ 4 It an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully compiled with? ❑ Yes ❑ No — ......................... ................. _- _...-.._........._............. -.... -----._.................. _—.............. -----..._._..................._....................._....................._.__..........._......._............----- 5 Doas or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes E No (Section 65850.2 of the Califomia Government Code requires that the requested Information be furnished on applications for ran -residential building permits). ...... .................................. ................ ................................. .... .................... ............-...... ...................................................................... ................................... 1.111.1111.......................... ............ _ 6 WIII any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (it 'yes', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). it fro................................_.....------ ------......-------ne-_._._......_......................._................c—o-n._....d"i's"..,i'c"t.............a'*n.........................__....._.I'h.......r,k.....—_._........—•--------...... 7 It a permit from the South Coast Air Qua]ity Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ........................................................................................ ......................... ...................................... ......................... ......................... ...................................................... ..,................ ,...................... B (I1 yes", attach certificate of compliance from the appropriate air pollution control officer), CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Slgnalme: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with at] state laws and City ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described properly for inspection purposes. I agree not to occupy or silow occupancy of any building authorized by this permit until final inspection. Siopafure Of Legal Ow r Date And1Or Authorized Appilo6nt _ Date CODE 5SPECn0Pf TfPE 2AN NTrRALS CODE 1 INSPEGnpll TYPE 2M IIS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical rr7� 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mFIRE SUPRESSION PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92526 Job Address: 3333 BRISTOL ST Status: ISSUED Suite: SEAR Applied: 05/01/2003 Vicinity: LOADING DOCK AREA Issued: 05114 021 03 Parcel Number: 41250106 Zoning: PDC PDC - - ISSUED BY' Applicant: COFFMAN, JASON,/,-, Address: ✓' r.%..',� . , Phone:, 714-870-1010 Zip: \ Owner:/,SEARS, ROEBUCK -&CO - , Address DI768TAX,B2-116A: = ` HOFFMAN ESTATESAL " Phone: 3333 BEVEkl_Y_' � Zip: 60179 .Contractor: SIMPLEkGRINNELL LP Address: 1701 W. SEQUOIA AVE Phone: (714) 870-1010 ORANGE, CA Zip: 92868 License: 802591 ' 'SCOPE OF PERMIT - RELOCATE 4 SPRINKLER HEADS. ADD 2 NEW SPRINKLER HEADS FOR SEARS LOADING DOCK ENCLOSURE. REF: B03-00220. 'FEE SOMMARY.... 1 _. Plan Check: $29.15 Calc Valuation: $1,200.00 Permit: $44.85 Claimed Valuation: $1,200.00 Other: 10.00' Total: $74.00 , l t � NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 446.46 (Stoo) DECLARATIONS WORKERS' COMPENSATION DECLARATION: - hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. Thave and will maintain work9rs' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My wo ers' compensation Itisurancpotarrier and vVY number are: pr f Q Carrier: ��� �ZM � G� �0/✓y Policy Number: /Q/i7LC/� 3� r / (This section need not be completed it the permit is valued at one hundred dollars ($100) or less.) ❑ I cenity that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Calitomia, and agree that if I should become subject to the workers' compensation provisions o1 Section 3700 of the Labor Code, I shall forthwith comply with these pr ions PP Appficant Signa Date: WARNING: FAIL/RE TCURE W s' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3700 OF THE IA4BOR COOE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) o1 Division 3 of the Business and Professions Code, and my license is in full force and effect. Llc. q Class q /G Contractor's S Date: gzlz CONSTRUC LENDI AGENCY: ❑ I hereby affirm that there is A construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: _ Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any City or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he for she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more then five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or Improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, Am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractors) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. _ Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bili or deed): DIVISION OF INDUSTRIAL SAFZTY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person Is required to descend, will be made in Connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Dale: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure), ..............................................................._...................•.........................................................,.,.,,......................................................... .........._........................................................................................ 2 Does or will the applicant or present or future building occupant need to fife a registration form for acutely hazardous malerfels7 ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume o1 55 gallons, or 200 cubic feet of compressod gas at standard temperature and pressure). ....... . ................................ ............................ I................ •................................................................... ............................. .....................-----........................................................................................................................................................... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and tiling with the Fire Department of an RMPP by businesses which are required 10 register acutely hazardous materials with the Fire Department. .......................—._._...................___�.........,............................_----------.................... forma ---......-than....................._......_............. __._..................,...............................................—.................._........................_....... 4 if an RMPP i9 presently required, has Section 25534 of the California Health and Safety Code boon fully Complied with? Yes ❑ No — ....................... _....................._............,....................... _—........................... ---...................._................................................. —_............................... _................ ................. 5 Does or will the applicant Of present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification from the South Coast Air QuAlity Management District or from any other air pollution control district or agency? (J Yes No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). .......... ....._............................................. ................. --.._............................... _._—.............................................-----..........................................._ ................-- 6 Will any part of the facility to be constructed under this permit be within 1000 teat from the outer boundaries of a school? ❑ Yes ❑ No (it 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code)........ _....................._..._.......................__................--•---------................._...- ._._.............---...._............................- •• - -..........- - --- �........ __- � ......... . — ........ 7 If a permit from the South Coast Air Quality Management District of other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No .......................................-,.......................................................................................................... ......................................................... ........................ ................... _................................................._...................... B (I1 jres", attach certificate of Complianco from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. 1 agree not to occupy of allow occupancy of any building authorized by this permit until final inspection. igna re galOwner(s) Date S •/ . 4 uthorizad Applicant Date CO&J-41191=011 Ty Mu INTITIAL COPE; INSPECTION TYPE l2AIE jNTMALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final BuildingfOccupancy i Ak (714) 754-5273 • Fax (714) 754.4856 • www,ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 MECHANICAL PERMIT .fob Address. 3333 BRISTOL ST Suite No SEAR Vicinity: EQUIPMENT ENCLOSURE Parcel Number: 41250106 ISSUED BY: A licant• BOND KEITH Status: ISSUE=D Applied: 01/17/2002 issued: 01/17/2002 3333 BEVERLY RD Zip: 60179 Contractor: A T C TOWER SERVICES INC Address: 1940 S GROVE AV - � Phohe.800-551-8086, ONTARIOM, CA , Zip;" _ _ 91761 , License: 664262 , SCOPE OF PERMIT INSTALL 2 FOUR TON AIC UNITS, 2 AIR HANDLERS AND ONE EXHAUST FAN IN EQUIPMENT r " ENCLOSURE FOR COOLING.OF�CELL, EQUIPMENT. -REF: B01-01247, ISSUE FEE Inst'FAU_<100 k BTU Inst FAU >100 k BTU Repair 1 Alt Cooling/Heat Inst I Rep. Recess Wall Htr Refrig Sys <100 k BTU Refrig Sys >100 k BTU Gas Piping. Factory Fireplace Hood wlMech Exhaust VAV Box Vent Fan / Single Duct Appliance Fire Dampers Smoke Dampers ' Inst or Relocate Appl Vent' Air Handlers < 10000cfm, Air Handlers > 10000cfm ' Floor Furnace Floor or Suspend Heater Quantity $23.50- $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00-.....0 $0.00: 0 $6.00-,-,,o $0.00 0 $0.00 , 0 ,$21.30 2 $0.00 0" $0.00 . 0 $0.00, 0 FEE SUMMARY Repair / Alt "Absorbtion Unit Repair/ Alt Refrigeration Unit Ventillation System Evaporative Cooler ; Commercial Incinerator Domestic Incinerator Compressors I AbsoERtion Systems Up to 3 hp 1 100 k BTU 3 To 15 hp 1500 k BTU 15 To 30 hp 11,000 k BTU 30 To 50 hp /.1,750 k:BTU Over 50 hp I Over 1,750 BTU - Boilers ` Upto3hp 3To15hp ' 15to30hp 30 to 50 hp Over 50 hp Other Mechanical Fee Investigation Fee ' Plan Check Fee Reinspection Fee TOTAL CALCULATED FEES COMMENTS I SPECIAL CONDITIONS Quantity $0.00 - 0' $0.00 0• $0.00 0 $0.00 0 $0.00 0 $0.60 0 $0:00 0 $0.00 0 $0.00 0 $0.00 10 $a.oa, 0 $0,00 0 ,$54.30 2 $0.00 0 $0.00 0 $0.00 0 $0.00 $49.50 $0.00 $155.85 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION,. This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2488.46 (6=) Address: Phone:' 909-821-1025 Zip: Owner: SEARS, ROEBUCK 8' CO Address:, D1768TAX;B2-116A HOFFMAN ESTATES IL Phone' ." 3333 BEVERLY RD Zip: 60179 Contractor: A T C TOWER SERVICES INC Address: 1940 S GROVE AV - � Phohe.800-551-8086, ONTARIOM, CA , Zip;" _ _ 91761 , License: 664262 , SCOPE OF PERMIT INSTALL 2 FOUR TON AIC UNITS, 2 AIR HANDLERS AND ONE EXHAUST FAN IN EQUIPMENT r " ENCLOSURE FOR COOLING.OF�CELL, EQUIPMENT. -REF: B01-01247, ISSUE FEE Inst'FAU_<100 k BTU Inst FAU >100 k BTU Repair 1 Alt Cooling/Heat Inst I Rep. Recess Wall Htr Refrig Sys <100 k BTU Refrig Sys >100 k BTU Gas Piping. Factory Fireplace Hood wlMech Exhaust VAV Box Vent Fan / Single Duct Appliance Fire Dampers Smoke Dampers ' Inst or Relocate Appl Vent' Air Handlers < 10000cfm, Air Handlers > 10000cfm ' Floor Furnace Floor or Suspend Heater Quantity $23.50- $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00-.....0 $0.00: 0 $6.00-,-,,o $0.00 0 $0.00 , 0 ,$21.30 2 $0.00 0" $0.00 . 0 $0.00, 0 FEE SUMMARY Repair / Alt "Absorbtion Unit Repair/ Alt Refrigeration Unit Ventillation System Evaporative Cooler ; Commercial Incinerator Domestic Incinerator Compressors I AbsoERtion Systems Up to 3 hp 1 100 k BTU 3 To 15 hp 1500 k BTU 15 To 30 hp 11,000 k BTU 30 To 50 hp /.1,750 k:BTU Over 50 hp I Over 1,750 BTU - Boilers ` Upto3hp 3To15hp ' 15to30hp 30 to 50 hp Over 50 hp Other Mechanical Fee Investigation Fee ' Plan Check Fee Reinspection Fee TOTAL CALCULATED FEES COMMENTS I SPECIAL CONDITIONS Quantity $0.00 - 0' $0.00 0• $0.00 0 $0.00 0 $0.00 0 $0.60 0 $0:00 0 $0.00 0 $0.00 0 $0.00 10 $a.oa, 0 $0,00 0 ,$54.30 2 $0.00 0 $0.00 0 $0.00 0 $0.00 $49.50 $0.00 $155.85 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION,. This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2488.46 (6=) DECLARATIOMS WORKERS' COMPENSATION DECLARATION: 11111111116 A I hereby affirm under penalty of perjury one of the following declarations: ❑ I have'and will maintain a certificate of consent to self -Insure for workers' Compensation, as provided for by section 3700 of the Labor Code, for the performance of the w t� for which this permit Is Issued. - have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. My, workers' compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed if the permit is valued a1 one hundred dollars ($100) or fess.) ❑ 1 certify that in the performance of th work for whic is perm issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Califor nd agree the I sho come subject to the workers' compensation provisions of Section 700 oft a Labor Cada, I shall forthwith comply with those pro ' sl�l --Applicant Signature: Date: O WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PE TIES AN CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE (5100,000}, IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed un r provisions of Chap commencing with Section 7000) of Division 3 of the Business and Processions Code, and my license is in full force and affect. Lie. # Class # =Contractor's Signature:. Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 703 1.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) Or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of safe.). ❑ 1, as owner Of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner Of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.), ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Driver's License No. Expiros: Verification of Ownership by (typo of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in Connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, Calilomla Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division Of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Deparlment by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ..... ............................_........................_...............................................I......................... .... •...................._.._................ _---.................. _.... —_..-..................................... _....................... —_....... ..__.................—..........-- 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). --- --.___......'l t' .............._.. ....................._..._—..__......................p-r,—_............................(A-i.........._._......-en"'t..................v e--.......-Pr"9-r'...........-__...............ez-- ...............— Is-,... . 3 Does or will the appplicant ar present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acute]y hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. -_ ................-_ ........................ —................................................. ...........................................................---................ —_._................ ......-----...................._.-................................. __...................................... ... 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No ..........................................-............ .............. .................................................................................................................. ....................... ............................................................................................................................................................. 5 Does or will the applicant or present or future building Occupant require for the work which is the subject of this application a ermit for such construction or modification LJ from the South Coast Air Quality Management Disirici or from any other air pollution control district or agency? LJ Yes No (Section 65850.2 of the California Goverment Code requires that the requested information be furnished on applications for non-residential building permits). —_ .................. -................ _._.................................................. ....................... _ .__...... ......--.................—......................-----._......................._................................ _................ _............. -_............ .—....... 6 Wilt any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (N 'fres", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code), 7 If a permit from the South Coast Air Duality Management District Or Other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (If yes", attach certificate of compliance from the appropriate air pollution control Officer). CERTIFICATE OF COMPLIANCE: I Certify that under penalty of perjury the information given above is correct, i agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection pu agree n to occupy or allow occupancy of any building authorized by this permit until final inspection. Si f Leg Owner(3),,, I' ate ` AndfOr Authorized d �J Date CODE t• INSPECBON TIPS 2&M ll®64$ CODE o INSPECTION TYPE 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall. 212 Final Fire Prevention 202 Final Factory Fire. Place - 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy S.i'I Ah (714) 754-5273 • Fax (714) 754-4856 • www.cl.costa-mesa.ca.us MECHANICAL PERMIT Job Address: 3333 BRISTOL ST Suite No SEAR Vicinity: ' SEARS MAIN STORE Parcel Number: 41250106 77 FAIR DRIVE, COSTA MESA, CA 92626 F Status: ISSUED Applied: 06/19/2002 Issued: 06/19/2002 ISSUED BY: Applicant: FOSTER, GERALD Address: 3183 AIRWAY AVE - FEE SUMMARY BLDG F ; Phone: (714)445-0200 COSTA MESA, CA, Zip: 92626 Owner: SEARS,,ROEBUCK & CO Repair 1 Alt Absorbtion Unit ` Address: DI768TAX,B2-116A $0.00 0 Repair I Alt Refrigeration Unit $0.00 0 Inst FAU >100 k BTU $0.00 HOFFMAN ESTATES, IL Phone: $0.00 0 3333 BEVERLY RD Zip: 60179 Evaporative Cooler $0.00 0 Inst I Rep. Recess Wall Htr Contractor: ENCOMPASS MECHANICAL SERVICES Address: 3183 AIRWAY AVE 0 Refrig Sys <100 k BTU $0.00 BLDG F Phone: (714)545-0200 0 COSTA MESA, CA Zip: 92626 Compressors / Absorption Systems License: 513014 SCOPE OF PERMIT INTERIOR STORE TI FOR THE "SEARS" MAIN STORE. 3 VENT FANS/SINGLE DUCT, 11 SMOKE DAMPERS, 4 FLOORISUSPENDED HEATERS. -REF: B02700558 FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 Repair 1 Alt Absorbtion Unit $0.00 ' 0 Inst FAU <100 k BTU $0.00 0 Repair I Alt Refrigeration Unit $0.00 0 Inst FAU >100 k BTU $0.00 0 Ventillation System $0.00 0 Repair I Alt Cooling/Heat $0.00 0 Evaporative Cooler $0.00 0 Inst I Rep. Recess Wall Htr $0.00 0 Commercial Incinerator $0.00 0 Refrig Sys <100 k BTU $0.00 0 Domestic Incinerator $0.00 0 Refrig Sys >140 k BTU $0.00 0 Compressors / Absorption Systems Gas Piping $0.00 0 - Up to 3 hp 1 100k BTU $0.00 0 Factory Fireplace $0.00 0 3 To 15 hp 1500 k BTU $0.00 0 Hood wlMech Exhaust $0.00 0 15 To 30 hp /•1,000 k BTU $0.00 0 VAV Box $0.00 0 • 30 To 50 hp 11,750 k BTU $0.00 0 Vent Fan 1 Single Duct $21.75 3 Over 50 hp / Over 1,750 BTU $0.00 0 Appliance $0.00 0 Boilers Fire Dampers $0.00 0 Up to 3 hp $0.00 0 Smoke Dampers $79.75 11 3 To 15 hp $0.00 0 Inst or Relocate Appl Vent $0.00 0 15 to 30 hp $0.00 0 Air Handlers < I0000cfm $0.00 0 30 to 50 hp $0.04 0 Air Handlers > 10000cfm $0.00 0 Over 50 hp $0.00 0 Floor Furnace $0.00 0 Other Mechanical Fee Floor or Suspend Heater $59.20 4 Investigation Fee $0.00 Plan Check Fee $0.00 Reinspection Fee $0.00 TOTAL CALCULATED FEES $184.20 COMMENTS I SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days, or If work Is suspended or abandoned for a period of 180 days. INSPECTIONS: in order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 144646 (6=) F_-I DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certlllcate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued, �have and wGl maintain workers' compensation Insurance, as required by seal 700 01 the Labor Code, for the performance of the work for which this permit fs Issued. My orke pensati nsuranCe carrier and po11 number are: C '�t/,.� WL y/�v�j 7 L� Policy Number: I g ! 3 `•! / (This section need not i76 Completed 11 the permit rs valued a e hu dollars (S 1(H)) or less.) ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person In any manner so as to become subject to the workers' compensation laws of C to sa r that if I should become subject to the workers' compensation provisions of Section 3700 of the labor Code, I shall forthwith comply with these pro co Applicant Signature: Date: 4ZLI9 _ WARNING: FAILURE TO SE URE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLlARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9(co me wL a ion 7000) of Division 3 of the Business and Professions orf , and m license is i full force and effect. Lic. 4 Class M IC Contractor's Signature: Date: CONSTRUCTION LENDING AGENCY. ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth Into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, ialsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). -- 2 Does or wilt the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with soma exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _................_............................................_.........._-.........-........................ _ _................. ..... _ _......----._ _ _............................_.._........_ _ ....._ 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ............................................................................................................................ ......................................................... _...................._......................................................... . ................................... .......... ....................................... 4 li an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No .......................................................................................................................................................................................................................................................................................................................................................................................... 5 Does yr will the applicant or present or future building occupant require for the work which is the subject of this application a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? []Yes f No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ........................_.......................................................... .................... ...--............................................ ...................................... .................................................. ..... .I............. ... ...... .................. ...................... ..- B Will any part of the facility tc be constructed under this permit be within 1000 feel from the outer boundaries of a school? ❑ Yes ❑ No (If yos", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). _............................................... ...........--- ... _.............----............. _..—.............. —_.............. _—..__.._..........._.............__._ _ ................... _ _.............................................. _ ... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Salary Code Section 42303 been made? ❑ Yes ❑ No a (If "yes', attach certificate of compliance from the appropriate air pollution Control otficerJ. CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Aff&rner(s) dl Authorized Applicant _ Date C013E f. INSPECTION TYPE 299 IlllMILS CODE[ MSPECEONTYPE INTMAI„S 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1268 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final BulldinglOccupancy ELECTRICAL PERMIT Job Address:' 3333 BRISTOL ST Status: ISSUED Suite No SEAR Applied: 08/20/2003 Vicinity: SEARS 1ST FLOOR IN ELECTRONICS DEPTS Issued: 08/20/2003 Parcel Nunmber: 41250906 Applicant: LARSON, KEVIN ISSUED BY: Address: 5415 INDUSTRIAL DR f : Phone: 734-895-4588 HUNTINGTON.BEACH,CA'' 1 Zip: 92649 Owner SEARS, ROEBUCK &-COQ= Addres�f�'Dr768TAX-,B2-116A-ZZ HOFFMAN ESTATES;dL Phone: 3333 BEVERLY RD Zip: 60179 ` �! �Contractor CARSON, KEVIN Address: Phone: r . - Zip: License: 452070 -y SCOPE OF PERMITr.\ ELEC PERMIT IN-CONJUNCTIOIV WITH THE CONSTRUCTION OF A NEWV HIGH GLASS PARTITION WALL ON IN RETAIL AREA OF THE -FIRST FLOOR AT "SEARS." WORK TO INCLUDE RELOCATION \ POWER FOR 8 POKE-THRU FLOOR BOXES AND DISCONNECTIRECONNECT POWER TO CASH WRAP (REGISTERS). ; 8 RECEPT OUTLETS, 2.MISC CONDUITS, 2 MISC.CONDUCYORS! ,'REF: B03-01278 _ - , ._ , � r �' • FEE SUMMARY-----. Quantity - Quantity/� ISSUE,FEE ,_ : ' ,$23.50 �� :.. - ";Temp Dist System 1 Lighting $0.00 "0/ Temp service test" ''� $0.00 �;"�' ��Busway'/,100 ft $0.00 Res`alc.package �, $0.04 �_�''�:� Standing'Section tr $0.00"��� 0 New Res (1-2.units) ♦$0:00 0 _. •-;' Misc Electrical Equipment! �.$0.00%/ 0 New Res (3+u6its) $0.00 ' 0 : `: Transformers up to 1 kvalkw "% " $0.00 0 ; Pool / Spa �.'�''�� ;x;`_$0.00',. �` 0 ,; :7..............up to 10 kvalkw, $0.00 �'.'0 Lighting Fixts ti�'� ;. .� $0.00 0 _. ................. up to 50 kvalkw .' Recept Outlets $8.80 -, 8. `, .................up to 100 kvalkw $0.00 ; ,0 'f ' Switches ,� $0.00-11 0 ...............::.over 100 kva/kw $0.00"- j 0, Non Res Appl $0.00. 0 `. - - � Low Voltage Equipment , "$0.00 � ; 0;"- ,� Res Appl $0.00 0 Low Volt Wiring System 1 Ckt $0.00. ' ; 0' Service to 200a $0.00 0` ',',' . Misc. Conduit ". `• $36.40, --2 1 Service to 1000a -$0.00 01 i Misc. Conductor i' ' -$36.46� 2 Service over 1000a $000 _0 Circus ( gen or ride) $0.00 0 Motors to 1hp • $0.00 ,- 0 Circus (mesh ride or lights),, '$0.00 0 Motors to 10hp $0.00 0' J -->` , Christmas Tree.Stand'/ $0.00 0 Motors to 50hp $0.00 0 _ v Fireworks Stand- $0.00 0 Motors to 1 00h $0.00 0 -- Other Electrical Fee $0.00 NOTICE: The worts authorized by this permit shall comply with all applicable handicap access .requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2"&46 (sroo) r1 DECLARATIONS WORKERS' COMPENSATION DECLARATION: ML I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. T9� I have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. r 'My workers' compensation Insurance carrier and policy number are; Carrier.59 C 0 - Policy Number:J � � ✓✓ 30c::, (This section need not be completed it the permit is valued at one hundred dollars ($ 100) or less.) ❑ 1 certify that in the part orma of thow e work for hlch this permit Is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Calif ia, and ago t t If I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these pro vi v v �- Applicant Signature: Data: 2 L WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED AN THOUSD DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am ficens der provisions of Chap er 9 (commencing with Section 7000) of Division 3 of the Business an Professions Code, and my license Is in full force and effect. Lic. 4J Zc c7 Class p7 Contractor's Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction tending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors Lloense Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not Intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-bullder will have the burden of proving that he or she did not build or improve for purpose of sale.). ' ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Coda: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License taws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. Z Yes ❑ No Drivers License No. Expires: Verification o1 Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF 11415USTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet In depth into which a person is required to descend, will be made In connection with work authorized by this permit, and that no building structure, scaffolding, talsework, or demolAlon or dismantling thereof, will be more than thirty-six (36) feet high. (Chap, 3.2, Grp 2, Art 2, Sec. 341, Title 6, Califomla Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes . ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _........._.........................._...................................................................................................................................................................................................................................................................._.................................. 2 Does or w€ll the applicant or present or future building occupant need to fi]e a registration farm for acutely hazardous materials? ❑Yes ❑�Nv (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater then a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ..............._x..........................p...............................................................-------.................._........................._................ �............. .........._............. ....._......—.........................._.._._.._................ ---.._....... ..--------- - 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ IY (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. -- ................. ...........__........... ..... . . 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Coda been fully complied with? ❑Yes ❑ Na ................................................................................................................................................................................................................................................... _.......... 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this a pllcation aennit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Lj Yes [ No (Section 65850.2 of the California Government Code requires that the requested Information be furnished on applicatlons for non-residentlal building permits). _ ............._.—_....................-._____._..-•----- .............--................._.................. — .... -• _....................._.......................... -....... ............_ 6 Will any part of the facility to be constructed under th€s permit be within 1000 feet from the outer boundaries of a school? ❑ Yes L No (11 yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Heatth and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which Is the subject of this application, have all of the disclosures prescribed by Cafifomla Health and Safety Code Section 42303 been made? ❑ Ye' ❑ No -..... ...................................... .............................................. ................................ •-..-.... _................... ................. ---........................... _.._................ _•----................. 8 (1f lyes', attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the Information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I gree not 10 occupy or allow occupancy of any building authorized by this permit until final inspect€om natureOf caner Date �3-2�) - 3 And/Or Auth6rized Applicant Date CODE 0. INSPECTIONTYPE 2&M INTITIA 4 GO4E T INSPECTION TYPE 2&11 INTITIA)� 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 209 Final Plumbing 200 Final Re -Root 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Flre Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy Ask (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 BUILDING PERMIT .lob Address: 3333 BRISTOL ST Suite: SEAR Vicinity: PARKING LOT NEAR SEARS AUTO CENTER Parcel Number: 41250106 Zoning: PDC PDC Status: ISSUED Applied: 11/21/2001 Issued: 11/21/2001 Applicant: BOND, KEITH ISSUED BY: Address: 1940 S GROVE AV .r-- " ' Phone: 800-551-8088 - ONTARIOM„CA �, ` `� _ Zip: 91761 SEARS, ROEBUCK"& CO Owner: Address D1768TAX,B2-115A HOFFMAN ESTATES, IL` Phone: ,3333 BEVERLYRD r Zip: 60179` ' Contractor: `•A T C TOWER'SERVICES INC Address: 1940 S GROVE AV Phone: 800-551-8088 ” ONTARIOM, CA Zip: 91761 License:: 664262 ;. Arch . Eng: , Address: Address:' - Phone:7 Phone: Zip: License: License: SCOPE OF PERMIT _ CONSTRUCTION OF 28 LF TRASH ENCLOSURE (TWO WALLS) WITH 28 LF EXISTING, IN CONJUNCTION WITH CONSTRUCTION OF "SPRINT PCS" CELLULAR SITE -.ON TOP OF"SEARS AUTO CENTER BLDG. REF: B01-01247 Plan Check: Permit: SMIP Res: SMIP Com: Other: Inspection: Total: $17.26 $26.55 $0.00 $0.50 $0.00 $0.00 $44.31 SETBACKS MAIN STRUCTURE Front 0-0, ACCESSORY Front 0-0 PARKING Existing: 0 NOTES: FEE SUMMARY., Calc Valuation: Claim Valuation: PLANNING & ZONING Rear 0-0 Left 0-0 Rear 0-0 Left 0-0 Required: 0 Proposed: 0 Right '0- 0 Right 0-01 $560.00 $0.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12.21-92) EXPIRATION: This permit shall automatically expire and become void if work Is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspectlons and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754.5626 2446-46 (6=) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate o1 consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. My work rs' compensation Insurance carrier and policy number are: Carrier:�. ,k7w asd _ Policy Number: (This s ction need not be compreted if the permit is valued atone hundred dollars ($100) or less.) ❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Celifor ' , and agree that if ecome subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these pro i Applicant Signature: 4D Date: WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLL ARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under pr visions of Cha ter 9 (commencing with Section 7000) Of Division 3 of the Busins d Professions Code, and my license is in full force and effect. Lic. # Class # Contractor's Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a perm+' subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. It, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he Or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Cafe: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Data: Owner ID verified by drivers license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsewerk, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ......................... _.......... ................................... ......... _..............1111.....................: ----.......................,........................................................................... _.,........................................--------•................................................... 2 Does or will the applicant Or present or future building occupant need to file a registration form for acutely hazardous materials. [3 Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, Or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 1111... -..............................................................................................-----.......-----------.......................................................................................................................................... 3 Does or will theaappplicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? El Yes 1:1No Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ...... ................................................................................................................................................................",...................................1111. .......................................................................................................... 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with7 Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this N plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? UYes No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). "I'll", ........................................................................................................................................................................................................................... ..... ......... 1111 ....................... ..-------..................................................--•----- 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (It "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ....-...---........................................................................................................................._...............................--•---------.............................................----•-••-------.............................................---------•-•-••---.............................................................. 7 if a permit from the South Coast Air Quality Management District or other air pollution control district Or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No .......................'p"Ii ...... e, fi........................."ro, ............ a"ir,.po"I...............................---------.................................................................................................-•---------............................................•-•-......................... 8 (If "yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-describad property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Si I Owners) / r © date And/Or Authoriz plicant Date CODE #. INSPECT10NTY£E Q Jj CODE:INSPECTION-TYPE PATI 1[QTTIAL$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 206 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall y rn74,.� 212 Final Fire Prevention 202 Fina! Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building7Occupartcy (714) 754-5273 • Fax (714) 754-4856 • www.ci,costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT Job Address: 3333 BRISTOL ST Suite No SEAR Vicinity: BASEMENT Parcel Nunmber: 41250106 Applicant: DOUGLASS, ROBERT Address: Phone: Zip: Owner: SEARS, ROEBUCK & CO Address D/768TAX,B2-116A HOFFMAN ESTATES, IL Phone: 3333 BEVERLY RD Zip: 60179 Contractor: R L DOUGLASS ELECTRIC Address: 5415 INDUSTRIAL DR Phone: 714-895-4588 HUNTINGTON BEACH, CA Zip: 92649 License: 452070 Status: ISSUED Applied: 11106/2002 Issued: 11/06/2002 SCOPE OF PERMIT GENERAL SAFETY CLEAN UP. ELECTRICAL TO INCLUDE: 20 OUTLETS.LOCATED AT "SEARS" BASEMENT. REF.: B02-00558 AND E02-00499. NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and -all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of thi ermiL� FOR INSPECTIONS CALL: (714) 7545626 2446-46 t6=j -FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 Temp Dist System 1 Lighting $0.00 0 Temp service test $0.00 Busway 1100 ft $0.00 0 Res. a/c package $0.00 Standing Section $0.00 0 New Res (1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0 New Res (3+units) $0.00 0 -Transformers up to 1 kva/kw $0.00 0 Pool / Spa $0.00 0 _ ................up to 10 kvalkw $0.00 0 Lighting Fixts $0.00 0 .................up to 50 kvalkw $0.00 0 Recept Outlets. $22.00 20................. up to 100 kvalkw $0.00 0 Switches $0.00 , 0 .. .............over 100 kvalkw_, $0.00 0 Non Res Appl $0,00 0 Low Voltage Equipment $0.00 0 Res Appl /$0.001, 0 Low Volt Wiring System / Ckt $0.00 0 Service to 200a $0.00 Misc. Conduit $0.00 0 Service to 1000a $0.00 - 0 _ _ Misc. Conductor $0.00 0 Service over 1000a $0.00 0 Circus ( gen or ride) $0.00 0 Motors to 1hp $0.00 0- Circus (mech ride or lights) $0.00 0 Motors to 10hp $0.00 0 Christmas Tree Stand. $0.00 0 Motors to 50hp $0.00 0 Fireworks Stand $0.00 0 Motors to 100hp $0.00 0 Other Electrical Fee $0.00 Motors over 100hp $0.00 0 Communication drops $0.00 "0 .. Investigation Fee $0.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and -all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of thi ermiL� FOR INSPECTIONS CALL: (714) 7545626 2446-46 t6=j DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by section 3700 of the Labor Coda, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. My workers' ompensation Insurance carder and policy number are: Carrier: / D L Policy Number: `������_ O_ O (This sectioN-need not be completed it the permit is valued at one hundred dollars ($100) or lass,) ❑ 1 certify at in the erformance of the work or w • h this permit is Issued, I shall not employ any person In any manner so as to bocom subject to the workers' compo sats n laws f Califom' nd gree t It I Quid become bJeCt to the workers' compensation provisions;7,Zzlo the labor Code, I shall forthwith comply 't ovisions Applicant SignalDate: WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERA UN WFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMI AL PEN IES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOL LARE ($100,000), IN ADDITION TO THE COST OF COMPE TION, D GES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRA S DECLARATION: I hereby affirm th I am licans der prov ' s r 9 (commencing with Section 7000) of Division 3 of the Busines end Ploipssions Code, and my license Is in full force and effect. L fi Class q [ Contractor's Signatur . Date: CONSTRUCTION LENDING AGENCY: ❑ t hereby affirm that there Is a construction lending agency for the pe�Ince of the work for which this permit is issued. (Sec. 3097, CMI Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption, Any violation Of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not intended or offered for sale. If, however, the building or Improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an Owner Of property who builds Or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Data: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby cerlity that no excavation five (5) or more feet in depth into which a person is required to descend, will be made In connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the dhAsion. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 Of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas a1 standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need t0 file a registration fort* for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic foot of compressed gas at standard temperature and pressure). _—....................... _._.............. _._._....._._.. ....»......................._._.............................»».................. ................. »»....... ..............».»........................................................ _... ........................... »........ ..........._....................................... 3 Does or wilt the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ................................................»................................................._.._.......................................... _.............................................................. .._.... ............................................................................................................................._.................... _. a If an RMPP !s presently required, has Section 25534 of the California Health and Safety Code been fully compiled with? ❑ Yes ❑ No —._._._... _............ ........ _. ...11..1.1.........».. »_11_11.................................» ..........................»..............._.......I—....._._.........._. 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this application aQermit for Such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes L] No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). .............. »1111................................ 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? Yes 10"I o (if yes', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). _._._.._....................._.._.................................... ........ ...».... ................ ........................._....... _..................... —........................ —_.........................................................._.._.._....................... —.............. ---_............. —._.......... __. 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No --- W _........................ _....................-_._......... ----.....................................__............................_._.._........................ _.—_............................... __..._...................... ................ -----.......... 8 (if yes', attach certificate of compliance from the appropriate air pollution control Officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. 1 agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. re O Legal And/Or AuthorizeAppGc t /I Date CODE J. INSPECTION TYPE fflITRAL COOS I INSPECTION TYPE JNTMA 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical a� d 201 Final BlocktRetain)ng Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT Job Address: 3333 BRISTOL ST Suite No SEAR Vicinity: SEARS LOADING DOCK (NORTH SIDE OF SEARS) Status: ISSUED Applied: 05/29/2003 Issued: 05!2912003 Parcel Nunmber: 41250106 FEE SUMMARY/ Applicant: PICKAR, DENNIS - ___ ISSUED BY: Quantity ` ISSUE FEE $23.50 Temp Dist System 1 Lighting Address: 26081 BUENA VISTA DR__�.",--­' w $0.00 1100 ft $0.00 - 0. Res. a/c package :, $0.00 _Busway ; t� . Standing Section Phone: 714-850-0173 New Res`{1 2 units) , •, $0.00 LAGUNA'HILLS, CA " Zip: 92653 0 New Res`(3+units) ; $0.00 0 ;,- Transformers up.to 1 kvalkw $0.00"- 0 Pool l Spa �, •'J$0:00 .. ..... ......up to_10Lkvalkv•. Owner" ,'SEARS, ROEBUCK &-.CO' Lighting Fixts $5:50_ ...-.••••••-•••••uto50-kvalkw $0.00 • 0 Recept Outlets•\,, $2.20 Addressi�D1768TAX,B2116A"�% to.10,0 kvalkw "16.00" ,0 Switches � /� $0.00 ' ,;; ,. � 0` HOFFMAN ESTATES IL" Phone: 0 Non Res Appl $0.00. 3333 BEVERLY RD Zip: 60179���� 0 Res Appl \ /.$0.00 .` ; Low Volt Wiring System ) Ckt $0:00 ,0 , -� Service to 200a �� $0.00 0. = Misc. Conduit ' Contractor;' WAD,H INC Service to 1000a $0.00 - • " `Address: 26081 BUENA VISTA DR ,,0 ` \ $0:00 ' 0 Circus ( gen or ride) -�Phone: 714-850-0173 . Motors to 1hp `--$0.00-1- LAGUNA HILLS, CA' zip: 92653 0 Motors to 10hp $0.00; _ .0 _ ; Christmas Tree Stand $0.00 0 Motors to 50hp License: 404265 'Fireworks Stand $0.00 0 Motors to 100hp $0.00 0- = Other Electrical Fee $0.00 Motors over 100hp $0.00 ,SCOPE OF PERMIT,, ELEC PERMIT TO CHANGE -OUT 5 LIGHT FIXTURES AND RELOCATE TO OUTLETS IN CONJUNCTION WITH REMODEL TO"THE LOADING'DOCK AREA OF "SEARS. NO OTHER WORK AUTHORIZED WITH THIS PERMIT. REF: B03-00220 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 244646 (6=) FEE SUMMARY/ Quantity Quantity ` ISSUE FEE $23.50 Temp Dist System 1 Lighting $0.00 0 Temp service test $0.00 1100 ft $0.00 - 0. Res. a/c package :, $0.00 _Busway ; t� . Standing Section $0.00 . •„ ',0 New Res`{1 2 units) , •, $0.00 0 Y C'r -, Misc "Electrical Equipment $0.00"", 0 New Res`(3+units) ; $0.00 0 ;,- Transformers up.to 1 kvalkw $0.00"- 0 Pool l Spa �, •'J$0:00 .. ..... ......up to_10Lkvalkv•. 0 Lighting Fixts $5:50_ 5 ...-.••••••-•••••uto50-kvalkw $0.00 • 0 Recept Outlets•\,, $2.20 2 to.10,0 kvalkw "16.00" ,0 Switches � /� $0.00 ' ,;; ,. � 0` ...................over 10D kvalkw $0.00 0 Non Res Appl $0.00. 0' - `0 ` Low Voltage Equipment . - , v$0.00 0 Res Appl \ /.$0.00 .` ; Low Volt Wiring System ) Ckt $0:00 ,0 , -� Service to 200a �� $0.00 0. = Misc. Conduit ' $0.000 Service to 1000a $0.00 - ! 0. ~ -_ Misc. Conductor, $0.00, ,,0 Service over 1000a \ $0:00 ' 0 Circus ( gen or ride) $0.00 ";f' 0 Motors to 1hp `--$0.00-1- 0:. Circus (mech ride'or lights) $0.00 0 Motors to 10hp $0.00; _ .0 _ ; Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 0 L _ 'Fireworks Stand $0.00 0 Motors to 100hp $0.00 0- = Other Electrical Fee $0.00 Motors over 100hp $0.00 0 Communication drops $0.00 0 Investigation Fee $0.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 244646 (6=) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one at the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the Work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: I _ Q G 3 Carrier: S hot- -/ F �- -- J3 Policy Number: + (This section need not be co oto d It the permit is valued a ne hundred dollars ($100) or less.) ❑ I certify that in tho p arm nce of the work for whi thi permit is iss d, I shall not employ any person in any manner so as to become subject to the workers' compensation laws i Calif rnia, and agree that 4 sho d become bject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these rovisi s. Applicant Signature: Date: WARNING: FAILURE TO ACURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUEUECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3705 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am license der provisions of C )Ier(co ncing with Section 7000) of Division 3 of the Business and Professions Code, and my license Is in full force and effect. Llc, q n 40 H 2 6 -s— Class a h Contractors Signature: Date: s r' S�a4 CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there Is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lenders Name: Lender's Address: Signature: T Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he Or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or Improvement Is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of industrial Safety, as noted above, unless such person has e permit to do such work from the division, Signature: Date: Division of Industrial Safety Permit Number:._ HAZARDOUS MATERIALS AND EMISSION% CERTIFICATION: 1 WIII the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Masa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _.............................................................................................................1.............................._...........................................................................................................................,......................................................................... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater then a weight of 500 pounds, Or a volume of 55 gallons, or 700 cubic feet of compressed gas at standard temperature and pressure). ...............................................................................................................................................................................................................................----.--'ll..................................................................................................................... 3 Daes or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No Section 25534 of the Califomia Health and Safety Code provides that the Casts Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses Which are required to register acutely hazardous materials with the Fire Department. 4 li an RMPP is presently required, has Section 25534 of the California Health end Setety Code been fully complied with? ❑Yes ❑ No ..................... .................._..._..—_......................._....................... _.................-.....................—....................................................... -----.................................... .._..................... _............... 5 Does or will the applicant or present or ftiture building occupant require for the work which is the subject of this a plication aPPermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? lLl Yes LJ No (Section 65850.2 of the California Government Code requires that the requested Information be furnished on applications for non-residential building permits). ................................ ..._.._..............................._...................._...--- - ...._....-................ —_......... .....-------- — ........ _.__.......... _................—_ ._. 8 Wi11 any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If -yes-. the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). --- ............................................................ _................... __.—._..................... __....................................... 1-1----_.111 ............................... ----.... .................. _.................... ....._.............. 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which Is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ......................................................................................................._..................................._........................_._................... _.................................................................. ................................................................. 8 ([f yes', attach certlllcate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I cerlify that under penalty of perjury the information given above is correct. I agree to comply with all stale laws and city ordinances regarding Hazardous Materials and Emissions. Signature: _ _ ..__ Date: CERTIFICATE OF PUANCE AND AUTHORIZATIO F ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. t agree __T o of with all state laws and ci rd1 antes relatin to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-describ d props y for inspection purposes. ogre not to occu or allow occupancy of any building authorized by this permit until final inspection, Signature L ner s Date A 60, Atilh&ZQ Applicant I Date copE f. INSPECTION 7]PE DALE Iii CODE QiSPECnONTYPE INTMA�4 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final BlocklRetaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy City of Costa Mesa Development Services Department CERTIFICATE OF OCCUPANCY No. 001343 Building safety Division P. O. Box 1200 Costa Mesa, California The Building located at 3333 BRISTM SMET has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group B-2 Occupancy. Use of Building RE'TP1ZL SAMS Legal Description 412-501-01 (See reverse side for Metes and Bounds) Building Permit No B17938 Electrical Permit,No. E17997 Plumbing Permit No. P17988 Mechanical Permit NO. Number of apartments and/or quest rooms ISSUED TO: Building Official - — M.--- by. -n*n RRT.qWT._ ME -SL VA. ;2 Date This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premise's'/and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. CMF 1015-46 rev, 1183 White - Owner; Canary - Numerical File; Pink - Bldg. Permit File .i . } City of Costa Mesa Development Services Department CERTIFICATE OF O C C U P A.N C Y No. G 01 3 9 6 Building Safety Division P. O. Box 1200 Costa Mesa, California The Building located at 3333 }XYstr)l Strpe-t has been inspected and found to comply with'the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group R--2 Occupancy. E Use of Building Retail qt= Legal Description 412-5ia�r__QL.__.. .. (See reverse side for Metes and Bounds) " I Building Permit No. _FpJ.Sn'7A - -Electrical Permit No. RF-1AQ74 Plumbing Permit No. Mechanical Permit No. Number of apartments and/or guest rooms .ISSUED TO: ,� �- Building Official Sears Roe v- 3333 Bristol Street by' Costa M-- 2526 Date This Certificate of Occupancy SHALL BE posted in -a conspicuous place on the premises and SHALL INOT'BE• removed except by the Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. CMF 1015-46 rev. 1/83 White - owner; Canary - Numerical File; Pink - Bldg. Permit File , •;• ,' •' F� ,'L. 7�� •.. �. R.,s `ice'' f ;S" ,% ��.�-..:. `.` i •h ,; y . y City of Costa Mesa ! Buildi g Safety l]epartment? CERTIFICATE OF OCCUPANCY 2176 _P P.O. Box 1200 ' Costa Mesa, California; • The Building located-at'a �-4 'R,••;.1• %} .. has been inspected and found to comply with the provisions of aIL.City of Costa Mesa Ordinances applicable thereto' { for a Group" Occupancy. s . Use of'B'uilding 1, L'W. egal Description` ' 3" fC]1 t' "• ` ' �' "` `• s {see reverse side for-Metes and Bound_ sl `= ~:BuiIding'P'e�mif-No ""'r' '{"� �� +'.�: o'. - :.. E lecfrical•P.erm it N P IumbingSPermit,No: -.Number of apartments +and/or'guest rooms .' ;f f ISS,U ED T01'r,;r° s:. ' ' '_a ; �' Builfiing Official; Date �' : r 5 R I: , This Certificate of Occupancy SHALL BE p p p �A p y posted in a cons icuous lace on the remises and SHALL NOT BE removed except by the:' •Building Official of the City of Costa-Mesa under Sec. 306 le) U.B.C, _ ' 3 Form BU .34 Rev. 11/70 ," ' City of Costa Mesa ' 'Building Safety Department CERTIFICATE OF OCCUPANCY N? 2423 C P. O. Bax 317 Costa Mesa, California The Building located at R 3333 Bri6t(l Street has been inspected and found !to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group F-2 Occupancy. Use of Building Rat311 Stare Legal Description 14o—o52—oi (See reverse aids for Males and Bounds) Building Permit No. 23919 Electrical Permit No. 261112 Plumbing Permit No. 46,12; Floor Load Signs have been installed as required under Sec. 2308 U. B. C. Room Capacity Signs have been instated as required under Sec. 3301 (1) U. B. C. 17050.' CERTIFICATE OF OCCUPANCY. (a) No apartment house, hotel, or lodging house shall be used or occupied until the owner or operator has been issued a valid certificate of occupancy by the enforcement agency. (b) A new certificate of occuponcyishall be obtained whenever there is a change in: 1) Occupancy classification of a -building or portion thereof 2) The number of apartments or guest rooms 3) Ownership If Group H Occupancy, number of apartments and/or guest rooms as required under Sec. 17050.1 (d), California Administrative Code, Title 8, Chapter 9, Article S. Number of apartments and/or guest rooms ISSUED TO: Building Official SMS-113MCK & CMIPANY Date Member 16, 1%6 This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 306 (e) U.B.C. Form $U34—IM—ii-g3 -q $ P City of Costa Mesa Building Safety Department CERTIFICATE OF OCCUPANCY N? 2422 C P. O. Box 317 Costa Mesa, California The Building located at.___. 3333 BrintOl Str0e*i_ has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group F-2 Occupancy. Use of Building_ Garden ShOp_ Legal Description (See reverse side for Metes and Bounds) 13uilding Permit No. 23920 _ Electrical Permit No, 26145 _ Plumbing Permit No. 16124 Floor Load Signs have been installed as Room Capacity Signs have been instaled as required under Sec. 2308 U. 6. C. required under Sec. 3301 (1) U. S. C. 17050. CERTIFICATE OF OCCUPANCY. (a) No apartment house, hotel, or lodging house shall be used or occupied until the owner or operator has been issued a valid certificate of occupancy by the enforcement agency. (b) A new certificate of occupancy shall be obtained whenever there is a change in: 1) Occupancy classification of a building or portion thereof 2) The number of apartments or guest rooms 3) Ownership If Group H Occupancy, number of apartments and/or guest rooms as required under Sec. 17050.1 (d), California Administrative Code, Title 8, Chapter 9, Article 8. Number of apartments and/or guest rooms ISSUED TO: Building Official SEARS -RACK & C131PANY by Date— DecemZer 16,966 This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 306 (e) U.B.C. F'onn BV34-1114•-11_e3-S-B P City of Costa Mesa Building Safety Department CERTIFICATE OF OCCUPANCY N? 2424 C P. 0. Box 317 Costa Mesa, California The Building located at 4-43-4 ]3rifltt-I SLY'£'et has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group _ Occupancy. Use of Building_ _ Service Station Legal Description 140-0 -Oi (See reverse side for Metes and Bounds) Building Permit No. 2 1. _ g W2 3�I Electrical Permit Na. �-.064S Plumbing Permit No. Floor Load Signs have been installed as Room Capacity Signs have been instated as required under Sec. 2308 U. B. C. required under Sec. 3301 (1) U. B. C. 17050. CERTIFICATE OF OCCUPANCY. (a) No apartment house, hotel, or lodging house shall be used or occupied until the owner or operator has been issued a valid certificate of occupancy by the enforcement agency. (b) A new certificate of occupancy shall be obtained whenever there is a change in: 1) Occupancy classification of a building or portion thereof 2) The number of apartments or guest rooms 3) Ownership If Group H Occupancy, number of apartments and/or guest rooms as required under Sec. 17050.1 (d), California Administrative Code, Title 8, Chapter 9, Article S. Number of apartments and/or guest rooms ISSUED TO: Building Official S -El? BUM. &s CCHPARY by �'�_1�--�/ (cam . `,r- j C -- Dare _ De comber 16, 3-W This Certificate of Occupancy SHALL BE posted in ,a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 306 (e) U.B.C. Fon„ B 34—IM-11-63-.-n P City of Costa Mesa Building Safety Department CERTIFICATE OF OCCUPANCY N? 2425 C P. O. Box 377 Coate Mesa, Colifornio The Building located at 3333 Bristol Strcmt- --- has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group �'`��- Occupancy. Use of Building Sorvice Mtftm SDS Legal Description. 110-4-41 _ �.— (See reverse side for Metes and Bounds) Building Permit No. 239 Electrical Permit No. 26115 T Plumbing Permit No. 46126 Floor Load Signs have been installed or, Room Capacity Signs have been instated as required under Sec. 2308 U. B. C. _ required under Sec. 3301 (1) U. B. C. 17050. CERTIFICATE OF OCCUPANCY. (a) No apartment house, hotel, or lodging house shall be used or occupied until the owner or operator has been issued a valid certificate of occupancy by the enforcement agency. (b) A new certificate of occupancy shall be obtained whenever there is a change in: 1) Occupancy classification of a building or portion thereof 2) The number of apartments or guest rooms 3) Ownership If Group H Occupancy, number of apartments and/or guest rooms as required under Sec. 17050.1 (d), California Administrative Code, Title 8, Chapter 9, Article B. Number of apartmen ISSUED TO: SDAM—ROMCK & CMIPA17Y and/or guest room Building Official Date— December 16,_1966_ !/ This Certificate of Occupancy SHALT. BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 306 (e) U.B.C. Form Bu34—,nR-11_63—s-B P Applicant to fill in all spaces except those within heavy border lines -and sign all appropriate declarations, .A r CMF 0865-46, rev. 10/84 White -Building; Canary -Applicant; Pink - Accounting;. Goldenrod - AsSeS$or CITY OF COSTA MESA CONSTRUCTION PERMIT PERMIT NO. TRACT NO- LOT NO. UNIT N0. Project Address' 3333 'P�rt�tn�_CoSTp mmb. O b Applicant's Mailing Address N-_> C .Jut TYPE OF CONSTRUCTION NEW ADD ALTERATION REPAIR ❑ CONVERSION ❑ DEMOLISH ❑ OTHER Owner's Name hone DESCRIPTION OF WORK/USE OF BLDG. Address Arch/Eng, License No. TYPE OF.PERMIT GRADING FOUNDATION STRUCTURAL Address ❑ TENANT ELECTRICAL_ ❑ PLUMBING ❑ MECHANICAL ❑ OTHER Contractor's Nam Phone -== Address (mailing) • L+� PROJECT DESCRIPTION SQ. FT. OCCUPANCY CON ST RUCTION TYPE VALUATION S CityLiCensCNo, s� ZONE GRADINGCU.YDS. ACRES LICENSED CONTRACTOR DECLARATION I hereby affirm that 1 am licensed under provisions of Charter 9 (commencing Remarks: with section 7000) of Division 3 of the Business and Professions Code, and my license Is In full fore and effect. 917 * O Licen I s5 L n e o. i - Date signature PLUMBING FEES WORKERS' COMPENSATION DEC ATION Bar Sink Showers I hereby affirm that I have a certificateof consent to self -insure or a certificate ' Workers' Compensation Insurance, Cr a certified copy thereof (Section Backflow Preventer Service Sink 00, Lab. C.) - olicy No. Company Backflow Irrigation Sewer Cap eCertified copy is hereby furnished. Certified copy is filed with the city Building Division. Bathtubs Sewer Connection . Date Applicant _ EXEMPTION FROM WORKERS' COMPENSATION DECLARATION Clarifiers Solar Collectors (Thissection need not be completed if the permit is for one hundred (5100) or less). Dishwasher Solar Piping I certify that in the performance of the work f which this permit is issued. I _ shall,not employ any person In any m4ane 0 est co a subject to the Drinking Fountains Solar Tank Werke C F1Cn n Laws of California. Date VL Signature Floor, Drains, Swimming Pool wlSpa NOTICE: If, after making -this declaration, u should become subject to the - Workers' Compensation provisions of th bor Code, you must forthwith Floor Sinks Urinal comply with such provisions or this mit shall be deemed revoked. CONSTRUCTION LENDING AGENCY Gas Service Outlets Water Closet I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is Issued (Section 3097 Civ, C.) Interceptors Water Heater Lender's Name Lender's Address Kitchen Sink Water Service OWNER BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's LlcenSe Law for the Lavatories Auto -Wash following reason (Section 7031.5 Business and Professional Code: Any city or County which requires a permit to construct, alter, Improve, demolish or repair 1P—Trap Laundry Trays any Structure, prior to its issuance, also requires the applicant for such permit to file a signed Statement that he/She is licensed pursuant to the provisions of Roof Drains the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he/she is exempt - - erefrom and the basis for the alleged exemption. Any violation of Section 31.5 by any applicant for a permit subjects the applicant to a civil -salty of not more than five hundred dollars ($500). $ 3 L.a 1, as owner of the property or my employees with wages as their sole Reinspection Fee $15 issue Fee , Compensation, will do the work, and the structure is not intended or offered for sale (Section 7044, Business and Professional Code: The Contractor's MECHANICAL FEES License Law does not apply to an owner of d property who builds or Improves thereon, and who does such work himself/herself or through his or her own employees, provided that such Improvements are not Intended or offered for Boiler Hood or Type I ❑ , gala. If, however, the building or Improvement is sold within one year of cam- Canopy Type I I ❑ pletion, the Owner will have the burden of proving he/She did not build or Im- Duct - Under Ground prove for the purpose of sale). ❑ 1, as owner of the property, am exclusively contracting with licensed con- Duct - Structural Refrigeration System tractors to construct the project (Section 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who Duct - Ventilating ❑4100,000 BTU C1100,000BTU builds or Improves thereon, and who contracts for such projects with a Con- tractor(s) license pursuant to the Contractor's License Law), I am aware that Exhaust System ❑ Multiple ❑ System Repair/Alteration proof of their Worker's Compensation Ins4rance Should be provided to me. ❑ I am exempt under Section B & P. C. for this reason Firepl/Fact. Bit. ICBO'Ik Fire Dampers _J'U _ Owner Heating System & Ducting Registers 1 hereby Certify that 1 have read th' application and state that the above _ ❑4100,000 BTU ❑100,DOOBT _ Information is Correct. I agree to Co ly with all city and county ordinances and state la S rel,�ting to uilding construction, and hereby authorize repre- sentatives o thi! •cit e r er upon thq above=mentioned property or V inspection Pu A s , a� Signature Oa[e privets' trees e r SS � Reinspect 1745 A.P. # I Zone S Main Building: Accessory Building: E T Front B Rear A C Right K S Left Ping. Ref. # Parking Req./Provided Planning Notes: ELECTRICAL FEES Automatic Washer Construction Pole Sub. Transformer "❑ 15-50 KW ❑ 50 + KW Cooking Unit Meter El up to 100 amps Dishvirasher Meter ❑over 100amps Dryers ❑Gas ❑Electric Sub Panel Fan Motors ❑41 HP ❑I%-8 F.A.U. Inc. Solar 09-15 HP ❑16-15+' Fixtures Microwave Device Boxes Pole Light t r L Outlets Range Switches Garbage Disposal Sign Standing Sections Generator 00-5 KW ❑5.15 KW Trash Compactor _ r SMIP $ PLAN CHECK $ PERMIT PLUMBING $ ISSUANCE $ ' PLAN.CHECK 2596 $� ENERGY P.C. $ ` ELECTRICAL $ GRADING $ PLAN CHECK 50% $ MICROFILM $ MECHANICAL $ TOTAL FEE $ _ �O PLAN -CHECK 25% $ ion Fee $15 Issue Fee $ 3 r CMF 0865-46, rev. 10/84 White -Building; Canary -Applicant; Pink - Accounting;. Goldenrod - AsSeS$or CITY OF COSTA MESA CONSTRUCTION PERMIT PERMIT NO. TRACT NO- LOT NO. UNIT N0. Project Address' 3333 'P�rt�tn�_CoSTp mmb. O b Applicant's Mailing Address N-_> C .Jut TYPE OF CONSTRUCTION NEW ADD ALTERATION REPAIR ❑ CONVERSION ❑ DEMOLISH ❑ OTHER Owner's Name hone DESCRIPTION OF WORK/USE OF BLDG. Address Arch/Eng, License No. TYPE OF.PERMIT GRADING FOUNDATION STRUCTURAL Address ❑ TENANT ELECTRICAL_ ❑ PLUMBING ❑ MECHANICAL ❑ OTHER Contractor's Nam Phone -== Address (mailing) • L+� PROJECT DESCRIPTION SQ. FT. OCCUPANCY CON ST RUCTION TYPE VALUATION S CityLiCensCNo, s� ZONE GRADINGCU.YDS. ACRES LICENSED CONTRACTOR DECLARATION I hereby affirm that 1 am licensed under provisions of Charter 9 (commencing Remarks: with section 7000) of Division 3 of the Business and Professions Code, and my license Is In full fore and effect. 917 * O Licen I s5 L n e o. i - Date signature PLUMBING FEES WORKERS' COMPENSATION DEC ATION Bar Sink Showers I hereby affirm that I have a certificateof consent to self -insure or a certificate ' Workers' Compensation Insurance, Cr a certified copy thereof (Section Backflow Preventer Service Sink 00, Lab. C.) - olicy No. Company Backflow Irrigation Sewer Cap eCertified copy is hereby furnished. Certified copy is filed with the city Building Division. Bathtubs Sewer Connection . Date Applicant _ EXEMPTION FROM WORKERS' COMPENSATION DECLARATION Clarifiers Solar Collectors (Thissection need not be completed if the permit is for one hundred (5100) or less). Dishwasher Solar Piping I certify that in the performance of the work f which this permit is issued. I _ shall,not employ any person In any m4ane 0 est co a subject to the Drinking Fountains Solar Tank Werke C F1Cn n Laws of California. Date VL Signature Floor, Drains, Swimming Pool wlSpa NOTICE: If, after making -this declaration, u should become subject to the - Workers' Compensation provisions of th bor Code, you must forthwith Floor Sinks Urinal comply with such provisions or this mit shall be deemed revoked. CONSTRUCTION LENDING AGENCY Gas Service Outlets Water Closet I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is Issued (Section 3097 Civ, C.) Interceptors Water Heater Lender's Name Lender's Address Kitchen Sink Water Service OWNER BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's LlcenSe Law for the Lavatories Auto -Wash following reason (Section 7031.5 Business and Professional Code: Any city or County which requires a permit to construct, alter, Improve, demolish or repair 1P—Trap Laundry Trays any Structure, prior to its issuance, also requires the applicant for such permit to file a signed Statement that he/She is licensed pursuant to the provisions of Roof Drains the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he/she is exempt - - erefrom and the basis for the alleged exemption. Any violation of Section 31.5 by any applicant for a permit subjects the applicant to a civil -salty of not more than five hundred dollars ($500). $ 3 L.a 1, as owner of the property or my employees with wages as their sole Reinspection Fee $15 issue Fee , Compensation, will do the work, and the structure is not intended or offered for sale (Section 7044, Business and Professional Code: The Contractor's MECHANICAL FEES License Law does not apply to an owner of d property who builds or Improves thereon, and who does such work himself/herself or through his or her own employees, provided that such Improvements are not Intended or offered for Boiler Hood or Type I ❑ , gala. If, however, the building or Improvement is sold within one year of cam- Canopy Type I I ❑ pletion, the Owner will have the burden of proving he/She did not build or Im- Duct - Under Ground prove for the purpose of sale). ❑ 1, as owner of the property, am exclusively contracting with licensed con- Duct - Structural Refrigeration System tractors to construct the project (Section 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who Duct - Ventilating ❑4100,000 BTU C1100,000BTU builds or Improves thereon, and who contracts for such projects with a Con- tractor(s) license pursuant to the Contractor's License Law), I am aware that Exhaust System ❑ Multiple ❑ System Repair/Alteration proof of their Worker's Compensation Ins4rance Should be provided to me. ❑ I am exempt under Section B & P. C. for this reason Firepl/Fact. Bit. ICBO'Ik Fire Dampers _J'U _ Owner Heating System & Ducting Registers 1 hereby Certify that 1 have read th' application and state that the above _ ❑4100,000 BTU ❑100,DOOBT _ Information is Correct. I agree to Co ly with all city and county ordinances and state la S rel,�ting to uilding construction, and hereby authorize repre- sentatives o thi! •cit e r er upon thq above=mentioned property or V inspection Pu A s , a� Signature Oa[e privets' trees e r SS � Reinspect 1745 A.P. # I Zone S Main Building: Accessory Building: E T Front B Rear A C Right K S Left Ping. Ref. # Parking Req./Provided Planning Notes: ELECTRICAL FEES Automatic Washer Construction Pole Sub. Transformer "❑ 15-50 KW ❑ 50 + KW Cooking Unit Meter El up to 100 amps Dishvirasher Meter ❑over 100amps Dryers ❑Gas ❑Electric Sub Panel Fan Motors ❑41 HP ❑I%-8 F.A.U. Inc. Solar 09-15 HP ❑16-15+' Fixtures Microwave Device Boxes Pole Light t r L Outlets Range Switches Garbage Disposal Sign Standing Sections Generator 00-5 KW ❑5.15 KW Trash Compactor _ r SMIP Z O N 1 N G R E Q M T S Reinspection Fee $15 Issue Fee $ 3 DEVELOPMENT SERVICES REQUIREMENTS: Zoning Approved By pate Building Approved ByData Application Issued By— Dat SUMMARY OF FEES BUILDING PERMIT $ SMIP $ PLAN CHECK $ PERMIT PLUMBING $ ISSUANCE $ ' PLAN.CHECK 2596 $� ENERGY P.C. $ ` ELECTRICAL $ GRADING $ PLAN CHECK 50% $ MICROFILM $ MECHANICAL $ TOTAL FEE $ _ �O PLAN -CHECK 25% $ CONSTRUCTION AND PLANNINGPOOL APPROVALS Permit.# Date Inspector- r & SPA APPROVALS Permit # Date Inspector 1. !Temporary Electrical Service or Pole 52. Pool & Equipment Location \ 2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd.}-g1 _C 54. Forms 4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6. Electrical LIFER Grnd. 57. APPROVAL TO COVER-GUNITE 7. Footings 58, Electrical Conduit-Undrgrnd. 8. Foundation 59. Gas Pipe, ❑ Undrgrnd., Test .,9. Water.Pipe-Undrgrnd.` 60. Backwash Lines, P -Trap, ❑ Undrgrnd. 10. Structural Floor System 61. APPROVAL TO DECK 11. Property Sewer Line & House Connection 62. Backwash & Receptor -Final 12. Sewer Cap 63. Heater & Vent -Final 13. Roof Drains 64. Plumbing System - Final 14, Rough Plumbing 65. Electrical -Final 15. Rough Electrical -Conduit . Solar System -Final 16. Rough Electric Wiring encing & Access Approval 17. Rough Wiring Sign 68. APPROVED FOR PLASTEF ING 18. Rough Electrical -T Bar Ceiling 69, POOLISPA SYSTEMS FINA 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREM�VT APPROVALS Permit n 20. Rough Factory Fireplace 21. Ducts, in Structure 70. Underground Hydro 22. Ducts,,Ventilating 71. Product Piping ❑Gas ❑Oils 23. Gas Pipe -Rough & Test 7-2. Underground Flush 24. Roof Framing 73. Undergrnd. Storage Tank ❑ ❑ Oil 25. Roof Sheathing 74. Overhead Hydro (�• 26. T -Bar Ceiling (Structural) & Monocoat r 75. Dry Chemical 27. Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding 77. FIXED SYSTEM FINALt-i 29. Insulation 78, FIRE PREV. FINAL u: 30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat 79. FINAL INSPECTION 16. 32. Electrical Power Meter -Final 0. FOOD C TIFICATE ISSUM 33. Final Electric r B 34. Final Heating & Air Conditioning rf 35. Final Gas Pipe -Test s 36Hood or Canopy of 37C�Jinal Factory Fireplace 38.�final Plumbing •r 397 -Water S rvice-Final 40. Gas Ser'vJce-Final 't° Qr Solar Dp ejtic-Final n `42. BackfIdW Preventer _ 4 Backflov{i ` irrigation 4... r r �'� •� n • P 4. Laricfscape,lrrigation System Sound Attenuation L 46 rHandicap Regulations 47-FINALSTRUCTURE & BUILDING 1 r ..7 �. J �•. it At 48.,fSpecial equirements Completed .'r 49. Electri 4Release to Edison (. 50. Gas Ree to Southern California Gas Co =~ 51. CERTIFICATE OF OCCUPANCY No. Date 7 11 Ey 9� REi UQ,'it Applicant to fill in all spaces except those within heavy bo'Y -...1%9— �: P MIT NO. TRACT NO. rf�f sSi►'•l ESA CONST UCTION PE/7 3� - 30FT rojectress`vS 3 /rS aC SS �rca5 �-- 333 S us iLCe T PE OF CONSTRUCTJI0�11 NEW' ADD pplicant's Mailing Address a..wsign all appropriate declarations. OT NO. UNIT NO. • 6, ATION 10d REPAIR Se„ ,s �d r 6 -�c 4 SYy �. 3733 LJ CONVERSION DEMOLISH � OT A.P. # /a �• Owner's Name Cp Phone 33 3 B . �,� DESCRIPTION OF WORK/USE F BLDG - Address QQ ,/ License Na. Address Contractor's N a m e1654 X,, e" F"Z.,t4e 549!t Address (mailing) SF C' City License No_— _ 1 LICENSED CONTRACTOR DECLARATION' P 3 q toil 1 hereby affirm that I am licensed under provisions of Charter 9 (commencing with section 7000) of Division 3 of the Business and Professions Code, and my license is in full for and effect. License CI ss ense No. Date 2 Signature WORK RS' OMPENSATION DECLARATION hereby affirm that I have a certificate of consent to self -Insure or a certificate ' Workers' Compensation Insurance, or a' cirtifled copy thereof (Section s800, Lab. Po y No. Company' ` Certifle opy is hereby furnished, / LLL�� Cert' e pp Ith the city Building T4 on. , Date G Applicant �L EXEMP1iON ROM WORKERS' COMPENSATION DECLARATION (This section need not be completed if the permit is for one hundred ($100) or less). I certify that in the performance of the work for which this permit Is Issued I shall not employ any person in any manner so as to become subject to 6. Workers' Compensation Laws of California. �- . Date Signature 'NOTICE: If, after making this declaration, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for whlchw �,!'�Is permit Is Issued .(Section 3097 Civ, C.) Lender's Name Q� P Lender's Address OWNER BUILDER DECLARATION ' I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5 Business and Professional Code: Any city or county which requires a permit toconstruct, alter improve, demolish or repair any structure, prior to Its issuance, also requires the applicant for such permit to file a signed statement that he/she Is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or'that he/she Is exempt therefrom and the basis for the alleged exemption. -Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil enatty of not more than five hundred dollars ($500). I, as owner of the property or my employees with wages as their sole compensation will do the work, and the structure is not Intended or offered for sale (Sec{ion 7044, Business and Professional Code: The Contractor's License Law does not apply to an owner of a property who builds or improves thereon, and who does such work himself/herself orthrough his or her own employees, provided that such Improvements are not Intended or offered for sale. If, however, the building or improvement is sold within one year of com- pletion the owner will have the burden of proving he/she did not build or Im- ro VI, for the purpose of sale). .I, as owner of the property, am exclusively contracting with licensed con- tractors to construct the project (Section 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who bulldi or Improves thereon, and _who contracts for such projects with a con- tract6r(s) license pursuarit to"the Contractor's License Law). I am aware that proof• of their Worker's Compensation insurance should be provided to me. L1 I am exempt under section B. & P. C. for this reason r' t Date Owner ' ',� s I hereby certify that I ha 'read this application and State that the above information is correct. I ree to comply with all city and county ordinances -_� and state laws relatin buildi construction, and hereby authorize repre- Sentatives of this c to en rupon the above-mentioned pro2per y for inspection purposes _ J Signature tef 5 Drivers' License or 55 J]S Main Building: TYPE OF PERWT T GRADING LJ FOUND ION TRUCTI.RAL T Front ❑ TENANT ❑ ELECTRICAL ❑PLUM 61 G ❑MECHANICAL B Rear ❑ .OTHER A PROJECT DESCRIPTION Sit. FT. 2 33 0040 SIC OCCUPANCY G, Right 7 CONSTRUCTION TYPE /A VArh,L''U//ATTI2ION S 411100, o0p $ Left ZONE ,/y GRADING CU. YDS. AIM- ACRES N f Ping. Ref. Remarks: 7� � Y r Qc�-.Tj C L: Planning Notes: Bar Sink Backflow Preventer Backflow Irrigation Bathtubs Dishwasher Drinking Fountains Floor Drains Floor Sinks Gas Service Outlets Interceptors Kitchen Sink Lavatories P—Trap Roof Drains Reinspection Fee Boiler $15 Duct - Under Ground Duct - Structural Duct - Ventilating Exhaust System ❑ Multiple ❑ Firepl/Fact, Bit. ICBO # Heating System & Ducting 130.100,000 BTU ❑ 100,000 BT' Reinspection Fee f $15 �(1 CMF 0865-46, rev. 10/84 White - Building; Canary - Applicant; Pink - Accounting; Goldenrod - Assessor Showers Service Sink Sewer Cap Sewer Connection - Solar Collectors Solar Piping•, rf' Solar Tank 'r Swimming Pool vv/Spe Urinal r Water Closet Water Heater Water Service Auto -Wash Laundry Trays _. f FE Automatic Washer Construction Pole Sub. Cooking Unit Dishwasher Dryers ❑Gas ❑Electric Fan F.A.U. Fixtures Device Boxes Outlets Switches Garbage Disposal. Generator ❑0.5 KW C)rr15 KW Trash Compactor' . t y A Zone S Accessory Building: Z O- N I- N G R Parking Req./Provided E Q / M. T S" ELECTRICAL Transformer ❑ .15-50 KW ❑ 50 + KW Meter Dup to 100 amps, Meter ❑over 100 amps Sub Panel i Motors ❑0.1 HP ❑1'lk 8 Inc, Solar ❑9-15.HP'❑16-15+ Microwave Pole Light -•+ Range Sign `. ,Standing Sections FEES Ma Mo rt1� ttttt111r Issue Fee $ 3 ] 1 —.Reinspection Fee $15 Issue Fee ',$ 3 dANICAL Hood or Type I ElDEVELOPMENT CanopyType II ❑ FEES SERVICES Zoning Approved By Acxc Building Approved By Application Issued By REQUIREMENTS; AW Data Date Dat �"42 Refrigeration System ❑0-100,000BTU 0100,000 BTU 5 BUILDING -PERMIT $ PLAN CHECK $ PLUMBING, , $ PLAN CHECK 2596• $ ` ELECTRICAL $ i PLAN CHECK 50% $ MECHANICAL $ .PLAN CHECK 25%- $ MM�j A � RY OF FEES o '• �LSMTP $ PERMIT -r' ISSUANCE $ - ENERGY P.C. $, GRADING $•_ - MICROFILM $ ;TOTAL FEE $ .' C " �� /` System Repair/Alteration Fire Dampers Registers Issue Fee $ 3 ONSTRUCTION AND PLANNING FPPROVALSPermit # Date Inspector POOL &SPA APPROVALS Permit # Date Inspector + Temporary Electrical Service or Pole 52. Pool & Equipment Location 2. Soil Pipe Undrgrnd. 53. Steel Reinforcement 3. l=lectrical Conduit Utility-Undrgrnd. �, '54. Forms 4. bectrical"Conduit=Undrgrnd. 55. Electrical Bonding C5. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6• Electrical UFER Grnd, 57. APPROVAL TO COVE R-GUNITE i 7. Footings 58. Electrical Conduit Undrgrnd. 8. Fowndation 59. Gas Pipe, 0 Undrgrnd., Test 9. Water Pipe-Undrgrnd: 7 60: Backwash Lines, P -Trap, C1 Undrgrnd. 10. Structural Floor System 61. APPROVAL TO DECK 11. Property Sewer Line &, House Connection 62. Backwash &Receptor -Final Sewer Cap 63. Heater & Vent -Final ' 3. Roof Drains64. Plumbing System - Final 4. Rough Plumbing 65. Electrical Final 15: Rough Ele`ctrical•Conduit% 66. Solar System -Final 16. Rough Electric Wiring 67. Fencing & Access Approval 17i• Rough Wiring Sign 68. APPROVED FOR PLASTERING 18. Rough Electrical-T.Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19: Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit # 20.' Rough Factory Fireplace 21. Ducts, in Structure 70. Underground Hydro 22.- Ducts, Ventilating 71. Product Piping ❑Gas D Oil 23:' Gas Pipe -Rough & Test t 72. Underground Flush 24. Roof Framing 73. Undergrnd. Storage Tank. ❑ Gas -Oil 25. Roof Sheathing 74. Overhead Hydro T -Bar Ceiling (Structural) & Monocoat 75, Dry Chemical 27, Frame and FI Shing ' X 76. Dry Standpipe 28'.� Lathing & Siding 77. FIXED SYSTEM FINAL 29. Insulation 78. FIRE PREV. FINAL 30. prywal! Nailing` 76W4Q HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat. .• 79. FINAL INSPECTION 32. Electrical Power Meter -Final 80. FOOD CERTIFICATE ISSUED 33. Final Electric Notes: 34. Final Heating & Afr'Conditioning ` - ` Lkk. 35. Final Gas Pipe -Test Y --r• a 2106-d A.1- 36. Hoo d,or Canopy' 1 _ .7 I'� � t t 37. Final Factory Fireplace 38. Final Plumbing 39. Water Service -Final 40. Gas Service-Fina!/� I W 1 pk_ fit! f , r i 1k. ow Lzaa 41. Solar Domestic Final i 42. Backflow Preventer t 43. Backflow Irrigation 44. Landscape Irrigation System 4.� _ __ T • r 45. 'Sound Attenuation t 46. Handicap Regulations ' ; 8 g IA t • 47. FINAL STRUCTURE & BUILDING 48. Special Requirements Completed 49. Electric Release to Edison 50, Gas'Releaseto Southern California Gas Co /,r,- /7 Tv /H !6, 7 • -' , No1. CERTIFIC ��C�ODatePANJY�A?75 - / _ P7 Applicant to fill In all spaces except those within heavy 4Qrder lines and sign all app&priate declarations. 4- VHRC, t _ __:ONSTRUCTION RER`i�IIIT MIT NO. i � Z TRACT NO. LOT NO. AR } UNIT NO. licy No. C 7 Olin Companyi;3f/�.i�01�1_ 3 33 Se'1m � �Rr �.O.34 - Cap �o $15 issue Fee $ 3 ' Project Address .-- Sewer Construction Pole Sub. . Certified copy is hereby furnished. `,..� Applicant's Mailing Address / IIUfrY TYPE OF CONSTRUCTION NEW ADD ry ALTERATION REPAIR ❑ ❑ ❑ $15- / Owner's CONVERSION DEMOLISH OTHER A.P. # SI Name Phone Address��>�#f+�+ ' DESCRIPTION OF WORK/USE OF BLDG. `r1' �i l S Main Building: Solar Collectors tr�7 Dishwasher (This section need not be completed if the permit is for one hundred•($100) or less). r Arch/Eng. F License No. TYPE OF PERMIT GRADING FOUNDATION 57RUCTURAL ;T Front f I certify that in the performance of the work for which this permit is issued I ❑ TENANT ❑ ELECTRICAL ❑ PLUMBING ❑ MECHANICAL H Address d Name_ ,�N, n �iLCh 577[S �1iC ph g �T� ❑ 'OTHER A Rear Contractor's -3 S- Sf[A �frrl) ��I Ix> PROJECT DESCRIPTION SQ. FT. OCCUPANCY C Right Address (matting) _ J ��� �• �CONSTRUCTIONTYPE � �tl~r~C VALUATION$ 2GID0 S Left City•LicenseNo. y - ZONE 1 GRADING CU.YDS. ACRES Pin Ref. # Ping..Ref. LICENSED CONTRACTOR DECLARATION � hereby affirm that I am licensed under provisions of Charter 9 (commencing Remarks: 5 - Planning Notes: with section 7000) of Division 3 of the Business and Professions Code, and Urinal my license is in full f rce and effect. comply with such provisions or this permit shall be deemed revoked. Llcense Class I LI nee N X528 ' CONSTRUCTION LENDING AGENCYWate Date Signature I ' PLUMBING , FEES =' ` WORKERS' COMPENSATION DECLARATION i 1: I hereby affirm that 1 have a certificate of consent to self -insure Ora certificate Bar 5irik Showers -r ' of Workers' Compensation Insurance, or a'certifled copy thereof (Section - 8/13/ Lis Q Zone Accessory Building: i 51 NOS -goo, Lab. C.) --`` Backflow Preventer Service Sink , Automatic Washer licy No. C 7 Olin Companyi;3f/�.i�01�1_ Backflow Irrigation - Cap Reinspection Fee $15 issue Fee $ 3 Reinspection Fee ' Sewer DEVELOPMENT SERVI Zoning Approved By ___4 Building Approved By Application Issued By_ Construction Pole Sub. . Certified copy is hereby furnished. Hood or Type I ❑ Canopy Type I I '❑ $15- Cerled copyljs�j.led with the city 12.Z ivisio . �j �i 7P�ff Bathtubs Sewer Connection , - Cooking Unit Date �'-'4( Appllcant'74Ll�Gy1��( EXEMPTION FROM WORKERS' COnnPENSATION D LARA ON - 4 Clarifiers Solar Collectors �, Dishwasher (This section need not be completed if the permit is for one hundred•($100) or less). r Dish!;i asher Solar Piping Dryers ❑Gas ❑Electric I certify that in the performance of the work for which this permit is issued I shall not employ any person, in any manner so as to become subject to tke Drinking Fountains Solar Tank - Fan Workers' Compensation Laws of California. Date Signature t Floor Drains Swimming Pool w/Spa - F.A,U.- NOTICE: If, after making this declaration,, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith Floor Sinks Urinal Fixtures comply with such provisions or this permit shall be deemed revoked. ' CONSTRUCTION LENDING AGENCYWate Gas Service Outlets r Closet ' Device Boxes I hereby affirm that there is a construction lending agency for the performance ofthe work for which this permit is issued (Section 3097 Civ. C.) Interceptors ' Water Heater Outlets Lender's Name Lender's Address Kitchen Sink Water Service Switches ). OWNER BUILDER DECLARATION f th Lavatories A t ELECTRICAL FEES Transformer ❑ 15.50 KW El50 + Kw Meter IJ up to 100 amps - Meter El over 100 amps Sub Panel Motors E30-1 HP EllX, - 8 Inc. Solar ❑ 9-15 HP. ❑ 16-15+ Microwave Pole Light Range , Sign' i I hereby a. irm that I am exempt from the Contractor s License Law or o uto-Wash Garbage Disposal, Standing Sections following reason (Section 7031.5 Business and Professional Code: Any city or - county which -requires a permit to construct. Alter, improve, demolish or repair P—Trap Laundry Trays Generator C1 0-5 KW 05-15 KW Trash Compactor an Structure prior to its issuance also requires the applicant for such permit to file a signed statement that he/she is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he/she is exempt therefrom and the basis for the alleged exemption. Any violation of Section Roof Drains Heating System & Ducting ❑0-100,000 BTU ❑100,000 BT , - 7031.5 by any applicant for a permit subjects the applicant to a civil naity of not more than five hundred dollars (5500). i I, as owner of the property or my employees with wages as their Sole compensation, will do the work, and the structure is not intended or offered for sale (Section 7044, Business and Professional Code: The Contractor's License Law does not apply to an owner of a property who builds or improves thereon, and who does suchiwork himself/herself or through his or her own employees, provided that such Improvements are not intended or offered for sale. If, - however, the building or improvement is sold within one year of com- pletion, the. owner will have the burden of proving he/she did not build or Im- prove for the purpose of sale}. , ❑ 1, as owner of the property, am exclusively contracting with licensed con- tractors to construct the project (Section 7044, Business and Professions Code: PLUMBING $ 155UANCE $ PLAN CHECK _ 25% $ ENERGY P.C. $ ' ELECTRICAL $ GRADING $ _ - _ MICROFILM $ PLAN CHECK 50% $ _ MECHANICAL $ TOTAL FEE , $ PLAN CHECK 2596 $ Date Owner I hereby certify that i have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state law r to bu ding nstructlon, and hereby authorize repro- senand tate of i to a ter on the ab, and hereby a property for 5 Spection p p g ectl e Y Date$ -F r Drlirs' Llcense or SS Reinspection Fee $15 issue Fee $ 3 Reinspection Fee ' MECHANICAL FEES DEVELOPMENT SERVI Zoning Approved By ___4 Building Approved By Application Issued By_ - Boiler Hood or Type I ❑ Canopy Type I I '❑ $15- Duct - Under Ground 4 1 Duct - Structural Refrigeration System _ $15 1 1 Issue Fee W N N G R E O M T S The Contractor's License law oes not apply to an owner of property who Duct - Ventilating ❑0-100,000 BTU ❑ 100,000 BTU SUMMY OF EES bullds-or improves thereon, and who contracts for such projects with a con- tractos) license pursuarit-to-the. Contractor's License Law). 1 am aware that BUILDING PERMIT $ A rSMIP $ proof of their Worker's Compensation insurance should be provided to me. Exhaust System ❑ Multiple ❑ System Repair/Alteration PLAN CHECK $ ) Z�-' 3 PERMIT ❑-I am exempt under Section B. & P. C. for this reason ' Firepl/Fact. Bit_ ICBO # Fire Dampers CMF 0865-46, r6y. 10/84 - White .-Building; Canary - Applicant; Pink - Accounting; Goldenrod - Assessor Heating System & Ducting ❑0-100,000 BTU ❑100,000 BT Registers PLUMBING $ 155UANCE $ PLAN CHECK _ 25% $ ENERGY P.C. $ ' ELECTRICAL $ GRADING $ _ - _ MICROFILM $ PLAN CHECK 50% $ _ MECHANICAL $ TOTAL FEE , $ PLAN CHECK 2596 $ Date Owner I hereby certify that i have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state law r to bu ding nstructlon, and hereby authorize repro- senand tate of i to a ter on the ab, and hereby a property for 5 Spection p p g ectl e Y Date$ -F r Drlirs' Llcense or SS _ - Reinspection Fee $15- Issue Fee $ 3 CMF 0865-46, r6y. 10/84 - White .-Building; Canary - Applicant; Pink - Accounting; Goldenrod - Assessor CONSTRUCTION AND PLANNING . APPROVALS Permit # Date Inspector POOL &SPA APPROVALS Permit # T Date Inspector 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location, 2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement I 3. Electrical Conduit Utility-Undrgrnd. F 54. Forms 4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6• Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE 7. Footings 58. Electrical Conduit-Undrgrnd. 8. Foundation 59, Gas Pipe, ❑ Undrgrnd., Test 9. Water Pipe-Undrgrnd: 60. Backwash Lines, P -Trap, ❑ Undrgrnd. ; 10. Structural Floor System 61. APPROVAL TO DECK 11. Property Sewer Line & Hou'se,Connection fit. Backwash & Receptor -Final 12. Sewer Cap 63. Heater & Vent -Final I 13. Roof Drains _ 64. Plumbing.Systern - Final 14, Rough Plumbing 65. Electrical -Final 15, Rough Electrical -Conduit 66. Solar System -Final 16. Rough Electric Wiring 67. Fencing & Access Approval 17, Rough Wiring Sign 68. APPROVED FOR PLASTERING 18. Rough Electrical -T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT, REQUIREMENT APPROVALS Permit # 20. Rough Factory Fireplace 21. Ducts, in Structure 70. Underground Hydro 22. Ducts, Ventilating 71. Product Piping ❑ Gas OOil '23. Gas Pipe -Rough & Test 72. Underground Flush 24. Roof Framing 73. Undergrnd. Storage Tank ❑ Gas ❑ Oil 25. Roof Sheathing 74. Overhead Hydro 26. T -Bar Ceiling {Structural) & Monocoat 75. Dry Chemical 27. Frame and Flashing �s s Jr 8 rq 76. Dry Standpipe 28. Lathing & Siding y gZ-04- $ 77. FIXED SYSTEM FINAL 29. Insulation 78, FIRE PREV. FINAL ' 30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Piaster Brown Coat 79. FINAL INSPECTION 32. Electrical Power Meter -Final 80. FOOD CERTIFICATE ISSUED 33. Final Electric Notes: 34. Final Heating & Air Conditioning 35. Final Gas Pipe -Test r 36. Hood or Canopy 37. Final Factory Fireplace 38. Final Plumbing 39. Water Service -Final 40. Gas Service -Final 41. Solar Domestic -Final .42. Backflow Preventer _ 43. Backflow Irrigation r 44. •Landscape Irrigation System " 45. Sound Attenuation i 46. Handicap Regulations 47. FINAL STRUCTURE & BUILDING S� 48. Special Requirements Completed 49. Electric Release to Edison 50. Gas Release to Southern California Gas Co NSt CERTIFICATE OF OCCUPANCY �I Date I1 1 • - Applicant to fit$ in all spaces except those within heavy borderlines and sign all appropriate declarations. MESA COiVSTD "r—rION PERMIT PEfjp11T NO, , TRACT NO I LOT NO, UNIT NO. Applicant's Mailing Address Owner's Name +' Address - - >-i�.'L`I<L'cc, &313 Arch/Eng. License No. Address Contractor's Nam = - Phona� Address (mailing) -t'r�_ E GCkTi- '•'�_��� City License No. LICENSED CONTRACTOR DECLARATION I hereby affirm that i am licensed under provisions of'Charter 9 (commencing with section 7000) of Division 3 of the Business and professions Code, and my license is in full for(I effect. Licens Class �? License No. Date A9 LEK3__ Signature WORKERS' COMPENSATION DECLARATIpN I hereby affirm that I have a certificate of consent to s If -insure or certificate ' Workers' Compensation Insurance, or a certified copy thereof (Section Lab. C.),I_4 rolicy No. 110i7� Company Certified copy is hereby furnished- Cer ified copy is flied with the city Building Division. pate ApplicantOR EXEMPTION FROM WORKERS' COMPENSATION DEG ARATIO (Thissection need not be completed It the permit Is for one hundred ($100) or loss). i certify that in the performance of the work for which %his permit is •issued, i shall not employ any person in any manner so as to become subject to the Workers' Compensation taws of California. Date Signature 'NOTICE: If, after making this declaration, you shoutd become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such :provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a'conslrllCtiOn lending agency for the performance of the work for which this permit Is issued (Section 3097 Civ. C.) Lender's Name 'Lerider's Address OWNER.€ OLDER DECLARATION I hereby affirm that,l am exempt from the Contractor's License Law for the following reason (Section 7031.5 Business and Professional Code: Any city or county which requires a permit to construct, alter, improve, demolish or repair ' any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he/she Is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commeneing with Section 7000) of Division 3 of the Business and Professions Code) or that he/she is exempt `herefrom and the basis for the alleged exemption. Any violation of Section 131.5 by any applicant for a permit subjects the applicant to a civil nalty of not more than five hundred dollars ($500).' D 1, as, owner of the property'or my employees with wages as their sole compensation, will do the work, and the structure Is not intended or offered , for sale (Section 7044, Business and Professional Code: The Contractor's License Law does not apply to an owner of a property who builds or improves thereon, and who does such work himself/herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the.bulldMq or improvement is Sold within one year of cam• ptet€on, the owner will nave the burden of proving he/she did not build or im- prove for the purpose of sale). ❑ 1, as owner of the property, am exclusively contracting with licensed con. tractorstd construct the project (Section 7044, Business and Pro fesSions.Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a con- tractors license pursuariLi t'to the Contrattor's cense Law). 1 am aware that proof of, their Worker's Compensation insurance should be provided to, me. ❑ 1 am exempt.under section B. & P. C. for this reason Date Owner — Ihereby certify that I nave read this information is correct. I agree to comp and state laws relating to building con sentatives of this city to ente � i inspection purposes. Signature Nk_na1+U A P i Drivers' License or SS on and state that the above 11 city and county ordinances and hereby authorize repre- v Ontioned property for Date C TYPE OF CDNSTRUCTiON L_. NEW " ADD 29 ALTERATION L-) REPAIR ❑ CONVERSION ❑ DEMOLISH ❑ OTHER, A.P.6 7 DESCRIPTION OF WORK/USE OF BLDG. r"�- ! 5 A&M iSuaSTCf N AML S1.7O irt S Main Building: TYPE OF PERMITrr�� GRADING FOUNDATION STRUCTURAL T Front 13 TENANT El ELECTRICAL ❑ PLUMBING ❑ MECHANICAL 13 A Rear ED•OTHER C Right PROJECT DESCRIPTION Sq: FT-- MhCA An —OCCUPANCY CONSTRUCTION TYPE VALUATION$ JMC5f2 g Left ZONE GRADING CU -YDS. ACRES - Ping. Flet. + Remarks: Planning Notes: FEES 13E�7 3/ i 5f�6 c'Gu:;r tt k l , . I Zone G I Accessory Building: Z O N _ I N G R Park€ngIReq, /Provided E Q M T S Bar Sink Showers ELECTRICAL FEES ' Backflow Preventer Service Sink Automatic Washer Construction Pole Sub. Transformer ❑ 15-50 KW ❑ 50+ KW Backflow Irrigation Sewer Cap Bathtubs Sewer Connection Cooking Unit Meter L] up to 100 amps Clarifiers Solar Collectors Dishwasher Meter Dover 100amps Dishvvasher Solar Piping Dryers •❑Gas DElectric Sub Panel Drinking Fountains Solar Tank Fan Motors C30-1 HP 0114-8 Floor Drains+ Swimming Pool w/Spa F,A:U. Inc. Solar 139-15 HP ❑ 16-15+ Floor Sinks Urinal Fixtures Microwave Gas Service Outlets Water Closet Device Boxes Pole Light Interceptors Water Heater Outlets Range Kitchen Sink - Water Service Switches Sign Lavatories Auto -Wash Garbage Disposal ; Standing Sections P -Trap Laundry Trays Generator 00.5 KW 05-15 KW Trash Compactor Roof Drains Reinspection Fee $15 Issue Fee $ 3 i Reinspection Foe$15 Issue Fee $ 3 MECHANICAL FEES Boiler good or T7ypel❑ T ❑ 'coning DEVELOPMENT SERVICES Approved By Approved By Application Issuers By 8EQUIREMENCanopy Date 'pateDuct pat Duct - Under GroundBuilding - Structural Refrigeration OG-100,60OBTU 0100,000BTU Duct - Ventilating BUILDING'PERMIT PLAN CHECK PLUMBING PLAN CHECK 25% ELECTRICAL PLAN CHECK 50% MECHANICAL PLAN CHECK 25% SU-M'tMAY OF FEES $ `• S&41P $ .� $ PERMIT $ ISSUANCE $ ENERGY P.C. , $ $ $ GRADING S $ MICROFILM S $ TOTAL FEE S ' $ Exhaust System C3 multiple ClSystem Repair/Alteration Firepi/Fact, Bit. ICBO alk Fire Dampers Heating System & Ducting 00.100,000 BTU 0100,0008T Registers Reinspection Fee $15 issue Fee /)$ 3 CMF 0865-46, rev. 10/84 White - Building; Canary - Applicant; Pink - Accounting; Goldenrod Assessor CONSTRUCTION AND PLANNING' APPROVALS . ,Permit # Date inspector POOL & SPA APPROVALS Permit # Date Inspector 1, Temporary Electrical Service or Pale 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. 54. Forms 4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding 5. Steel Reinforcement 56, Rough Plumbing & Pressure Test 6. Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNiTE 7. Footings 58. Electrical Conduit-Undrgrnd. 8. Foundation 59. Gas Pipe, ❑ Undrgrnd., Test 9. Water Pipe-Undrgrnd. 60. Backwash Lines, P -Trap, © Undrgrnd. 10. Structural Floor System 61. APPROVAL TO DECK 11. Property Sewer Line & House Connection 62, Backwash & Receptor -Final 12. Sewer Cap 63. Heater & Vent -Final 13. Roof Drains 64. Plumbing System • Final 14. Rough Plumbing 65. Electrical -Final 15, Rough Electrical -Conduit 66. Solar System-Finaf 16. Rough Electric Wiring 67. Fencing & Access Approval 17. Rough Wiring Sign 68. APPROVED FOR PLASTERING 18. Rough Electrical -T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19, Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit # 20. Rough Factory Fireplace 21. Ducts, in Structure 70. Underground Hydro 22. Ducts, Ventilating 71,. Product Piping ❑ Gas ❑ Oil 23. Gas Pipe -Rough & Test 72. Underground Flush 24. Roof Framing 73. Undergrnd. Storage Tank ❑ Gas ❑ Oil 25. Roof Sheathing 74. -Overhead Hydro 26. T -Bar Ceiling (Structural) & Monocoat 75, Dry Chemical 27. Frame and Flashing -4 Y �� 76, Dry Standpipe 28. Lathing & Siding 77• FIXED SYSTEM FiNAL 29. insulation 78. FIRE PREV. FINAL 30. Drywall Nailing ld( HEALTH DEPT. REQUIREMENT r 31. Plaster Brown Coat 79. FINAL INSPECTION 32. Electrical Power Meter -Final 80. FOOD CERTIFICATE ISSUED 33. Final Electric Notes: �� a 34. Final Heating & Air Conditioning r 35, Final Gas Pipe -Test 36. Hood or Canopy 37: Final Factory Fireplace ; 38. Final Plumbing - 39, Water Service -Final 40. Gas Service -Final 41. Solar Domestic -Final 42. Backflow Preventer 43. Backflow Irrigation 44. Landscape Irrigation System . 45. Sound Attenuation 46. Handicap Regulations 47. FINAL STRUCTURE & BUILDING ` 48. Special Requirements Completed 49. Electric Release to Edison 50. Gas Release to Southern California Gas Co 51, CERTIFICATE OF OCCUPANCY No. Date - F { -- --------- Applicant ---_Applicant to fill in all spaces except those within heavy border tines and sign all appropriate declarations. CITY OF (700 MESA NSTR UCTI ON PSR IT PERMIT NO. TRACT NO. LOT NO. I UNIT NO. Prr+lect Address 3333 S'ra L r Ss�esi Applicant's Mailing Address Owner's Name SC -4 asBuUC "f- Phone 54 0 Address Arch/Eng. License No. Address Contractor's Name Phone Address (mailing) City License No. LIC£NSEO CONTRACTOR DECLARATION I hereby affirm that I am licensed under provisions of Charter 9 (commencing with section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Class .__ _�. _..� License No. Date Signature WORKERS' COMPENSATION DECLARATION hereby affirm that I have a cortificate•of consent to self -insure or a certificate ' Workers' Compensation- Insurance, or -a certified copy thereof. (Section 300, Lab, C.) Policy No. — Company Certified copy is hereby furnished. Certified copy is filed with the city Building Division. Date Applicant EXEMPTION FROM WORKERS' COMPENSATION DECLARATION - (This section need not be completed if the permit is for one hundred ($100) or ; loss)' ' I certify that in the performance of the rk for which thi permit is issued, I shall not employ any person In any er So as t be subject the Workers' Co7�pens +qn Laws of Cali Data _ q _ ` ! n � `7' Signature __- 'NOTICE: If, after making this declaration, you should become subject to the _ Workers' Compensation provisions Of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance ' Of the work for which this permit" Is issued (Section 3097 Civ. C.) Lender's Name --_ Lender's Address OWNER BUILDER DECLARATION I hereby afflrm that l am exempt from the Contractor's License Law for the following reason (Section 7031.5 Business and Professional Code: Any city or county which requires a permit to construct, alter, Improve, demolish or repair -any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he/she is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9(commencing with Section 7000) of -Division 3 of the Business and profession$ Code) or that he/she is exempt 4erefrom and the basis for the alleged exemption. Any violation of Section 031,5 by any applicant for d ,permit, subjects the applicant to a civil alty of not more than five hundred dollars ($500). I; as owner of the property will do the work, and the structure is not Intended or offered for sale (Section 7044, Business .and Professional Code: The Contractor's License Law does not apply to an owner of'a property who builds or improves thereon, and who does such work himself/herself or through his or her own employees, provided that such irnprovements are not' intended or offered for sale. If, however, the building or improvement Is sold within one year of cam- , pletlon, the owner will have the burden Of proving he/she did not build or im- prove for the purpose of sale). 0 1, as owner of the property, am exclusively Contracting with licensed con- tractors to construct the project (Section 7044, Business and Professions Code: The Contractor's License taw does -not apply to an owner of property who builds or improves thereon, and.who contracts for such projects with a con- tractors) license pursuant'to the, Contractor's License Law)- am aware that , proof of their Worker's Compensation Insurance should be drovlded to me.' ' ❑ 1 am exempt under Section _ 8. & P( for this rppson Date - `_ Owner I hereby Certify that I have rea information is correct. I agree to and state law&i to buildir sentatives of to riteo, inspectlon pur Signature Drivers' License or SS Yt s application and state that the above ply with all city and county ordinances nstruction, and hereby authorize repre- in the ove-mentioned property for Date TYPE OF CONSTRUCTION n NEW LJ ADD L_) ALTERATION " REPAIR ❑ CONVERSION ❑ DEMOLISH ❑ OTHER A.P. # DESCRIPTION OF WORK/USE OF 8LDG. E�tiJU (� (' S Main Building: TYPE OF PERMIT i GRADING FOUNDATION STRUCTURAL' T Front ❑ TENANT ❑ ELECTRICAL kPLUMBING '❑ MECHANICAL B Rear ❑ OTHER -A PROJECT DESCRIPTION SQ. FT. OCCUPANCY C Right K CONSTRUCTION TYPE VALUATION $ $ Left ZONE - GRADING CU. YD5. ` ACRES Ping. Ref. # Remarks: AU *fit r/ tl/& &AAYIIrI�IL Planning Notes: Zone Accessory Building: z O I N ' I N G R Parking Req./Provided E Q M T CMF 0865-46, rev. 10/84 White • Building; Canary - Applicant; Pink - Accounting; Goldenrod - Assessor PLUMBING FEES ELECTRICAL FEES Automatic Washer Transformer 0 15.50 KW Construction Pole Sub, ❑ 50 + KW Bar Sink Showers Backflow Preventer Service Sink 1 Backflow Irrigation Sewer Ca Cap Bathtubs Sewer Connection Cooking Unit r ` Meter ❑up to 100 amp Clarifiers Solar Collectors Dishwasher Meter ❑over'100 ps_' Dishwasher Solar Piping Dryers ❑Gas . (Electric Sub Panel Deinking Fountains Solar Tank Fan' Motors -1 HP 0 /:: B Floor Drains Swimming Pool w/Spa F,A',U. Inc. ar El 9,115 HP 016.15+ Floor Sinks Urinal Fixtures icrowave Gas Service Outlets Water Closet Device Boxes Pole Light Interceptors Water Heater - Outlets Range Kitchen Sink Water Service Switches Sign Lavatories P—Trap Auto -Wash Laundry Trays Garbage Disposal Generator ❑0.5 ❑5.15 KW ; Standing Sections , Trash Compactor Roof Drains _ '1a 0;,L �k " 00 Reinspection -Fee $15 Issue Fee - $ 3. einspection Fee $15 Issue Fee $ 3 MECHANICAL FEES Boiler Hood or Typo I � El_ Canopy Type II ❑ DEVELOPMENT SERVICES REQUIREMENTS: zoning Approved 8y Building Approved ByDate 1 014, Application Issued By j Date Date Duct -Under Ground Duct - Structurat Refrigeration Syste ❑0 100b9U ❑100;000 BTU Duct - Ventilating SUMMARY BUILDING PERMIT $ PLAN CHECK $ PLUMBING $ PLAN CHECK 25% $ ELECTRICAL $ PLAN CHECK '50%. $ MECHANICAL $ PLAN CHECK 25% $ OF FEES SMIP $ . PERMIT Ito) (0) ISSUANCE $ " ENERGY P.C. $ r, `�D GRADING i $ MICROFILM $ TOTAL FEE $ L Exhaust System ❑ Multiple ❑ System Repair/Alteration Firepl/Fact. Sit. ICBO # Fire Dampers Heating System & Duch g ❑0100,000 B 100,000 ST Registers k,.�FA�Ioin.p.ctkn Fee $15 Issue Fee $ 3 CMF 0865-46, rev. 10/84 White • Building; Canary - Applicant; Pink - Accounting; Goldenrod - Assessor CONSTRUCTION AND PLANNING Date APPROVALS Permit # 4 Inspector POOL PA APPROVALS Permit # Date Inspector s 1.f Temporary Electrical Service or Pole 52. Pool & Equipment Location �2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement "3. Electrical Conduit Utility-Undrgrnd. 54. Forms i 4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6. Electrical LIFER Grnd. 57. APPROVAL TO COVER-GUNITE 7, Footings r 58. Electrical Conduit-Undrgrnd. 8. Foundation 59. Gas Pipe, ❑ Undrgrnd.,iTest 9. Water Pipe-Undrgrnd, 60. _Backwash Lines, P-Trap; ❑ Undrgrnd. 10" Structural Floor System 61. APPROVAL TO DECK, 11. Property Sewer Line & House Connection 62. Backwash & Receptor-Final 12, Sewer Cap 63. Heater & Vent-Final 13. Roof Drains 64. Plumbing System - Final 14. Rough Plumbing 65. Electrical-Final ' 15. Rough Electrical-Conduit - 66. Solar System-Final 16: Rough Electric Wiring 67, Fencing & Access Approval 17. Rough Wiring Sign 68. APPROVED FOR PLASTERING 18. Rough Electrical-T Bar Ceiling'. 69. POOL/SPA SYSTEMS FINAL 19.-Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit # 20. Rough Factory Fireplace 21. Ducts, in Structure 70. Underground Hydro 22. Ducts, Ventilating 71. Product Piping ❑ Gas ❑ Oil 23. Gas Pipe-Rough & Test 72. Underground Flush 24, Roof Framing 73. Undergrnd. Storage Tank ❑ Gas ❑ Oil 25. Roof Sheathing 74, Overhead Hydro 26. T-Bar Ceiling (Structural) & Monocoat 75. Dry Chemical 27. Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding 77. FIXED SYSTEM FINAL 29. Insulation 78. FIRE PREV. FINAL 30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31.'Plaster Brown Coat 79. FINAL INSPECTION 32, Electrical Power Meter-Final 80. FOOD CERTIFICATE ISSUED 33. Final Electric Notes: , 34. Final Heating & Air Conditioning 35. Final Gas Pipe-Test 36. Hood or Canopy 37. Final Factory Fireplace 38. Final Plumbing s5 �G 39- Water Service-Final 40, Gas Service-Final 41. Solar Domestic-Final 42. Backflow Prev®nter 43. Backflow Irrigation 44. Landscape Irrigation System ' 45. Sound Attenuation 46. Handicap Regulations 47. FINAL STRUCTURE & BUILDING 48, Special Requirements Completed 49. Electric'Release to Edison 50., Gas Release to Southern California Gas Co } 51. CERTIFICATE OF OCCUPANCY No. Date Applicant to fill in all spaces except those within he.7 border lines and sign all appropriate declarations. CITY OF COST ESA CONSTR PERMIT N0, TRACT NO. LOT NO. lrrviT NOProject Address 3 33t3i2►S�DL' S.4as Applicant's Mailing Address + Owner's Name Y U C 1Z P1one�2y�-�495 Address -j Arch/Eng. License No. Address ` Contractor's Na L_ ��► ~one ��%`�foQ City License No. TRACTOR DECLARATION I hereby affirm that I am licensed under provisions of Charter 9 (commencing with section 7000) of Division 3 of the Business ani r/Code, and my license is in full for a and e/f�fect. License Class c+ License o. Date —Z 1gnatu e QA WORKERS' COMPENSATION DECLARA I I hereby affirm that I have a certificate of Co so t to self -insure or a certificate )of Workers' Compensation knsurance, or' a - t",od copy thereof (Section 3800, Lab. C. Policy NO.* Company R' IF rtl�•+� , Certified copy is hereby furnished. .Certified copy Is a with the city B "IdI sion. Date Z -Cr Applicant EXEMPTION FROM WORKERS' COMPE S CLAMRATION (Thissection need not be completed if the er it i!fE,fTe hundred ($100) dr less). Icertify that in the performance of the work for wh this permit is issued I shall not employ any person In any manner so as to become subject to tete Workers' Compensation Laws of California. Date Signature 'NOTICE: If, after making this declaration, you should become subject to the Workers' Compensation provisions of the Labor -Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance - of the work ,for which this permit is issued (Section 3097 Civ. C.) Lender's Name Lender's Address OWNER BUILDER DECLARATION I hereby affirm that I am exempt from,the Contractor's License Law for the following reason (Section 7031.5 Business and Professional Code: Any city or county which requires a permit to construct, alter, improve, demolish or repair any structure, prior to its issuance, also requires the applicant for such permit to file'a signed statement that he/she is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9:(commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he/she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil enalty of not more than five hundred dollars ($500). I, as owner of the property'or myemployeeswith wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Section 7044, Business and Professional Code: The Contractor's License Law does not apply to an owner of a property who builds or improves thereon, and who does such work himself/herself or through his or her own employees, provided that such improvements are not intended or offered for We. if, however, the building or improvement is sold within one year of com- pletion, the owner will have the burden of proving he/she did not build or im- prove for the purpose of sale). ❑ 1, as owner of the property, am exclusively contracting with licensed con- tractors to construct the project (Section 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or Improves thereon, and _who contracts for such projects with a con- tractor(s) license pursuant to the Contractor's License Law), 1 am aware that proof off their Worker's Compensation insurance should be provided to me. ❑ 1 am exempt under Section B. & P. C. for this reason Date Owner I hereby certify that I have read this application and state that the above Information i c rre_ct. I agree to comply with all city and county ordinances and state -law ng t building construction, and hereby authorize repre- , t i sentative, ofy �o enter upon the above-mentioned propertF for Drivers' 14 CMF 0865-46, TYPE OF CONSTRUCTION I J NEW LJ ADD X ALTERATION LJ REPAIR EMOLISH 1:1 OTHER A P DESCRIPTION OF WORK S`EOF BLDG7J—e"C4=-T��"'`� Date Building Approved By S Main Building: E TYPE OF PERMITLJ GRADING FOUNDATION LJ STRUCTURAL T Front �} ❑ TENANT 9! ELECTRICAL ❑ PLUMBING ❑ MECHANICAL B _ ❑ OTHER 1 7 A Rear PROJECT DESCRIPTION SQ. FT. i I OCCUPANCY C Right CONSTRUCTION TYPE I 1 VALUATION $ 5 !Left ZONE GRADING CU.YDS. ACRES A # Ping. Ref.00 r 'Remarks: Planning Notes: Bar Sink + Backflow Preventer Backflow Irrigation Bathtubs Dishwasher Dririking Fountains Floor Drains Floor Sinks Gas Service Outlets Interceptors Kitchen Sink - Lavatories P—Trap Roof Drains Reinspection Fee $75 Boiler Duct - Under Ground Duct - Structural Duct - Ventilating Exhaust System ❑ Multiple ❑ Firepl/Fact. Bit. IC80 # Heating System & Ducting ❑0.100,000 BTU ❑100,00013TL Reinspection Fee I , $15 10/84 White - Building; Canary - Applicant; Pink - Accounting; Goldenrod - Assessor PLUMBING Showers Service Sink Sewer Cap Sewer Connection Solar Collectors Solar Piping Solar Tank Swimming Pool w/Spa Urinal i Water Closet Water Heater Water Service Auto -Wash Laundry Trays Issue Fee Hood or Type ❑ Canopy Type 11 ❑ FEES Refrigeration System 110-100,000 BTU E3100,000BTU System Repair/Alteration Fire Dampers Registers Issue Fee $ 3 2529 4/04/86 ►hoEC T', Zone Accessory Building: Parking Req,/Provided ELECTRICAL Automatic Washer Construction Pole Sub, Cooking Unit Dishwasher Dryers ❑Gas ❑Electric Fan F.A.U. Fixtures Device Boxes Outlets • LO Switches Garbage Disposal, Generator 00.5 KW ❑5.15 KW Transformer ❑ 15-50 KW y +❑ 50+KW Meter 0 u to 100 amps Meter ❑over 100 amps Sun Panel Motors El 0-1 HP ❑1''A - 8 Inc. Solar ❑9-15 HP ❑ 16-15+ Microwave Pole Light Range Sign Standing Sections' Trash Compactor ' FEES , I Rainspection Fee 1 $15 1 1 Issue Fee 1 $ 3 1 Z 0 N 1 N G R E Q M T S DEVELOPMENT SERVICES REQUIREMENTS: Zoning Approved By Date Building Approved By Date' Application Issued By- y 13 - /3 .3/3'f SUMMARY OF FEES Pct• BUILDING PERMIT $ SMIP $ ' PLAN CHECK $ PERMIT PLUMBING $ ISSUANCE $ PLAN CHECK 25% $ ENERGY P.C. $ ELECTRICAL $ ��1GRADING $ PLAN CHECK 50% $ ICROFILM $ MECHANICAL $ TOTAL FEE $ PLAN CHECK 25% $ `j CONSTRUCTION AND PLANNING - _ tir APPROVALS" Permit # Date Inspector POC .SPA APPROVALS Permit # Date Inspector 1, Temporary Electrical- Service or Pole 52. Pool &Equipment Location 2. Soil Pipe=Undrgrnd. ' 53. Steel Reinforcement ' 3. Electrical Conduit' Utility-Undrgrnd. 54. Forms _ 4.,Electrical'Conduit-Undrgrnd. 55. Electrical Bonding 5.,Steel.Reinforcement'• 56. Rough Plumbirig & Pressure Test ` 6: Electrical LIFER Grnd.. 57. APPROVAL TO COVER-GUNITE 7, Footings l` 58. Electrical Conduit-Undrgrnd, 8.' Foundation59. Gas Pipe, ❑ Undrgrnd., Test 9.'Water Pipe-Undrgrnd. 60. Backwash Lines, P-Trap, ❑ Undrgrnd. J0.•Structural Floor System 61. APPROVAL TO DECK 11.. Property Sewer line'& House Connection 62. Backwash & Receptor-Final 12. Sewer Cap 63. Heater & Vent-Final 13. Roof •Drains 64. Plumbing System - Final , 1`4. Rough Plumbing 65. Electrical-Final _ by 15., Rough Electrical, Conduit 66. Solar System-Final 16. Rough Electric Wiring 67. Fencing & Access Approval 171 Rough Wiring Sign C, CC 68, APPROVED FOR PLASTERING 18. Rough Electrical-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit # 20, Rough Factory Fireplace 21. Ducts, i6 Structure 70. Underground Hydro 22. Ducts, Ventilating 71, Product Piping ElGas 0Oil 23. Gas Pipe-Rough & Test 72. Underground Flush 24, Roof Framing 73. Undergrnd. Storage Tank C1 Gas ❑ Oil 25. Roof Sheathing 74. Overhead Hydro 26. T-Bar"Ceiling (Structural) & Monocoat 75. Dry Chemical 27. Frame and Flashing y 76. Dry Standpipe 28. Lathing & Siding 77. FIXED SYSTEM FINAL 29. Insulation 78. FIRE PREV. FINAL 30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat 79. FINAL INSPECTION 32. Electrical Power Meter-Final 80. FOOD CERTIFICATE ISSUED 33. Final Electric y Notes: 34. Final Heating & Air Conditioning 35. Final Gas Pipe-Test 36. Hood or Canopy 37. Final Factory Fireplace 38, Final Plumbing 39. Water Service-Final 40. Gas Service-Final { 41, Solar Domestic-Final t 42. Backflow Preventer 43. Backflow Irrigation 44. Landscape Irrigation System 45. Sound Attenuation ' :r • 46. Handicap Regulations r _ 47, FINAL STRUCTURE & BUILDING _-48. Special Requirements Completed 49. Electric Release to Edison; 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY No. Date } �, - - .i PROSECT ADDRESS:3333 BRISTOL ST UNIT: SEARS ADORESS: OWNER'SNAME: C J . SEGERSTROM L SONS AD3�i5 FAIRVIEW RD COSTA MESA CA 92626 ARCHIENGINEER: ( 7 14 ) 5 4 6- 0 1 1 0 REG.NO.: ADDRESS: UNIT: PERMITTEE: AMAN ENVIRONMENTAL CONST. (818)967-4287 AggRESS: ((''((����1J 007 U00J� S. CITRUS 201 LICENSED CONTRACTMELUI.f IAN: I hereby affirm that I am licensed under �provisionss at G apter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. CITY LIC.: STATE LIC.: CLASS: 671303 Date: Signature: WORKERS OMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to sell -insure or a certificate of Workers' Compensation Insurance, or a certified copy thereol (Section 3800, Lab. C). POLICY NO.: UD 0 5— 0 4 9 3— 0 1 7 9 1 EXP. DATE: 01/01/94 COMPANY: UN I CARE IN CC� ❑ Certified copy 1s ere y furnished. Certs ted copy is til �h the city � ildiJv','an- '-7 ^ � /� oale:q q Applicant: _ f,_ ,,- EXEMPTION F OM W RXERS' COMPENSATION DECLARATION: (This section need not be completed if the permit is far one hundred ($100) or lessj. I certify that in the performance of the work for which this permit is issued. I shall not employ any person in any manner so as to become subject to The Workers' Compensation Laws of California. Date: Signature: NOTICE: If, atter making this declaration, you should become subject to the Workers' Compensation provisions of the Labor Code. you must forthwith comply win such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency lar the performance of the work for which this permit is issued (Section 3097, Civ. C). LENDER: ADDRESS: OWNER BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractors' State License Law for the following reason {Section 7051.5 Business and Professional Code: Any city of county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance. also requires the applicant for such permit to file a signed statement that he/she is licensed pursuant to the provisions of the Contractors' State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or trial he/she is exempt therefrom and the basis lot the alleged exemption. Any violation of Section 7031.5 by any appticant for a permit subjects the applicant to a civil penalty of not more than live hundred dollars ($500). I, as owner of the property or my employees with wages as their sole compensation, will do the work, and the ❑ structure is not intended or offered tar sale (Section 7044, Business and Professional Code: The Contracfars' State License Law does not apply to an owner at a property who builds or improves thereon, and who does such work himselfthersell or through his at her own employees, provided that such improvements ase not intended or offered for sale. If, however the building or improvement is sold within one year of completion, the owner will have the burden of proving he/she did not build or improve for the purpose of sale). I. as owner of the property, am exclusively contracting with licensed contractors to construct the project (Section 7044, Business ❑ and Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon and who contracts lot such projects with a conttactor(s) license pursuant to the Conlractors' State License Law). I am aware that proof at their Worker's Compensation insurance should be provided to me. ❑ I am exempt under Section: B. & P. C. tar this reason: Date: Owner: I do hereby certify that I am aware at and understand the requirements of California Health and Safety Cade Sections 25505, 25533, and 25534 and that I or any future building occupant wi"11 not icirde one) need to comply with said state codes and the requirements far a permit for construction or modilmation from the Air Quality Management District. Residential construction applications are exempt from those provisions. Elate: Applicant: 1 hereby certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and stale Ian + relating to building con81ruclion and hereby authorize representatives of this city to enter upon the abave•mentioned property for irppectijinpurposes. ll``i^l Dale: Signature: _ /L/L/1/� 1�_N/_1AMAn Driver's License or Social Security k. 1641-48 While—Building: Green—Code Enlarcemem; Canary—Applicant: Pink—Revenue; Goldenrod—Assessor CITY OF COSTA MESA - BUILDING PERMIT PERMIT NO: E 062945 PLAN CHECK NO: N CONSTRUCTION TYPE: PERMIT TYPE: ELE JOB DESCRIPTION ; TEMPORARY POWER FOR SOIL REMEDIATION CLAIM VALUE: CALL -VALUE: PERM NO: E Q62 45 GOVT: N SUPP: N PURPOSE; 0TH SQ FT: GROUP OCC; B-1 / COMMENTS: SOIL EXCAVATION a REMEDIATION PROJECT AT SC PLAZA/SEARS PARKING L #####�!-If####if###iF�F#E��if*****#####iE.*#############!t•iEltit•##fFiF#iEik#fit#iE#########Tk9k#iE###TEiF Z O N I N G S E T B A C K S R E Q U I R E M E N T S ------------ MAIN BUILDING ---------- --------- ACCESSORY BUILDING----------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR; FT IN LEFT: FT IN RGHT: FT IN LEFT; FT IN RGHT: FT IN PARKING RE • PROV: PARCEL; 41250102 ZNE; REF NO; PLANNING N TES> D E V E L O P M E N T S• E `Jl V I C E S R E Q U I R E ME N T S ZONING APPROVED BY DATE: BUILDING APPROVED BY DATE; APPLICATION ISSUED BY; r DATE: kIt-1liEirt#it>E*#lEi6iElklFi4iE*9f�#dFTEdEfF#16#it'16ft ii############ #*###�(-iE#it#TFiI-#Te####iF#��#it�(-!E#!liF'lt3E## LEGALIZATION:N F E E S U M M A R Y STRUCTURAL SEGMENT:N BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT 15,75 50% SMIP/NON-RES PLAN ISSUE FEE 15,00 BUILDING -DIV-> PERMIT ISSUE PLAN -CHECK TOTAL PAID DUE TOTALS ---- > 15.75 15.00 0,00 30.75 30.75 .00 REVENUE DIVISION TOTALS--> COLLECTED: 30.75 OVER/SHORT: .00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN --CHECK 30.75 it•#it*###iE######Tk###*###t!-itit>tit#TI-#*#TETE####*#*##ik##*iFiFT434##frtll-14�*1E-14�E##########�EiE#iE###TES I N D I V I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST ELE 1 TEMP SERV PWR POLE W/OUTLETS ELE 1 FIXTURES, LIGHTING 1 ST 20 END OF FEES EA. A, 15.05 15.00 75 01 00142490-00142490 T O T 30.71 DATE: 07/08/93 TIME: 14:15 CONSTRUCTION AND PLANNING - APPROVALS Permit �i` _Date Inspector POOL jPA APPROVALS Permit # Date Inspector 1. Temporary Electrical Service or Pole - 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. - 54. Forms 4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding 5, Steel Reinforcement 56. Rough Plumbing & Pressure Test 6. Electrical LIFER Grnd, 57. APPROVAL. TO COVER•GUNITE •7. Footings 58. Electrical Conduit. Undrgrnd. 8. Foundation 59. Gas Pipe, ❑ Undrgrnd., Test 9. Water Pipe-Undrgrnd, 60. Backwash lines, P -Trap, ❑ Undrgrnd. 10, Structural Floor System 61. APPROVAL TO DECK 11. Property Sewer Line & House Connection 62. Backwash & Receptor -Final 12. Sewer Cap * y 63. Heater & Vent -Final 13. Roof Drains 64. Plumbing System - Final 14. Rough Plumbing 65. Electrical -Final 15, Rough Electrical -Conduit 66, Solar System -Final 16. Rough Electric Wiring 67. Fencing & Access Approval 17. Rough Wiring Sign 68. APPROVED FOR PLASTERING 18. Rough Electrical -T Bar Ceiling 69, POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit # 20. Rough Factory Fireplace 21. Ducts, in Structure r 70. Underground Hydro 22, Ducts, Ventilating 71. Product Piping ❑ Gas ❑ Oil 23. Gas Pipe -Rough & Test 72. Underground Flush 24. Roof Framing , 73. Undergrnd. Storage Tank ©Gas ❑ Oil 25. Roof Sheathing 74. Overhead Hydro 26, T -Bar Ceiling (Structural) & Monocoat 75. Dry Chemical 27. Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding F 77. FIXED SYSTEM FINAL 29. Insulation f; 78. FIRE PREV. FINAL 30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat 79. FINAL INSPECTION 32. Electrical Power Meter -Final f 80. FOOD CERTIFICATE ISSUED 33, Final ElectricQ! 34. Final Heating & Air Conditioning Notes: 35. Final Gas Pipe -Test 36. Hood or Canopy I t t 1 i 37. Final Factory Fireplace r 38. Final Plumbing 39. Water Service -Final 40. Gas Service -Final 41. Solar Domestic -Final 42, Backflows Preventer I r 43. Backflow Irrigation 44. Landscape Irrigation System 45. Sound Attenuation 46. Handicap Regulations 47. FINAL STRUCTURE & BUILDING i 48. FINAL PLANNING 49. Electric Release to Edison 50, Gas Release to Southern California Gas Co 51, CERTIFICATE OF OCCUPANCY No. Date (714) 754-5273 • Fax (714) 754-4856 • www.cl.costa-mesa-91WILDING PERMIT Job Address: 3333 BRISTOL ST Suite: 1219 Other: $0.00 Vicinity: SPACE 1219 (JOHN VARVATOS) Primary Occ! M Display/Sale Merchandise Type of Construction: I -FR Parcel Number: 41250107 Zoning: PDC Applicant: JACOBS, ERIK Address: 620 POINSETTIA ST _ = Phone: 714-547-7161 SANTA ANA; CA, ' - Zip: 92701-3936 Owner: SOUTH -COAST PLAZA Address _ �. PLANNING & ZONING COSTA MESA CA = Phone: 3315 FAIRVIEW ROAD %'_ Zip: 92626 MAIN STRUCTURE'Fron%026' �'_ /,'/-Rear, 0-0- Left'' 0- 0 Contractor: AMERICAN DEMOLITION/CONCRETE CT Address: 620 POINSETTIA ST ! 'Left, Front�0 0 Phone: 714-547-7181 0- 0 - Right 0- 0.,,' SANTA ANA, CA Zip: 92701;3936 ,License:. 390754 Progosed: 0. Arch _ - i- " ' Eng: Address: Address Zip: Phone: 'License: r 77 FAIR DRIVE, COSTA MESA, CA 92626 Status: ISSUED Applied! 06/23/2005 Issued: 06/23/2005 ISSUED BY: Phone: License: -�I •. , ,- . SCOPE OF PERMIT.-, INTERIOR STORE MOLITIO OF NONBEARING WALLS, CEILING, FLOORING AND CASEWORK IN CONJUNCTION WITH THE INTERIOR 4234 SF STORE TI R " VARVATOS" IN. SPACE T219' ELEC S MEC14 WORK TO BE DONE. REF: 805-00943 FEE SUMMARY/ Plan Check: $0.00Calc Valuation: ;. , $20,000.00 Permit: $321.25 Claim Valuation: $20,000.00 SMTP Res: $0.00 . 5MIP,Com. � $4.20 Other: $0.00 inspection* $0:00 Total: $325.45: PLANNING & ZONING SETBACKS MAIN STRUCTURE'Fron%026' �'_ /,'/-Rear, 0-0- Left'' 0- 0 Right" , 0-0 ACCESSORY ! 'Left, Front�0 0 Rear, - 0-,0' 0- 0 - Right 0- 0.,,' PARKING Existing: 0 ;Required: _ 0 Progosed: 0. NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or If work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 190 DECLARATIONS WORKERS' COMPENSATION DECLARATION: hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. 70 I�J have and will maintain workers' oompensation insurance, as required by sectlon 3700 of the Labor Code, for the performance of the work for which this permit is Issued. My workers' compensation Insurance carder and�1olacy number are: ..•r,..�rr CA erg iT 2USJX45S SSW+CZS lifs�7�.- Pollcy-N ddYin �ObLi cdon need not be carnpleted if the permit Is valued alone hundred dollars f$100) or less.) — ❑ t certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith Apptt comply with these provisions. WAR 41 n4NO FAILURE TO SECURE WO RS' COM BJ COVERAGE IS UNLAWFUL AND SWILL SUBJECT AN EMPLOYER P � AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is In full force and affect. LE; i 2gp-4 � tractor's 5ignatureata CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3D97, Civil Code), Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that 1 am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any dry or county which requires a permit to construct. alter, improve, demolish, or repair any structure, prior to Its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Cade) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (5500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or Improves thereon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not Intended or offered for sale. If, however, the building or improvement is said within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). • ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license, ❑ Yes ❑ No Driver's License No, Expires: Verification of Ownership by (type of document, i.e. - property tax bill or dead): DIVISION OF INDUSTRIAL SAFETY {HERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person Is required to descend, will be made In connection with work authorized by this permit, and that no building structure, scaffolding, fatsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Data: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and Certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Secdon 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or w€ll the appl€cant or present or future building occupant need to file a reg€strsdon form for acutely hazardous materials? ❑ Yes ❑ Na (Section 25533 of the Califomla Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _ ................................... ........................--..................... _.—_........................... _....................... __._.................................... _.._.... -•---...................... _................ _..................... — 3 Does or will the applicant or present or future building occupant need to prepare an FiMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ................... _. _............ .............................................................................................................................................................................................,.,...,,.......,..................................................................................................... 4 If aIn RMPP Is presently required, has Section 25534 of the California Health and Safety Code been fully compiled with? Yes ❑ No --- ................._._ _.......-............_—......._......---............_..—._...............—_................_........... _......... ---............ _.—................. ................. 5 Does or will the applicant or present or future build€ng occupant require for Lha work which is the subject of this a plication a ffPrmit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? [� Yes LJ No (Section 65850.2 of the California Government Code requires that the requested information be fum€shed on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Menagemeni Distdct or other air pollution control district or agency Is requ€red for the work which Is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑Yes ❑ No _ ............. __----.._._..--...... .._................ _ ........................._ ......................_—............ --........................................ .........---.........:_..._._................. ---............. 8 (if yes attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the Information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the Information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costs Mesa to enter upon the above-described property for Inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. ,SignatureLegal Owner(s) to ����� Or; ttfo d,Applicant iTdte CODE ir, INSPJNSPECT PEC IOC j SPE pAI1; INMIA CcQQI! INSPjN jINS ONS EPE f&¢. IKML 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 206 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final BlocklRetaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Bullding/Occupancy Ma (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mosa.ca.us RESSION PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Suite: 1219 Vicinity: UNIT 1219 Parcel Number: 41250107 Applicant: ANDREA ZAVALA% Address: P O BOX 90952 r ,+ CITY OF INDUSTRY, CA Owner. SOUTH COAST -PLAZA Address COSTA MESA CA's 3315 FAIRVIEW ROAD Contractors LEUNG; I<ANE • Address: Zoning: PDC PDC ISSUED BY: i i Phone: 562-908-1660 Zip: 91715-0952 Phone: Zip: 92626 Status: ISSUED Applied: 07/07/2005 Issued: 07/20/2005 Phone: Zip: License: 657954 SCOPE OF PERMIT RELOCATE 36 OVERHEAD SPRINKLERS FOR "JOHN VARVATOS" SUITE 1219. REF.: B05-00943 FEE SUMMARY' Plan Check: $99.61 Calc Valuation: $7,639.00 Permit: $153.25 Claimed Valuation: $7,639.00 Other: $0.00 Total: $252.86 ; NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or It work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and ail required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result In the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 2aa6.46 (0=) DECLARATIONS A WORKERS' COMPENSATION DECLARATION: hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -insure for workers' oompensation, as provided for by section 3700 of the Labor Code, for the performance of the work'f which this permit Is Issued. e and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. My wo rs' mpenn��, tion�lfosurance carrier and pollcy number are: Carrier:.,.,: / Y�U�G{ Po��� ,(7h(6ictlor► n ed not be completed f1 the permit is valued at one hundred dollars ($100) or less.) ❑ I certify that in the performance of the work for which this permit is Issued, I shall not employ any person in any manner so as to become subject to the workers' Compensation laws of Cal' to, d t If I s become subject to the workers' compensation provisions of Sectl 3700 the Labor Code, I shall forthwith comply with these pr vl WAplpSE Date:_ Poar. RE WORKERS' TION COVERAGE IS WA AWFUL AND SHALL SUEUECT AN EMP NAL PF_NALn s AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE (1100,000}, IN ADOfr101J TO THE CDST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3709 OF THE LABOR RODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirmthat,l am licensed render revisions 0f Chapter 9 (commencing with Section 7000) of Division 3 of the Business a Professions Code, and my license is in full d eClJc. 0 cf� 0M C�+aetar D�1t . yrLID CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there Is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lenders Address: Signature: Dale: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to Its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors Ucense taw (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own amployses, provided that such Improvements are not Intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Drivers Ucense No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation live (5) or more feet in depth Into which a person is required to descend, will be made in connection with work authorized by this permit. and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high, (Chap. 3.2, Grp 2, An 2, Sec. 341, TItle 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has e permit to do such work from the division. Signature: Data: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every buslness which has at any one time during a reponed year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ......... __.— .......................... �� _..._.......... _... ....... _..................................................................................... _ 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Saction 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Depanment of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. _..................................---................._..._..........................................................................................................1 1....................... 1 ......... .................. _ ....... _._ 4 If an RMPP Is presently required, has Section 25534 of the California Health and Safety Code been fully compiled with? Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this a plication apermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes U No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 foot from the outer boundaries of a school? ❑ Yes ❑ No (If yes', the facility must meet the requirement of Sectkmns 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (If yes', attach certificale of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the Information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Dale: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY. I certify under penalty of perjury that I have read this application and state thal the information given is correct. I agree to comply with all state laws and city ordinances relating to butiding construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for Inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. 5i u 07120�Dto 05- ri 0ifie ze TAtl d pplican " - f �E�ate1 CODg! INSPECTION TYPE 9M IN1M6Le`E CODE INSPE00161ITPE DAIS INTrM 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final BlockfAstaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Flnal Demolition 250 Final Bullding/QCcupancy r (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 MECHANICAL PERMIT .lob Address: 3333 BRISTOL ST Suite No 1219 Vicinity: UNIT 1219 Status: ISSUED Applied: 07121!2005 Issued: 07l�21 /2005 V ! �>� Parcel Number: 41250107 ISSUED BY: - -, SCOPE OF. PERMIT , .. MECHANICAL PERMIT FOR INTERIOR 4234 SF STORE TI FOR "JOHN jVARVATOS" IN SPACE 1219. ELEC & MECH WORK TO BE DONE. :J REF #805-00943 ' Applicant: GARRY, BOBBY --''--"_ Address: WORK TO INLCUDE: 4 VAV BOX.. Phone:. FEE SUMMARY' : ".Zip:. ` Quantity ISSUE FEE,, $23.50 Repair 1 Alt Absorbtion Unit $0.00 0 Inst FAL)'<100.k BTU , $0.00 D.. Owner: SOUTH COAST PLAZA 0 Inst FAU X100 k BTU Address: $0.00 0 Repair / AIt , Cooling/Heat ` $0.00 0 ", ' Evaporative Cooler ' .% %' $0.00 0 Inst / Rep. Recess Wall Ht.r COSTA MESA CA Phone: $0.00 'o Refrig Sys <100 k BTU $0.00"'` 0't' `° Domestic incinerator '" •'' ',/ $0.00 3315 FAIRVIEW ROAD Zip: 92626 �$6ob ,; 0 •Com ressors 1 Absor tion.S•'stems Gas Piping . .. � %� y $0 00',, ;0 �� Up to 3 hp 1-100 k,BTU�,/=�"' �� {/ $0.00 0 Contractor: TALENT AIR '.' .� °, 3 To 15 hp 1500 k-B7U - _C _ %� / �" $0.00 Address: 10880 WALKER ST_ , $0.00 0" = =,:•,� �._. __ I5,_To,30 h L:1,D00 k�BTU�-, `' ' �.. �. p l ' l �i x$0.00 0 \� $42:60 =.30 To 50 Yip 1 1,750 k BTiJ`� .� �,,- $0.00 Phone: 714-484-9600 Vent Fan 1 Single Duct �\ $OPD l.' 0 ` ; • - ' Over 50 hp 1 Ove 1,750 BTU' : , ' CYPRESS, CA - Zip: 90630-5011 Appliance ~ $0.00` `0 \ License: 702568 Fire Dampers $0,00 D Up to 3 hp - J $0.00 - -, SCOPE OF. PERMIT , .. MECHANICAL PERMIT FOR INTERIOR 4234 SF STORE TI FOR "JOHN jVARVATOS" IN SPACE 1219. ELEC & MECH WORK TO BE DONE. :J REF #805-00943 ' WORK TO INLCUDE: 4 VAV BOX.. FEE SUMMARY' : Quantity ` Quantity ISSUE FEE,, $23.50 Repair 1 Alt Absorbtion Unit $0.00 0 Inst FAL)'<100.k BTU , $0.00 D.. f:" c"° •--Repa€r / Alt Refrigeration Unit . $0.00 0 Inst FAU X100 k BTU $0.00 D Ventillation System ' i .,,. $0.00 0 Repair / AIt , Cooling/Heat ` $0.00 0 ", ' Evaporative Cooler ' .% %' $0.00 0 Inst / Rep. Recess Wall Ht.r ;, `$0.00 0 Commercial'Ihcinerator-, . _ -., .. %� $0.00 'o Refrig Sys <100 k BTU $0.00"'` 0't' `° Domestic incinerator '" •'' ',/ $0.00 0 Refrig Sys >100 k BTU .%. �$6ob ,; 0 •Com ressors 1 Absor tion.S•'stems Gas Piping . .. � %� y $0 00',, ;0 �� Up to 3 hp 1-100 k,BTU�,/=�"' �� {/ $0.00 0 Factory Fireplace _A $0.00 ��-0=: ���, " �` '.' .� °, 3 To 15 hp 1500 k-B7U - _C _ %� / �" $0.00 0 Hood w/Mech Exhaust , \ VAV Sox V""4,- , $0.00 0" = =,:•,� �._. __ I5,_To,30 h L:1,D00 k�BTU�-, `' ' �.. �. p l ' l �i x$0.00 0 \� $42:60 =.30 To 50 Yip 1 1,750 k BTiJ`� .� �,,- $0.00 0 Vent Fan 1 Single Duct �\ $OPD l.' 0 ` ; • - ' Over 50 hp 1 Ove 1,750 BTU' : , ' $0.00 0 Appliance ~ $0.00` `0 Boilers, „ Fire Dampers $0,00 D Up to 3 hp - J $0.00 0 Smoke Dampers $0.00 .0�_ 1 Iv .3 To 15 hp r -.� j' $0.00 0 Inst or Relocate Appl Vent $0.00 �`O _ \ 15 to 30 hp 0 Air Handlers < 10000cfm$0.00 $0.00 0 ` - 30 to'50 hp $0.00 0 Air Handlers > 10000cfm $0.00 0Oyer SO hp $0.00 0 Floor Furnace $0.00 0 Other Mechanical Fee NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result In the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 2446-46 (6113o) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ 1 have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. My we a corn nsatira�n �I'nsurance carrier nd policyEnumber are: Carrier: 19 `—''rn 7y'[r" A 1 A ` 1 Policy Number: ® `t i (J l91-7 q (This action need not be completed if f e permit is valued ar one hundred dollars ($100) or fess.) 1:cerliiy1hat In the p rmanca of the work for hlch permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation la of alifomia, and agree th If 1 s uld become subject to the workers' compensation provisions of 8 t n 3700 of the labor C e, I shall forthwith comply with t visions. {�{�f? ,Lgant•519natura- WARM! C FAILURE TO SECURE WORKERS' COMPENSATI OOVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYERTOCRIMINAL P TIES AAD CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLI.ARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: etebby....aliir�m [hat i am lice ed amnd ro hapter 9 (commencing with Section 7000) of Division 3 of the Business�md Pr ss6s Code, and my license is in full etl dW and ec� t. Licfi v C�` C_ L1 t onti'actor's Signal g"7 Da j�L d CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performanco of the work for which this permit Is Issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not Intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who bunds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professio s Code for this reason: Signature: A Owner [D verified by driver's license. ❑ Yes ❑ No 1N ti Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet In depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ...................m............................................................................................... ................................................................................................................................................................. ........ ............ ....................... ....._................. 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one lime has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _....................................---... ........................................ _.—.................... _....................... ...... ......_....................... .............. ...................................................................................................... .............................. 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the Califomia Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department, 4 If an RM PP is presently required, has Section 25534 of the Califomia Health and Safety Code boon fully complied with? ❑Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this a pllcat€on afeica rmit for such construction or modiftion from the South Coast Air Quality Management District or from any other air pollution control district or agency? IU Yes �f No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). --- ....... .. . .. ................... ._.. ................---..................._....................-- ... ................ — _................................... ........................................ ....__-.....................__....... art of e c ...... 6 Will any pthe facility to be under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). —..... ............ ._........ ...... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by Calitomla Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (If 'yes', attach certificate of comp€€ince from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the Information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that i have read this application and state that the information given is correct. I agree to comply with all state laws and dry ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the abov 'bed property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signet Legal ner(s) 7i 1 D to nd/Or, AutKorizod AAplfcent�--- CODES• l"2Fl;C1I0N TYPE 17AiE INTMA CODE IN SPEC-n4d TYPE DAIE 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 2D8 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.00sta-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT Job Address: 3333 BRISTOL ST Suite No 1219 Vicinity: SPAC E1219 (JOHN VARVATOS) Parcel Nunmber: 41250107 Applicant: SCHELIN, KEVIN Address: 136 E GARRY Phone: (714)556-8591 ISSUED BY: f Status: SANTA ANA,.CA Zip 92707 06/30/2005 Issued: 07/06/2005 SCOPE OF -PERMIT . INTERIOR 4234 SF.STORE TI FOR.JOHN VARVATOS" IN SPACE -1219.- ELEC4 MECH WORK TO BE DONE. Owner:- SOUTH COASTPLAZA�- Address; REF: B05-00943 COSTAWESA,CA , Phone: FEE SUMMARY 3315 FAIRVIEW ROAD Zip: 92626 Quantity' . l $23.50 - Temp Disf System 1 Lighting $0.00 01' Temp service test $0.00 1 i $0.00 0 Res: a/c package $0.00 Standing Section Contractor. SMALLCOMB WIRING CORPORATION Address: 136 E GARRY $0.00 """"o New Res"(3+units) -,',$0.00 0 Phone: (714)556-8591 $0.00 ;% `0 SANTA ANA', CA'; .: Zip: 92707' up to 10 kvalkw $0.00 ', 0" ' License: 145961 ISSUED BY: f Status: ISSUED Appiied: 06/30/2005 Issued: 07/06/2005 SCOPE OF -PERMIT . NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12.21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2aa6-46 (eroo) SCOPE OF -PERMIT . INTERIOR 4234 SF.STORE TI FOR.JOHN VARVATOS" IN SPACE -1219.- ELEC4 MECH WORK TO BE DONE. 138 LIGHT FIXTURES, 66 OUTLETS, 6 SWITCHES, 2 SUB PANELS TO 200A , REF: B05-00943 FEE SUMMARY Quantity Quantity' -ISSUE FEE $23.50 - Temp Disf System 1 Lighting $0.00 01' Temp service test $0.00 Busway 1100 ft `- - $0.00 0 Res: a/c package $0.00 Standing Section $0.00 ",0,/, New Res (1-2 units) , ` ". $0.00 0 �.ri>•"',:' "" Misc Electrical Equipment $0.00 """"o New Res"(3+units) -,',$0.00 0 , , Transformers up to 1 kvalkw $0.00 ;% `0 Pool !Spa $0.00 0 -. up to 10 kvalkw $0.00 ', 0" ' Lighting Fixts` $249.03, .4 331%"' - , ..................up to 50 kvalkw; - . $0.00- 0 ' Recept Outlets ' $36.6p ,. 40 J :............up to 100 kvalkw $0.00 0 Switches j S9.90"- - 9 "., . .....:.::.........over 100 kvalkw " , ' $0.00 , . 0 Non Res Appl $0.00 0" Low Voltage Equipment - $0.00 "';0 Res Appl $0.00 �, .fl Low Volt Wiring System/ Ckt $0.00,' 0 Service to 200a _ $0.00 , ". 0 _ �, ` "_ ""-. ,., Misc. Conduit - - r - �� $0.00' 0' Service to 1000a $0.00' r 1 ,'' 0 .,. Misc-. Conductor 0 Service over 1000a \" : 50.00` /;" 0 Circus ( gen or ride) $O.OD' ' 0 Motors to 1hp \, $0.00' 0 ,1,t ,�-~ ` ' -,Circus (meth ride or lights) $0.00" '� 0 Motors to 10hp $0.00' ; _ 0-" _ ; Christmas Tree Stand-' ;'- $fl.00" 0 Motors to 50hp ` $0,00-1 0.. 1 Fireworks Stand $0.00 0 Motors to 100hp $0.00 D other Electrical Fee $D.00 Motors over 100hp $0.00 0 __ "• Communication drops $0.00 0 - - Investigation Fee $0.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12.21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2aa6-46 (eroo) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the wfor which this permit is issued. i have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. M wI r ars' com ens lion Insurance carrier and policy number are: / • ro �,7t ®� � arcler ��i+'e�.P )S POAgy Number: t�iJ /`( `(Rtrs'se`ctlan treed gat be plated it the permit is valued atone hundred dollars ($100) or fess.) ❑ I certify that in the rformance of the w%rk for which this permit is issued, I shall not employ any person In any manner so as to became subject to the workers' compensation laws of afifoml a d a rea hat if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith pwith these r visions. f €lp�icant, tore: I- Date: y—tea—(— WARNING: FAILURE TO SECURE WORKE S' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed and p ovislons of Chapter 9 (commencing with Section 7000) of Division 3 of.the usiness�anrj.Professions Code, and my license is In full force and effect. L rte# Clas N CC�� (( Contractor's SIgOAIure: CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Cade). Lender's Name: Lenders Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (S500).): ❑ I, as owner of the property, or my employees with wages as their sofa compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement Is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ' ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .............................................................................................................................................................................................................................................................................................................................................................. 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the Califom€a Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ....-.....................................................................**............................................................................................................................................................................................................................................... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ........... ................................................................................................................................................._.................................................................................................................................. ............ 4 If an RMPP is presently required, has Section 25534 of the Califomia Health and Safety Code been fully complied with? ❑ Yes ❑ No ............................................................................................................................................................................................................................................................................................................................................................................ 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ormit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes jJ No (Section 65850.2 of the California Government Code requires that the requested Information be furnished on applications for non-residential building permits). ... ...........................................................-.......................................................................................................... ..................................... 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries o1 a school? []Yes ❑ No (If 'yes", the facility must meet the requirement o1 Sections 25534 and 42303 of the California Health and Safety Code). ................................................................................................................................................................................................................................................................................................................. 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ............................................................ ria"'---..i1r,..................................................................................................................................................................................................................................... e (lf yes", attach certificate of compliance from the appropriate air, pollution control offloer}. CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above Is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the abovescribed property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. 5' nature Of Legal Owner(s) Date _�-as nd/Or Rilthbrized'Appkaagt CODE R. INSPECTION TYPE 2AM INTMALS CODE I INSPEC170N_TYPE SAIF INTMA 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing a,pZ 206 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wail 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final BulldlnVOccupancy t- _.Ah ' (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 BUILDING PERMIT Job Address: 3333 BRISTOL ST Suite: 1219 Vicinity: SPACE 1219 (JOHN VARVATOS) Primary Occ: M DisplaylSale Merchandise Parcel Number: 41250107 Type of Construction: I -FR Zoning: PDC Status: ISSUED Applied: 0611012005 Issued: 07/06/2005 Applicant: JOE PRICE ISSUED BY: Address: Phone: 239-851-4418_ Zip: Owner: SOUTH•COAST`PL'AZA Address COSTA MESA CA,• yam'-� Phone: 5' -61 W ' 3315 FAIRVIEW.ROAD-� Zip: 92626 Contractor: RICHTER'&'RATNER Address: 5505 FLUSHING AV i - Phone: 718-497-1600 \ j MASPETH NY Zip: 11378 _ _ J 'License: -`300045 Arch , PAUL•J RUEFING, AIA Eng:, Address: 1101 DOVE STREET ,'� - . Address: SUITE 140 Phone: 949-660-8062 ` -Phone: NEWPORT'BEACH:•CA Zip: 92660 License: C4264 �. �, License: SCOPE OF;P.ERMIT,�,", �: �. INTERIOR 4234 SF STORE TI FOR JOHN-VARVATOS" IN SPACE -1219. —EC 8: MECH WORK TO l3E DONE. FEE SUMMARY Plan Check: $359.87 _ .. Calc Valuation: $317,550.00 Permit: $2,214.55 - Claim Valuation: $317,550.00 \ , SMIP Res: $0.00 -SMIP Corn: ,• $66.69 Other: ;. $0.00 IriSpection: `$0.00 • .,� ri,,'% .Total: $2,641:11, PLANNING& ZONING77 SETBACKS ` MAIN STRUCTURE Front' "&0 : f.. `,. Rear --0;.0` � ��- Left -0-0, Right.,, ;0- p j �r -ft- V ACCESSORY Frant `' 0- 0 Rear_ 0- 0 , Le 0- 0 ! Right,, 0- 0' PARKING ExisGn -•'"o .` Re uired: 0_ 'Proposed:' '0' ? � NOTES: - - NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shad automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable code , d/all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of vp FOR INSPECTIONS CALL; (714) 754-5626 244&46 t(Voo) Wk. LIE DECLARATIONS WORKERS' LAR COMPENSATION DECLARATION: N; heraby affirm under penalty of perl'ury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. 14r`e ' oompensatlon Insurancene and ollcy number are: , I?A Prnicy Ntimbar: a� �, isi ctlon need not be completed if the permit is value at on hund ed dollars ($100) or fess.) certify that in the performance of the work which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Cal' la, and ag th t if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith coon l-ywith• these pro W AILUR OSE RE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPL RTOS 'C NAL PENALTIES AND GVIL FINES UP TO ONE HUNDRED USAND DOLLAR 1 1. IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I here b affirm t- .1 am license under provision Of Chapter 9 (commencing with Section 7000) of Division 3 oLthe.Business and Professions Code, and my license is in full ce and effei t. L1c. ' CI' #.— u, CONSTRUCTION LEN AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of pe►jury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec, 7031.5, Business and Professions Coda: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or Improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ i am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ............................................................................................................................................................................................................................................................................................................................................................................. 2 Qoes or will the applicant or present or future building occupant need to file a registration farm for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ............................................................................................................................................................................................................................................................................................................................................................. 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ............................................................................................................................................................................................................................................................... ...-...........................................................I............................ 4 11 an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No .................................................................................................................................................................................................................................................................................................................................... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication aEermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? (I Yes LJ No (Section 65850.2 of the Califomla Government Code requires that the requested information be furnished on applications for non-residential building permits). ....................................................................................................................................................................................................... .......................................................................................... 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). _ ........................... _...................................................................... ........................ ._................................ ......................... .................................................................... ......................................... ........................ ......... ....... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which Is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ................................................................................................................................................................................................................................................................................................................................ 8 (If yes attach certiTicate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above Is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. natu Of Legal Owner(s) Date ut •Applicant---��;;_�Y�,;.� ate^—��•- INSPEGT1Qj E I?Affi Ittlm64$ copEf QAIE INTMAL 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wail 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 260 Final BulldingrOccupancy (714) 754-5273 • Fax (714) 754-4856 • www.cl.costa-mesa.ca.usNG PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 job Address: 3333 BRISTOL ST Suite: 1219 Vicinity: POLO SPORT (STE 1219) Parcel Number: 41250107 Applicant: MORRIS, KEVIN Address: $1,553.75 SMTP Res: 1 )%,.0 Owner: TH COAST PLAZA AddressSERGERSTOM Inspection: $0.00 1 COSTA MESA, CA 3315 FAIRVIEW RD Contractor. CONTI-HURLEY ASSOC, INC Address: 25 EDWARDS COURT STE 206 BURLINGAME, CA Zip: 94010-2424 Arch : OSHIMA, BRIAN M Address: 107 S FAIR OAKS AVE Zoning: PDC PDC Phone: 800-275-1236 Zip: Phone: Zip: 92626 Phone: (650)373-3930 License: 747287 PASADENA, CA Phone: 626-449-1990 Eng: Address: Status: ISSUED Applied: 09/27/2000 Issued: 12/05/2000 f ISSUED BY: Phone: Zip: 91105 License: C25849 License: SCOPE OF PERMIT "POLO SPORT" TENANT IMPROVEMENT, 4234 SO. FT. FEE SUMMARY Plan Check: $252.49 Permit: $1,553.75 SMTP Res: $0.00 SMIP Com: $42.00 Other: $0.00 Inspection: $0.00 Total: $1,848.24 Calc Valuation: $200,000.00 Claim Valuation: $200,000.00 PLANNING & ZONING SETBACKS MAIN STRUCTURE Front 0-0 Rear 0-0 Left 0-0 Right 0-0 ACCT-SSORY Front 0-0 Rear 0-0 Left 0-0 Right 0-0 PARKING Existing: 0 Required: 0 Proposed: 0 NOTES: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12.21.92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work Is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 2446.46 46/00) U WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the rk for which this permit is issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued, My workers' compensation Insurance carrier and polity number are: Carrier: Policy Number: (Thls section need not be completed if the permit is valued of one hundred dollars ($ t 00) or fess.) ❑ 1 certify that in the perform" ce of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Cel' mia, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these pro ons, \ !�� Applicant 5igvfe: Date: ✓'2 l(- / WARNING: F&W-66ECLIRIE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL. AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE (S100.000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR W SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed nder provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license Is In full force and effect. Uc. 0 Class # Contracttor's��'� ure: /I Hate: Q mor C� CONSTAU9TWrN/LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is Issued. (Sec. 3097, Civil Code). Lendees Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter. Improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. It, however, the building or Improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors Ucenge Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. _ Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation live (5) or more feet In depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 6, California Administrative Code). ❑ As owner-builder, t will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division, Signature: _ _ _ Data: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ................................................ ......__...................................._ ....................-- .................... - _ ................ .........................,....... 1111. 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? [ Yes 0 No (Section 25533 of the California Health and Safety Code, with soma exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .................._-........,................._._................................... _.........-._........................... ...-.... .._.......... I........ ....... -_................................... 3 � >r will th❑e applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? No (Section 25534 of the California Health and Safety Code provides that the Costd Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by bgsinesses which are required to register acutely hazardous materials with the Fire Department. .................... ......... -..................... ...................................................................................................................... .......................................................... ......... .................................... _........................... 1111....1..1..1.1..................... 4 If an RMPA is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No .......................... ................................. ••................................ ................... ........ ..................................................... --------................................... .... ..............................-............................. ....."............................... ............................................. 5 Does or will the appiicanl or present or future building occupant require for the work which is the subject of this a plication aggermit for such construction or modification from the South Coast Air Quatity Management District or from any other air pollution control district or agency? Ll Yes LJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). _- .........---�..... ......__...-------._....... ............................. __..................... _—.............................................................. __................ .....__................—._._.............. _ 6 Will any part 01 the facility to be constructed under this permit be within 1000 feet from the outer boundaries o1 a school? ❑ Yes ❑ No (if 'yes', the facility musl meat the requirement of Sections 25534 and 42303 o1 the California Health and Safety Code), ... .......................... ............................... I'll ............. ............................................... ............................. ....................................................... -.......................................... ..................... _............................................. _......................... .._.............. 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ..............11111­'­­­.­...............................................................................................................­---------------•--.......................................................................................................................................................----.......... attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Of Legal Owners Date thorizecl Applicant Date CODE 1, QM VIALS CODE ► INSPECTION TYPE au 1NTITI6L$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/OCcupancy 07-- Z_7`c W M 1 Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations. CITY OF COSTA MESA CONSTRUCTION PERMIT PERMIT NO TRACT NO. LOT NO. UNIT NO. Project Address 33 33 M,e�sT-B t-. ma � `1 �q S POta� I � i(,e- Applicant's Mailing Address 137-1 t F re 1--z4AN A (if— Owner's Name O 14.4 e0 A14Phone -'W1-1r7Q� Address Arch/Eng.P9_AN0/9/" r�r"6U58A/ License No. IZO Address MOIr_1 ��tA Contractor's Name r_1 Address (mailing) f3,J City License No. R 1�- r LICENSED CONTRACTOR DECLARATION I hereby affirm that I am licensed under provisions of Charter 9 (commencing with section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. �g License ass Li n No. Date 51"11 Signature WORKERS' COMPENSATION DECLARATION icreby affirm that I have a certificate of consent to self -insure or a Certificate 800,La Workers' Compensation Insurance, or a certified copy t ereof (Section 3800, Lab.�+C..)��.ss� ! r7aV"hi��'�"T Policy No.sT�`��✓�--j-- Company , Certified copy is hereby furnished. Certified copy is filed with the city Building Division. DateApplicant EXEMPTION FROM WORKERS' COMPENSATION DECLARATION (This section need not be completed if the permit is for one hundred ($100) or less). I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any man er so as to boo sub' ct to the Workers' C pen i Laws of Califor i1 Date � Signature NOTIC : If, after making this declaration, you should b orae subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Section 3097 Civ. C.) Lender's Name Lender's Address OWNER BUILDER D LARATION I hereby affirm that ham exempt from the Contractor's License Law for the following reason (Section 7031.5 Business and Professional Code: Any city or county which requires a permit to construct, after, improve, demolish or repair any structure, prior to. its issuance, also requires the applicant for such permit to file a signed statement that he/she is licensed pursuant to the provisions of •he Contractor's License Law (Chapter 9 (commencing with Section 7000) of ivision 3 of the Business and Professions Code) or that he/she is exempt 'erefrom and the basis for the alleged exemption. Any violation of Section ,031.5 by any applicant for a permit subjects the applicant to a civil malty of not more than five hundred dollars ($500). I, as owner of the property or my,emptoyees with wages as their sole compensation, will do the work, and the structure is not intended or offered for, sale (Section 7044, Business and Professional Code: The Contractor's License Law does not apply to an owner of a property who builds or improves thereon, and who. does such work himself/herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of com- plejiof the owner will have the burden of proving he/she did not build or im- prove for the purpose of sale). ❑ I, as owner of the property, am exclusively contracting with licensed con- tractors to construct the project (Section 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a con- tractors! license pursuant to the Contractor's License Law). k am aware that proof of their Worker's Compensation insurance should be provided to me. ❑ I am exempt under Section B. & P. C. for this reason Date Owner I hereby certify that l have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize repre- sentatives of thi city to enter on a above-mentloned pr pe for Inspection pure s. m Signature Date D Drivers' License or SS TYPE OF CONSTRUCTION NEW LJ ADD ALTERATION REPAI R ❑ CONVERSION ❑ DEMOLISH ❑ OTHER •Q- A.P. # '7 5O1 DESC IP+T1ON OFPORK/USE O BLDG. • + S Main Building: TYPE OF PERMIT GRADING FOuNDATION STRUCTURAL T Front ❑ TENANT ❑ ELECTRICAL ❑ PLUMBING ❑ MECHANICAL B Rear ❑ OTHER A PROJECT DESCRIPTION S . FT. OCCUPANCY 1116 —.7j._ C Right CONSTRUCTION TYPE �� VALUATION $ 1�.yad 5 eft ZONE RADiNG CU.YDS. ACRES Ping. Ref. # Rema, s:7 t Planning Notes: (1.0 iQP-v� ax"o t.l JLJ Bar Sink Backfiow Preventer Backflow Irrigation Bathtubs Clarifiers Dishwasher Drinking Fountains Floor Drains Floor Sinks Gas Service Outlets Interceptors Kitchen Sink Lavatories P—Trap Roof Drains Reinspection Fee $15 Boiler Duct - Under Ground Duct - Structural Duct - Ventilating Exhaust System ❑ Multiple ❑ Firepl/Fact. Bit. ICBO # Heating System & Ducting ❑ 0.100,000 BTU ❑ 100,000 BT Reinspection Fee I $15 CMF 0865-46, rev. 10/84 White - Building; Canary - Applicant; Pink - Accounting; Goldenrod - Assessor P L VASWN G Showers Service Sink Sewer Cap Sewer Connection Solar Collectors Solar Piping Solar Tank Swimming Pool w/Spa Urinal 't Water Closet Water Heater Water Service Auto -Wash Laundry Trays Issue Fee Hood or Type ❑ Canopy Type II ❑ Refrigeration System ❑0.i0Q000BTU ❑100,000BTU System Repair/Alteration Fire Dampers Registers Issue Fee I FEES Automatic Washer Construction Pole Sub, Cooking Unit Dishwasher Dryers ❑Gas ❑Electric Zone Accessory Building: Z O N I N G R Parking Req./Provided E Q S ELECTRICAL Fan F. A. U, Fixtures Device Boxes Outlets Switches Garbage Disposal Generator ❑0.5 KW 05.15 KW Transformer ❑ 15.50 KW ❑ 50 + KW Meter LJup to 100 amps Meter ❑over 100 amps Sub Panel Motors [10-1 HP ❑ 1 h - 8 Inc. Solar 09-15 HP 016-15+ Microwave Pole Light Range Sign Standing Sections Trash Compactor FEES $ 3 Reinspection Fee $15 Issue Fee $ 3 FEES DEVELOPMENT SERVICES REQUIREMENT �' "�'�-�"�� Zoning Approved By - _ Date Building Approved By Issued Date} Gi Application By—DateJ SUMMARY OF FEES BUILDING PERMIT $ 707• Sa SMIP $ • Qo PLAN CHECK $ PERMIT PLUMBING $ ISSUANCE $ PLAN CHECK 25% $ ENERGY P.C. S ELECTRICAL $ GRADING $ PLAN CHECK 50% $ MICROFILM $ MECHANICAL $ TOTAL FEE $ $ 3 PLAN CHECK 25% $ U1 00010061-00010062 T 1] T 727.50 ' " CONSTRUCTION AND PLANNING , APPROVALS Permit # Date Inspector POOL &SPA APPROVALS Permit # Date Inspector 1.)Temporary Electrical Service or Pole 52. Pool & Equipment Location 2." Soil Pipe-Undrgrnd, 53. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. 54. Forms , 4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding 5. Steel Reinforcement 56. Rough Plumbing & Pressure "fest 6- Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE jr 7. Footings 58. Electrical Conduit-Undrgrnd. 8. Foundation 59. Gas Pipe, ❑ Undrgrnd., Test 9. Water Pipe-U�nd`r�grnd. 60. Backwash Lines, P -Trap, ❑ Undrgrnd. 10. Structural Floor System 61. APPROVAL TO DECK 11. Property Sewer Line & House Connection 62. Backwash & Receptor -Final 12. Sewer Cap 63. Heater & Vent -Final 13. Roof Drains 64. Plumbing System - Final 14. Rough Plumbing 65. Electrical -Final 15. Rough Electrical -Conduit 66. Solar System -Final 16. Rough Electric Wiring 67. Fencing & Access Approval 17. Rough Wiring Sign 68. APPROVED FOR PLASTERING , 18. Rough Electrical -T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT �{ APPROVALS Permit # 20. Rough Factory Fireplace 21. Ducts, in Structur@ 70. Underground Hydro 22. Ducts, Ventilating 71. Product Piping ❑ Gas ❑ Oil,? 23. Gas Pipe -Rough & Test 72. Underground Flush �J t - 24. Roof Framing 73. Undergrnd. Storage Tank ❑ Gas ❑ Oil 25. Roof Sheathing 74. Overhead Hydro ; it 26. T -bar Ceiling (Structural) & Monocoat 75. Dry Chemical t1 ,r . 'f 1 27. Frame and Flashing /L 76. Dry Standpipe 28. Lathing & Siding 77. FIXED SYSTEM FINAL f1 r, 29. Insulation 78. FIRE PREV, FINAL 30. Drywall Nailing HEALTH DEPT. REQUIREMENT i 31. Plaster Brown Coat 79. FINAL INSPECTION 32. Electrical Power Meter -Final 80. FOOD CERTIFICATE ISSUED r• , 33. Final Electric Notes: �� •a 34. Final Heating & Air Conditioning .. 35. Final Gas Pipe -Test 36. Hood or Canopy ±� 37. Final Factory Fireplace 38. Final Plumbing 39. Water Service -Final to p l 40. Gas Service -Final I' 41. Solar Domestic -Final v 42. Backflow Preventer P I �� 43. Backflow Irrigation 44. Landscape Irrigation System 45. Sound Attenuation 46. Handicap Regulations x1 47. FINALSTRUCTURE&BUILDING 48.,.:Special Requirements Completed t ' 49. Electric Release to Edison 50. Gas Release to Southern California Gas Co %I 51. CERTIFICATE OF OCGUPANC-Y No. Date ' Y I with section 7000) of Division 3 of the Business and Professions Code, and my license is in II force and effect. license Cies Llcen e Dated /� z Signafuro WORKERS' COMWENSATION DECLARATION hereby affirm that I have a certificate of consent to self -insure or a certificate Workers' Compensation Insurance, or a certified copy thereof (Section .00, Lab. C.) !+n� (/1 Policy No.� ��sa01_ Company v' rtified copy Is hereby furnished. Certifie co y IS filed with the city Buil Di ion r Date �' f' Applicant uu-��-��" EXEMPTION FROM WORKERS' COMPENS�DECLAR •ION (This section need not be completed if the permit is for one hundred ($100) or less). I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California. „ Date Signature NOTICE: If, after making this declaration, you should. become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance` of the work for which this permit is issued (Section 3097 Civ; C.) ,. Lender's Name Lender's Address OWNER BUILDER DECLARATION ' I hereby affirm that 1 am exempt from the Contractor's License Law for the following reason tSection 7031.5 Business and Professional Code: Any City or' county which requires a permit to construct, alter, improve, demolish or'repalr any Structure, prior to its issuance, also requires the applicant for such permit to file a signed stMement that he/she Is licensed pursuant to the provisions of the Contractor's Ucense Law (Chapter 9 (Commencing with Section -7000) of ' r)ivision 3 of the Business and Professions Code) or that he/she is exempt irefrom and the basis for the alleged exemption. Any violation of section 31.5 by any applicant for a permit subjects the applicant oto •a -civil - nalty of not more than five hundred dollars ($500). ❑ I, as owner of the property or my employees with wages as their sole' compensation, will do the work, and the structure Is not intended or offered for sale (Section 7044, Business and Professional Code: The Contractor's License Law does not apply to an owner of a property who builds or Improves thereon, and whq does such work himself/herself or through his or her -own employees, proviged that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of com- ptetion, the owner will have the burden of proving he/she did not build or im- prove for the purpose of safe). ❑ 1, as owner of the property, am exclusively contracting with licensed con- tractors to construct the project (Section 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a con- tractor($) license pursuant to the Contractor's License Law). I am aware that proof of their Worker's Compensation insurance should be provided to me. ❑ 1 am exempt under Section _ B. & P. C. for this reason Date - Owner I hereby certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize repre- sentatives of thi city to a ter po the Gave -mentioned propp- inspection pur s. Signature Date i! Drivers' License or SS :P Bar Sink Backflow Preventer Backflow Irrigation Bathtubs Clarifiers Dishwasher Drinking Fountains Floor Drains Floor Sinks Gas Service Outlets Interceptors Kitchen Sink Lavatories P -Trap Roof Drains Reinspection Fee Boiler Duct - Under Ground Duct - Structural Showers Service Sink Sewer Cap Sewer Connection Solar Collectors Solar Piping Solar Tank Swimming Pool w/Spa Urinal Water Closet r Water Heater +' Water Service Auto -Wash Lau ry Trays $15 Issue Ill MECHANICAL - Hood o �l Canopy Type 11 Duct - Ventilating Exhaust System ❑ Multiple ❑ Firepl/Fact Bit, ICBO # Heating System & Ducting Cl 0- 100,000 BT U ❑ 100,000 BT Reinspection Fee 1 $15 CMF 0865-46, rev. 10/84 White - Building; Canary - Applicant; Pink -.Accounting; Goldenrod - Assessor Refrig*-ation System 00-100,000 BTU 13100,000 BTU System Repair/Alteration Fire Dampers Registers Issue Fee FEES Automatic Washer Construction Pole Sub, Cooking Unit Dishwasher .' Dryers ❑Gas ❑Electric Fan F.A.U. Fixtures Device Boxes Accessory Building: Parking Req./Provided ELECTRICAL Outlets Switches Garbage Disposal Ge€terator 00.5 KW ❑5-15 KW Zone Transformer ❑ 15-50 KW ❑ 50+KW Meter LJ up to 100 amps Meter Clover 100 amps Sub Panel Motors 00-1 HP ❑ 1 % - 8 Inc. Solar Ll 9-15 HP Cl 16-15+ Microwave Pole Light Range Sign Standing Sections Trash Compactor FEES Z O N I N G R E Q M T S &LILMM FEES G+13SC .Se/r L' 1 $15 1 1 Issue Fee (,fppC-'jl:, L.GV("L f3JLr574% 1 G'TA�icant to fill in all spaces except those within heavy border lines and sign all appropriate declarations. COSTA MESA CIT�#Address_:�3 CONSTRUCTION PERMIT RMITr�NO. � � � � TRACT NO. LOT NO. UNIT NO. Date Dat 3 � 9151: id �-- 9' BUILDING PERMIT PLAN CHECK PLUMBING PLAN CHECK 25% ELECTRICAL PLAN CHECK 50% MECHANICAL ' PLAN CHECK 25% SUMMARY OF FEES $ IQO,5-a $ _ T1 • $ $ $ $ $ $ SMIP $ PERMIT . ISSUANCE $ ENERGY P.C. $ GRADING $ MICROFILM $ TOTAL FEE $ .Pr fTYPE Applicant's Mailing Address ! 0 (ao 1 /'J 61(e fi,lA e..AC ,$L !Ji OFCONSTRUCTIQN NEW ADD ALTERATION REPAIR ❑ Owner's Name d✓�G, 60433 L,AO/+ ❑ CONVERSION ❑ DEMOLISH OTHE A.P. # Phone+2y/-1760 DESCRIPT N OF W RKIUSE OF DG. ��'''� a 3/� 13121ST Address —�7,�, L ST -,50. �j , ,..L,r✓ 5 S Main Building: pp__ Arch/Eng. 1�L�1'2Q-1 / Yfar�/VSC(L/t. License No. /Vts // 69 TYPE OF PERMIT GRADING FOUNDATION STRUCTURAL T Front r3i�C� ❑ TENANT ❑ ELECTRICAL ❑ PLUMBIMECHANICAL NG ❑ MECHAN $ Address ._._�%/ Contractor's Name �L/0 r 0ee-Z /6AV CC &,er_k /% El OTHER A Rear 1.t-5 Rhone ✓/yy C Right Address tmailing)_ /0d o/ ,y6,6✓,1ee .e�Gll(Z___ Dina PROJECT DESCRIPTION Scat. FT. OCCUPANCY CONSTRUCTION TYPE VALUATION $���• K S Left Cif+j License No.217 Z - — ZONE - GRAOINGCU.YDS. ACRES - Ping. Ref. `- LICENSED CONTRACTOR DECLARATION f hereby affirm that I am licensed under provisions of Charter 9 (commencing Remarks:- r=7A1JJLW r, kr,-_ nw,f) ,� Planning Notes: with section 7000) of Division 3 of the Business and Professions Code, and my license is in II force and effect. license Cies Llcen e Dated /� z Signafuro WORKERS' COMWENSATION DECLARATION hereby affirm that I have a certificate of consent to self -insure or a certificate Workers' Compensation Insurance, or a certified copy thereof (Section .00, Lab. C.) !+n� (/1 Policy No.� ��sa01_ Company v' rtified copy Is hereby furnished. Certifie co y IS filed with the city Buil Di ion r Date �' f' Applicant uu-��-��" EXEMPTION FROM WORKERS' COMPENS�DECLAR •ION (This section need not be completed if the permit is for one hundred ($100) or less). I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California. „ Date Signature NOTICE: If, after making this declaration, you should. become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance` of the work for which this permit is issued (Section 3097 Civ; C.) ,. Lender's Name Lender's Address OWNER BUILDER DECLARATION ' I hereby affirm that 1 am exempt from the Contractor's License Law for the following reason tSection 7031.5 Business and Professional Code: Any City or' county which requires a permit to construct, alter, improve, demolish or'repalr any Structure, prior to its issuance, also requires the applicant for such permit to file a signed stMement that he/she Is licensed pursuant to the provisions of the Contractor's Ucense Law (Chapter 9 (Commencing with Section -7000) of ' r)ivision 3 of the Business and Professions Code) or that he/she is exempt irefrom and the basis for the alleged exemption. Any violation of section 31.5 by any applicant for a permit subjects the applicant oto •a -civil - nalty of not more than five hundred dollars ($500). ❑ I, as owner of the property or my employees with wages as their sole' compensation, will do the work, and the structure Is not intended or offered for sale (Section 7044, Business and Professional Code: The Contractor's License Law does not apply to an owner of a property who builds or Improves thereon, and whq does such work himself/herself or through his or her -own employees, proviged that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of com- ptetion, the owner will have the burden of proving he/she did not build or im- prove for the purpose of safe). ❑ 1, as owner of the property, am exclusively contracting with licensed con- tractors to construct the project (Section 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a con- tractor($) license pursuant to the Contractor's License Law). I am aware that proof of their Worker's Compensation insurance should be provided to me. ❑ 1 am exempt under Section _ B. & P. C. for this reason Date - Owner I hereby certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize repre- sentatives of thi city to a ter po the Gave -mentioned propp- inspection pur s. Signature Date i! Drivers' License or SS :P Bar Sink Backflow Preventer Backflow Irrigation Bathtubs Clarifiers Dishwasher Drinking Fountains Floor Drains Floor Sinks Gas Service Outlets Interceptors Kitchen Sink Lavatories P -Trap Roof Drains Reinspection Fee Boiler Duct - Under Ground Duct - Structural Showers Service Sink Sewer Cap Sewer Connection Solar Collectors Solar Piping Solar Tank Swimming Pool w/Spa Urinal Water Closet r Water Heater +' Water Service Auto -Wash Lau ry Trays $15 Issue Ill MECHANICAL - Hood o �l Canopy Type 11 Duct - Ventilating Exhaust System ❑ Multiple ❑ Firepl/Fact Bit, ICBO # Heating System & Ducting Cl 0- 100,000 BT U ❑ 100,000 BT Reinspection Fee 1 $15 CMF 0865-46, rev. 10/84 White - Building; Canary - Applicant; Pink -.Accounting; Goldenrod - Assessor Refrig*-ation System 00-100,000 BTU 13100,000 BTU System Repair/Alteration Fire Dampers Registers Issue Fee FEES Automatic Washer Construction Pole Sub, Cooking Unit Dishwasher .' Dryers ❑Gas ❑Electric Fan F.A.U. Fixtures Device Boxes Accessory Building: Parking Req./Provided ELECTRICAL Outlets Switches Garbage Disposal Ge€terator 00.5 KW ❑5-15 KW Zone Transformer ❑ 15-50 KW ❑ 50+KW Meter LJ up to 100 amps Meter Clover 100 amps Sub Panel Motors 00-1 HP ❑ 1 % - 8 Inc. Solar Ll 9-15 HP Cl 16-15+ Microwave Pole Light Range Sign Standing Sections Trash Compactor FEES Z O N I N G R E Q M T S &LILMM FEES Reinspection Fee 1 $15 1 1 Issue Fee $ 3 As _g ELOPMENT SERVICES Approved By Buildilg Approved ByDate Appli `tion Issued Byr6n REQUIREMENTS: Date Dat BUILDING PERMIT PLAN CHECK PLUMBING PLAN CHECK 25% ELECTRICAL PLAN CHECK 50% MECHANICAL ' PLAN CHECK 25% SUMMARY OF FEES $ IQO,5-a $ _ T1 • $ $ $ $ $ $ SMIP $ PERMIT . ISSUANCE $ ENERGY P.C. $ GRADING $ MICROFILM $ TOTAL FEE $ ' 33. Z3 $ 3 CONSTRUCTION AND PLANNING APPROVALS Permit # Date Inspector POOL & SPA APPROVALS Permit # Date Inspector 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. 54. Forms 4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding 5. Steel Reinforcement , 56. Rough Plumbing & Pressure Test 6• Electrical UFER Grnd. 57. APPROVAL TO COVE R -G UNITE 7. Footings 58. Electrical Conduit-Undrgrnd. 8. Foundation 59, Gas Pipe; 0 Undrgrnd., Test 9. Water Pipe-Undrgrnd: 60. Backwash Lines, P -Trap, 0 Undrgrnd, 10. Structural Floor System 61. APPROVAL TO DECK 11. Property Sewer Line & F Louse Connection 62. Backwash & Receptor -Final 12. Sewer Cap 63. Heater & Vent -Final 13. Roof Drains 64. Plumbing System - Final 14. Rough Plumbing 65. Electrical -Final 15. Rough Electrical -Conduit 66. Solar System -Final r 16. Rough Electric Wiring ' 9 9 67. Fencing &Access Approval 17. Rough Wiring Sign 68. APPROVED FOR PLASTERING 18. Rough Electrical -T Bar. Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough'Heating & Air Conditioning FIRE DEPT, REQUIREMENT APPROVALS Permit # _ 20, Rough Factory Fireplace yi 21. Ducts, in Structure F`.• 70. Underground Hydro 22, Ducts, Ventilating 71. Product. Piping DGas 00'sl 23, Gas Pipe -Rough & Test 1 72. Underground Flush 24. Roof Framing 73, Undergrnd. Storage Tank ❑ Gas D Oil 25. Roof Sheathing 74. Overhead Hydro 26. T -Bar Ceiling (Structural) & Monocoat 75. Dry Chemical 27. Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding 77. FIXED SYSTEM FINAL 29. Insulation 78. FIRE PREV. FINAL I 30. Drywall Nailing HEALTH DEPT.,REQUIREMENT 31. Plaster Brown Coat 79. FINAL INSPECTION 32. Electrical Power Meter -Final 80. F00 ERTIFICATE ISSUED 33. Final Electric Notes: s 34. Final Heating & Air Condit�ning 35. Final Gas Pipe -Test EXPIR ED 36. Hood or Canopy IrKV IPWe Ins xdkxa 37• Final Factory Fireplace 38. Final Plumbing Few 39. Water Service -Final 40. Gas Service -Final 41. Solar Domestic -Final 42. Backflow Preventer 43. Backflow Irrigation 44, Landscape Irrigation System 45. Sound Attenuation 46. Handicap Regulations 47. FINAL STRUCTURE & BUILDING 48. Special Requirements Completed 49. Electric Release to Edison 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY No. Date ! Applicant to fill In all spaces except those within MANY u—.7' TRACT NO, 4 3333 South Bristol pEp,MITS RE: AIR CONDITIONINGSYSTEM MR THE hAIN MALL STRUCTURE M17999 r A/C Elev. Equip. R[n. M4702 mix Sox Lower level M4701 Mix Bax Upper Level E6481 A/C 3rd Dr. maint M2810 HVAC Gen. Office 26632 Bailer Again Mall 28566 Duct upper level 28355 z Bailer Main Mall _ E1�8/82000 HISC . (A/C DEPT) / 7 _ M20080 ALT �-� y ► `-k Caari Applicant to fill in all spaces within heavy border lines and sign all appropriate declarations. CITY'OF COSTA MESA :4 PERMIT NO: TRACT NO. LOT NO. BLDG. NO. -• - - __. . . . CONSTRUCTION PERMIT �G� ' ' Project Address �> �. 1 3333 B2f5To4- - 5T, -• ^ ? - TYPE OF CONSTRUCT-IJ)N ' ` .-4 2560 2/25/82 s7•fl0 t : - -. - r -TL Owner `a V'r COA-YT' &AIA hone ❑ NEW ❑ ADD RA ALTERATION .-Address- -- ❑ REPAIR. ❑'CONVERSIOty' ❑DEMOLISH - 'ZONINGREGUL-ATIONS -- - - ' ArchlEn . - _ g. -- - • License No. O�O7H£R - I DESCRIPTION OF WORK 0 A -P. -y¢ _ Address - ' - S -5 ZONE - - P_LNG. REF, • ContractotCC.IAF;OZT'CovoeT+ejwr-G Co &30-32XX 2 TYPE OF PERMIT 71QOE6Yk?Pt?INE - -Phone Address I 140 D •- <Yvv+- 3T--. AnJAJ16r ❑ GRADING -- ❑ FOUNDATION ❑ STRUCTURAL - •'Y SETBACK C L ST. SIDE•YARD - - LICENSED CONTRACTOR DECLARATION CA _' ❑ TENANT❑ ELECTRICAL ❑PLUMBING 110MECHANIC LS IME YA I hereby affirm thi t I am licensed under provisions of Charter 9 (Com- - 7000) -of Divlslpn ❑ R G T _ mencing with section- , .3 of the. Business and Professions Code, and _ rn license Is In full force and effect. OTHER REAR'YARD'(TO P/L) Llcenso Class r -. Lic nse o!ZfS �� PROJECT DESCRIPTION ^- -'PKG, SPACE REQ. 'PROVIDED`. Date %2' ;u''�,- fj�.+- Signature _ _ SQ. FT'! -�.. _. - ... _ _ STREET WIDTH �f?ARK'FEE WORKERS' COMPENSATION.OECL R ON a�OCCUPANCY' CONS'1•RUCTION TYPE - ----� - - - 'ZONE ZONING APPROVED BY - = DATE -- ;I hereby affirm that I have a certificate b onsent to self4rnsure or a •' - •• •certificate -of Workers' -Compensation Insurance, or a certified copy ,VALUATION _ -- ----�� :thereof (Section 3800, La4.}- GRADING CU: YDS- ACRES SPECIAL CONDITIONS: r Iicy NoWAR (404• CompanAgEh[s�'P =w+Q ,....rTN- .ertlfied Copy is hereby furnished. . REMARKS• .• ._ 'ertified copy Is filed with the city Building Division. EXEMPTION'FROM WORKERS' COMPP-NSATION-DECLARATION '-` -- - - -^ L - .1 - - ((This,section_need not be- Completed _It lhe.permlt is for one hundred ' r (S100S ar Icss). i f fi certify that In the performance of the work for which this permit Is r- ~ ��ELECTRICAL Issued, 1 shall not employ any person In'eny-manner so as to:become PLUMBING -r` - PLAN CHECK' `-- - � �- PLAN Ci-iECK• subject to the Workers Compensation Laws of California. J ' ' • t - - - Date Signature - -_-- - - BATHTUBS - - SHOWERS"` -' - -� .._ _ SQ. FT NOTICE: It after making this declaration, you should become subject, TOILETS, 1 URINALS - LGENERATOR - 0-1 KW 1-10 KW to the Workers' Compensation provisions of the Labor Code, you must' - TRANSFORMER ++ for comply with such provisions Or this permit Shall be deemed LAVATORIES DOUBLE LAYS -- - - yAPPLIANCE - 10-50 KW_ 50.+ KW revoked. _ ^ _ CONSTRUCTION LENDING AGENCY -" KIT. -SINKS �- - DfSWWASHERS• - - - - - -- MOTORS- - O.1 -HP - 1-10 WP II hereby affirm that there is a construction lending agency for the per- SERVICE SINKS r SUMPS - -- - •- t(INC. SOLAR)__ 10.50 HP 50.tHe, I ' formance of the work for which this permit is Issued (Section 3097 ^ (Lender's FLOOR SINKS- FLOOR'DRAINS " �. -.i FIXTURES - --OUTLETS- - Stry1TCHES �- � _Name _ _ _ Lender's Atltlress - DRINKING FOUNTAINS' ^`�-- ` -- 'GAS TUBE SIGNS -- - - --- - OWNER BUILOER'DECLARRTiON' I hereby affirm that I am exempt from the Contractor's License Law for 'INTERCEPTORS CLARIFIERS "' - POLE LIGHTS -- - -- - -- - -- ` the•following reason (Section 7031.5 13u4iness and Professions Code: Any city or county which requires a permit to Construct, alter, SWIMMING POOL - 'PTRAP - -- - ' POLES- ' -METERED- 'SUB lmprove,'demotish-or-repair any structure, prior to -its issuance, also re-- WATER SERVICEALTERATION - - Y r 'PANELS, - - MAIN SUB -- - quires the ap.ticant for such permit to file a signed statement that he Is licensed pursuant -to the provisions of -the Contractor's License -Law GAS SERVICE OUTLETS - --- f -- SERVICE -- AMP- (Chapter 9 (commencing with Section 7000) of Division 3 of the Business -and Professions -Code) or that he is exempt therefrom -and the- - WATER -HEATERS- BTU'OUTPU.T >L, bags for the alleged exemption. Any violation of Section 7031.5 by z}applicant fora permit subjects the applicant to'a civil penalty SEWER CONNECTIONS—- - ----- ---- - - L'�'° t more than five hundred dollars ($500). ` �• `•as owner of `the property,br'my erhplOyees with wages as the1F -SOLAR TANK- - •--- - COCLECTORS 501¢ Compensation, will do the work, and the structure is not Intended or offered for sale. (Section 7044, BLiSineSs and Professions Code: The 'SOLAR PIPING SYS:-" ` ISSUE -FEE 'Contractor's. License Law does not apply to an owner of a property who builds or improves thereon, and who does'such work himself or ISSUE FEE - - - - " - - ` ` - - rAPPLICATION.APPROVED.BY - _ -DATE - through his own employees, provided that such improvements are not intended w ntended or offered for sale. If, however, the building'or improvement MECHANICAL: PLAN CHECK _ SUMMARY,OF FEES is sold within one year of completion, the owner will have the burden , +��� of proving h¢ did not build or Improve far the purpose of sale). } ❑• the - ,` HEATING SYSTEM 0.1DO,D00 BTU BUILDING - - - - 1 PERMIT $ I. as -owner of- -property, .am exclusively contracting with AND DUCTING DUCTING, licensed contractors to construct the protect (Section 7044, BUSiness I00,000 �. PLAN CHECK $ PERMIT. -Professions Code: -The Contractor's License Law does not apply to _ _ - _ s _ _ _ _ _ _ _ _ISSUANCE__ s .'and an owner of property who builds or improves thereon, and who con- tracts -from Such -projects with a contrattor(s) llcesned pursuant to REFRIGERATION 0.100,000 BTU I SYSTEM PLUMBING S GRADING $,'- the Contractor's License Law). 140,004 + BTU - PLAN CHECK $ } ❑ ram exempt -under Section _ B• a, P. C. for this reason 601LERS BTU -' $ + - ELECTRICAL $ MICROFILM S' ' T - [� SYSTEM REPAI R, ALTERATION 4 � PLAN CHECK $ - - Date Owner �7��7'�r TOTAL FEE•3'•• MECHANICAL $�L I hereby certify that I have read this application and state that the above Information is EXHAUSTSYSTEM MULTIPLE - � n LESS AD - PLAN CHECK correct. I agree to comply with all city- and County ordinances and state laws relating to construction, and hereby authorize $ VANCE PC $ _ representatives of this City to -enter upon the above mentioned propey for , spectlon rpo m rt FINAL FEE Signature r - # G,p $ �L. Drivers' License or ISSUE FEE CMF 0865.46 White-Buittling; Canary -Applicant; Pink -Accounting; Goldenrod -Assessor CONSTRUCTION AND PLANNING / APPROVALS Permit # G.7 Date Inspector POOL &SPA = ',APPROVALS Permit # 'Date Inspector 1. Temporary Electrical Service or Pole 43.Pool &Equipment Location - . Soil.,Pipe-Un rgrn 44. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrn ..45. Forms 4,- Electrical Conduit-Undrgrn 46. Electrical Bonding - 5. -Steel Rem orce - _ _ 47, Rough Plumbing & Pressure Test - 6. -Electrical UFER Grn __ 48. APPROVAL TO COVER-GUNITE 7. Footings 49, Electrical Conduit-Undr rn - •8. Foundation. - _-. 50. -Gas Pipe, 0 Undr rn, Test -9. --Water-Pipe-Undrgrn••-- _ _. _ _ 51. Backwash Lines P-Tra ' ❑ ndr rn' 10: --Structural. Floor.Systern r 52. APPROVAL TO DECK+ -11. - Property -Sewer -Line-& House. Connection 53. Backwash & Receptor -Final ------------ 12. - Street Sewer -Connection " -. - - 54. Heater & Vent -Final -13. Rough Plumbing _ _ �- .. _ - ��.: r 14. Rough Electric -Conduit - - - - --56.- -Electrical-Final 15. Rough Electric -Wiring - - 57. Solar System -Final '16. Rough Heating & Air ConditioningFencing & Access.Approval , 174 Ducts, in Structure APPROVED FOR PLASTERING 1& Ducts, Ventilating 60. POOUSPA SYSTEMS FINAL' 19: Gas Pipe -Rough & Test -- - -- - -- - 20. Roof Framing- raming 21. 21. Roof.Sheathin NOTES: 22:- -Frame and Flashing - 231 nsulation Insulation- 24! 24i Lathing & Siding -- - -- - - 25e OryWali Nailing r -- -- - 26. Plaster Rrown Coat -• -- 27. Electrical Power Meter -Final- 28. Final Electric - 29, Final Heating & Air Conditioning - �2 30.- FinalFGas Pipe -Test , 31. Final. Plumbing 32. Water Service -Final - 33. Gas Service -Final 34. Solar Domestic -Final 35. Landscape Spiinklinq System i 36. Sound Attenuation 37. Handicap Regulations 38. FINAL STRUCTURE & BUILDING 39. Special Requirements Completed 40. Electric Release to Edison-, -' 41. Gas Release to Southern California Gas Co. l 42. CERTIFICATE OF OCCUPANCY NoDate I 2C632 r COSTA MESA BUILDING -SAFETY DEPARTMENT P.O. BOX 1200 COSTA MESA, CALIFORNIA 02620 For Applicant to Ful In Completely TYPE OR PRINT 3333 BRISTOL STREET COSTA MESA. CALIFORNIA TSEGERSTROM r MAIL ^AWN NEER V I C= G8111 N Nom.,.. LIC, NO. 17322 SIZE SETBACK LINA FROM No. OF BLDGS. DESCRIPTION OF WORK EXTERIOR WALL ROOF I COVERING COVE', ORK 1 HIREBY ACKHOWL;DG; THAT.I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVKJS CORRICT AND A42MM 10 COY. PLY WITH ALL'CITY ORDINAN AND WS ■IGULAT G BUILDING CONSTRUCTION. SIGNATURE OF PERMITTB AUTHORIZED AGENT o o n c FEB-3-67CMSAOU 092: :. APPLICATION FOR PERMIT BUILDING For Office Use Only A. w RIGzIPT NO. LPuT32 Rn RI Iv - z =iauso ` sM Bu1LDING ADDR FIRE ZONE TYPE GROUP APPR / 6 BY L DATE j 9 ZONING ZON)� NO. OF Ua; OT NEW/`•- PLANS SVILDING A;DCRIT�ION V A. P. No. NOTE: NO RAVE OVERHANG SHALL BE LESS THAN 30- TO SIDE A REAR P. L. EAVES ALLOWED (U. B. REQUIREMENT) YARDS APPROV YARD APPROVED MAIN BUILD G /ACCESPORY BUILDING (FROM t/L4TR ET) FRONT R. SIDE rr_ PT. L. SIDIK FT. FT. REAR FT. FT. DISTANCE GET. MAIN BI-1302.ACCESS. BET. MAIN BLoas. VAR.* DATE C. APPROVED AFPROv[D � / — DATE w SQ. FT. TH; AMOUNT SHOWN UNDER VALUATION 18 FOR THE PVRPOSI OF iBTABLI¢HING A PERMIT FEE ONLY. VALUATION �ee s �Q o0 PERMIT FEB PLAN CtJ42K TOTAL FEE IF A. w •� COSTA MESA BUILDING- SAFETY DEPARTMENT P.O. BOX 120D COSTA MESA, CALIFORNIA 92620 For Applicant -to Fill In Completely TYPE �Z ,O�R .PRINT' ADDRESS MUTLDINQ '�J tJ1 "s�L <- {-' COSTA /MESA, CALIFORNIA oWNER l dAS-► CLl�'�-A MAIL annRa s� Ap- TEGT TEL NGiNESR - No. S T, . LIG. NO. U �y�Nmo- KI '3 SIZE NO. or BLDOS. OF LOT I' NOW ON LAT SETBACK LINK FROM DISCRIPTION OF WORT( BUILDING NO. OF SIZE ROOMS STOP EXTERIOR WALL ROOF COVERING I COVERING USE OF BUILOING AND WORK TO eE PERFORMED S i fT - K )I t M L I L''A' IHEREBY ACKNOW"DOQ THAT.1 HAVE READ MX APPLICATION AND STATE THAT THE ABOVE,IS CORK CT AND AGREE To COM. PLY WITHALL CITY 1 QB 1WITTS LAWS RSOULATING BUILUIHG CONSTRU O SIGNATURE OF PERM ITTA AUTHORIZED AGENT w i o�0o 541 n ** * **6.00 APPLICATION FOR PERMIT BUILDING For Office Us* Only 7 RECEIPT NO. PE NIT NO. RQCQ O ■ 1�ATQ RQCQIVQD PATK IRSUSO 3 �-/v ^� (' �►� /fes -- eu1LDINa ADDRTi RIR[ ZONE 7YP! GROUP APPROVED By, DATE ZONING ;O� S NO. OF uBE OF NQw PLANS Y BUILDING ( LaGwL. DESCRIPTION L U U {% ri A. P. NO. NOTE: NO SAVE OVERHANG SHALL BE LESS THAN 80' TO BIDE R REAR P. L. EAVES ALLOWED (U. B. % REQUIREMENT) YARDSAPPROVED YARDS APPROVED MAIN BUILDING ACCESSORY BUILDING ( FROM C/L STREET 1 FRONT FT. R. .SID FT. L slow FT rT. REAR FT. FT. DISTANCE BET. BET. MAIN & MAIN BL.DGS. ACCESS. BLOGS. VAR. # DATE C. 1j. P. APPROVED APPROVEDFy J1.1 d ATR 60. FT. THE AMOUNT SHOWN UNDER VALUATION IS FOR THE PURPOSE OF QSTABL.ISHING A PERMIT PEE ONLY. VALUATION /s PERMIT FEE (� TOTAL FEE 7 *. �X'-' " 28355 COSTA MESA BUILDING- SAFETY DEPARTMENT P.O. BOX 1206 COSTA MESA, CALIFORNIA 92M For Applicant -to Fill In Completely -93 "iYP PRINT 1-0-ILDING--'' I[AIt 25.0 652 v*****5.00 APPLICATION FOR PERMIT BUILDING For Office Use Only nuuHuwr vim•+ - RSCYIPT No, COSTA MUSA. LIFORNI RKCtr D SY TYI CEIY DATE Isau CNMIER MAIL ADDR ADDRRS2 FIRE TYP �Q G1TY O ZONE GROUP —NT11O. 'HITECT TEI� , ! L-4 N2. AYPROVRP �pATB Gl�- NG]NEER � �� SAS✓ �E`�,ea �% � � l� ZONING wflnsa.Eaa ZONE Aft NO. Or PLANS O USY OP NEW r 9UILDINO J STC S CONTRA R a i C C/}/s1 LaowL DKYCRIPnoN ADDIi ��// eel A. P. NO. O d J� CITY j NOTE: NO EAVE OVERHANG &HALL B8 LESS THAN STATE Ljy/ '�jy�� SO' TO SID$ R R$AR . L- C, NO.. EAVES LLOWED (U. B. C. REOUIRBMSNT) SIZE I (� b NO, OF SLDos. OF LOT f NOW ON LOT YARDSAPPROVED YARDS APPROVED USE OF Uam O NG B 1' MAIN BUILDING ACCESSORY BUILDING (FROM STREET) 96TBACK LINK FROM CENTER OP 8. R REAR YARIP FR NT FT. SID Y R LlSFT RIGHT R. ID FT. RESCRIPTION OF WORK 91D FT. FT. ALTERATION ADDITION REAR FT. FT. DISTANCB DBT. SET. MAIN a [SIZE EPAIR ?LOVING DBMOLISH MAIN BLDGa.ACCESS. BLOCS. UILDING NO.OF VAR•# DATB ROOMS RI C. APPROVED EXTERIOR WALL. ROOF APPROVED Q � COVERING COVERING DATB 6 USE OF BUILDING AND WORK TO SE PERFORMYQ ,V 57A 4LA7i aiJLE�?�2ie_ Q 1 NKRtDY ACKNOWLSDG* TNAT.I HAYS READ TWIS A►PLICATION THY AMOUNT SHOWN UNDER VALUATION 19 FOR THS AND BTATK THAT THS A1)OYS .IB CORRECT AND AOREY TO COM. PURPOSE OF YSTA6LIaHINO A PERMIT FEY ONLY. PLY WITH ALL CITY ORD ?1A1ICES AN TE LA REGULATING BUILDINOCONSTRUCTI VALUATION e SIGNATURE OF PERMITTB PERMIT FEE O� S TOTAL FEB___. _ AUTHORIZED AGENT ADDRESS OF BUILDOW: 3333 BRISTOL ST OWNER'S WEIFDIONN: C.J. SEGERSTROM & SONS ADDRESS. 3315 FAIRVIEW RD COSTA MESA 7A 92626 (714)546-0110 APPL. NAILING ADDRESS: ARCHITECT OR ENGINEER: uC. NO.: ARCH. OR ENG.'S ADDRESS: CONTIIACTOR's NAME: CONTRACTORS MAILM ADDRESS: UC. NO.: UHT: UNIT: UNIT: LICENSED CONTRACTORS DECLARATION: I hereby affirm under penalty d per[tay d1N I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and afred. C1rr LIC. NO.: LIC. Class: LIC. NO.: EXP: Date: Contractor OWNER BUILDER DECLARATION: I hereby affirm under penally Of Perjury that I am exempt from the Contractors License Law for the `' Iowing reason (Sedion 7031.5 Business and Professions Cade: Any city or county which requires a permit to construct, char, improve. imolish. or repair any stricture, prior to its issuance, also requires the apprrcara for such pwmd to file a signed statemeir l that he or she licensed pursuant to the pravisiars of the Contractors License Law [Chapter 9 (commanrag wbh Section 7000) of Division 3 of the Business and Professions Code] or that he or she is exempt therefrom and the basis for the a0agad exemption. Any violation of Section 7031.5 by any applicant for a Permit subjects the apprranl to a civil penshy of not more than We hundred dollars [5500[1. i f, as owner of the property or my amplvyses with wages as their ode compensation, will do the woric, and the structure is not intended or offered for sale (Section 7044. Business and Professions Code: The Contractors License Law does not apply to an owner of property who buds or improves thereon, and who does such work himself or herself or Ncough tris or her own employees, provided that such improvements are not intended or offered for sale. lf, howarar, the building or improvement is sold within one year of completion, the owner -builder will have the burden d proving he or she did rd build or improve for the purpose of safe). Q 1. as owner of the property, am exclusively oontrad6g with licensed c:oraractors so cagtnrd the project (Section 7044. Business and Professions Code: The Cantnsaors License Law does not apply to an owner of pmperry who builds or improves thereon and who contracts for such projects with a codrador(s) licensed pursuant to the Contractors Licanse Law). ❑ empt der Section: B. 5 P.C., for this reason: Is:/ Owner: I reby certify that I am aware d and understand the requi ens of California Health and Safety Code Sedia a 25505, 25533, and 25 ,and that I or eery haure huildirg oonxrpem vol$! will not (circle ane) need to oomph with said stats codes end the requirements for a permit forcorstruction or modification from the AF use ty ma t Dmtrid. Residomid m uvn-idm eppfratiorsare exempt from these provisions. Date: Applicant: WORKER'S COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one d the following declarations: ❑1 have and will maintaina certificated consent to selfdnsuro for workers' compensation, as provided for by Section 3700 d the Labor Code, for the maintain of oe work for which this permit is Issued. ❑ I have and will maintain worker.' compnrsallon insurance. as required by Section =of the Labor Cade, for the perfarmarba of the work for which this permit is issued, My workers' compensation insurance carrier and policy number are: Carrier: STATE Policy Number. (This section need not be completed I the poemil is lar ars hundred ddtars f$ roof or resit) © I certify Net in the pedonnence of the work kc which this permh is issued, I shall not employ any person in any manner so as to become subjed to the workers' compensation laws d California. and agree them d I should beeerne subject to the workers' compensation provisions d Sedion 3700 of the Labor Cods, I shah forthwith comply with those provisions. Owe: Applicant: Wamrlrp: Failure to ascan workerr comre nation eoverays Is unlawful. and shaft arefeer an employer ro criminal peraltisa and clv11 Urea rip to ons hundred thouasnd dollars ($100,0001 In &"don to the coir of compentsarlon, darning" as provfded for In Section 3706 of time Labor Code, Intens!, and atromreys feu. CONSTRUCTION LENDING AGENCY: i hereby affirm under peneity d perjury that there is a construction lending agency for the pedormanoe d the work for which this permit is issued (Section 3097, Civ. Q. LENDER'S NAME: LENDER'S ADDRESS: I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction end hereby authorize representatives of this city to anter upon the above-mentioned properly for inspection purposes. JACK MOHL Pnnt Name 4 Date: g 6 P Signature d AppicanVQonirattor (6151-46.wP) whha-W5d1n9 a Safety: Green -le: cane ppkara: Pink -Revenue: Goldenmd-Assesw CITY OF COSTA MESA - BUILDING PERMIT PERM NO: E 0740581 PERMIT NO: E 074058 PLAN CHECK NO: N GOVT: N SUPP: N CONSTRUCTION TYPE: IFR SP PERMIT TYPE: ELE PURPOSE: ALT JOB DESCRIPTION : ELECTRIC WATER HEATER AT LOADING DOCK A SQ FT: CLAIM VALUE: CALC--VALUE : GROUP OCC: B-2 / COMMENTS: LEGALIZE WORKAT LOADING DOCK A �**�+F*+I'���*�i��t�E��tt��E�EiE1E��E��iFaE�-1E*�+�3EiEi�->E*iE�EiE���E*�E�aE��*�aE3E1E*iE3Ei���eE3E���+�iEiE�i��E����ii•�r Z 0 N I N G R E Q U I R E M E N T S S E T B A C K S ------------ MAIN BUILDING ---------- --------- ACCESSORY BUILDING------____- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RIGHT: FT IN PARKING RES: PROV: PARCEL: 41250102.ZNE: REF NO: PLANNING N TES> �E iE iE iE iE iE iE ill- iE;E iE * iE iE iE iE iE iE iF iF � iE iE BE iE iE �f iE iF fE iE iF iE iF iE iE �E iE iE iE iF iE # iE iE -?(dE $E -)E � FE'lE iE 9E 3E iE �E iF iE it• }F }t= }F iE iE iE iE jE iE iE * �E iE iF jF iE iE'iE iE D E V E L O P M E N T S E•R V I C E S R E Q U I R E M E N T S ZONING APPROVED BY DATE: BUILDING APPROVED BY DATE: APPLICATION ISSUED BY: DATE: U ) iE -)F iF �E'1f �E dE � !E ♦E iE 4E iE * * * iE ilii 9E it iE 9E _ � iE iE iE jf IE If 4E 1F'YE iE iF �E LEGALIZATION:N F E E, S U M M A R Y STRUCTURALS GM NT:N � I BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT 29.50 50% SMIP/NON-RES PLAN ISSUE FEE 15.00 BUILDING -DIV-> PERMIT ISSUE PLAN -CHECK TOTAL PAID DUE TOTALS ---- > 29.50 15.00 0.00 44.50 44.50 .00 REVENUE DIVISION TOTALS--> COLLECTED: 44.50 OVER/SHORT: .00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN -CHECK 44.50 -IE'1E'IE -1E )E it• IE iE iE iE iE * * iE �E iF iE iE iE 1F iE iE � �E if iE iE iE iF 4E �E if dE iE iE �E iE iE -If iE iE iE �E 3E iE i6 iE 9E IE * fE iE 3E IE iE iE )E iE iE 14 IE iE �E iE if iE iE iE -IE * * iE dE � � iE�E i4iE I N D I V I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST ELE 1 MOTOR/POWR APPARATUS 1.1 - 10.0 HP 7.50 7.50 ELE 1 MISC APPARATUS NOT LISTED REQ PERMIT 11.00 11.00 ELE 1 MISC CONDUIT NOT LISTED REQ PERMIT 11.00 11.00 END OF FEES 01 0018941-00189641. TOT 4.4.50 0t1Tc_o 09eQ61?5 TIh€r: 11:45 - CONSTRUCTION AND PLANNINGPOG APPROVALS Permit # Date Inspector , SPA APPROVALS Permit # Date Inspector 1, Temporary Electrical Service or Pole 52. Pool & Equipment Location 2. Soil Pipe•Undrgrnd. 53. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. 54. Forms 4, Electrical Conduit-Undrgrnd. 55. Electrical Bonding 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6. Electrical LIFER Grnd. 57. APPROVAL TO COVER-GUNITE 7. Footings 58. Electrical Conduit-Undrgrnd, B. Foundation 59. Gas Pipe, 0 Undrgrnd., Test 9. Water Pipe-Undrgrnd, 60. Backwash Lines, P -Trap, 0 Undrgrnd. 10, Structural Floor System i 61. APPROVAL TO DECK .� 11. Property Sewer Line & House Connection 62. Backwash & Receptor -Final ' 12. Sewer Cap 63. Heaier & Vent -Final 13. Roof Drains 64. Plumbing System • Final 14. Rough Plumbing 65. Electrical -Final. 15. Rough Electrical -Conduit ', 66, Solar System -Final 16. Rough Electric Wiring -s 67. Fencing & Access Approval 17. Rough Wiring Sign 68. APPROVED FOR PLASTERING 18. Rough Electrical -T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit # 20, Rough Factory Fireplace 21. •Ducts, in Structure, 70. Underground Hydro 22. Ducts, Ventilating 71. Product Piping 0 Gas 000 23. Gas Pipe -Rough & Test 72. Underground Flush 24. Roof Framing 73. Undergrnd, Storage Tank 0 Gas 0 Oil 25, Roof Sheathing 74. Overhead Hydro 26, T -Bar Ceiling {Structural) & Monocoat 75. Dry Chemical 27. Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding SYSTEM FINAL 28. InsulationFIRE r77.FIXED PREV. FINAL 30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat .FINAL INSPECTION 32, Electrical Power Meter -Final P^. FOOD CERTIFICATE ISSUED 33. Pinal Electric l�,� • /P , �Eo s: 34, Final Heating & Air Conditioning 35. Final Gas Pipe -Test , 36. Hood or Canopy 37, Final Factory Fireplace T 38. Final Plumbing 39. Water Service -Final , 40, Gas Service -Final 41. Solar Oomestic•Finai 42. Backflow Preventer 43. Backflow Irrigation 44. Landscape Irrigation System 45, Sound Attenuation 46. Handicap,Regulations 47. FINAL STRUCTURE & BUILDING 48. FINAI_ PLANNING - ~ 49. Electric Release to Edison 50. Gas Release to Southern California Gas Co ~ ' 51. CERTIFICATE OF OCCUPANCY No. Date F262 ELOM: 3333 BRISTOL ST UNIT: aon: C.J, SEGERSTROM & SONS DBEs:3315 FAIRVIEW RD COSTA MESA.,6 (714)546-0110 ADPL. MAILING ADDRESS: ARCHITECT OR ENGINEER: UC. NO.: ARCH. OR ENW5 ADDRESS: UNIT: CONTRACTOR'S NAME: CONTRACTOR'S MAILING ADORES& UC. 1X1.: UIUT: LICENSED CONTRACTORS DECLARATION: I hereby affirm under penalty of perjury that I am licensed miler provisions of Chapter 9 (oommencing with Section 7000E of Division 3 of the Business and Professions Cada, and my license is in full force and erred. CITY LIC. NO.: LIC. CLASS: LIC. NO.: EXP: Dare: Contractor: OWNER BUILDER DECLARATION: I hereby affirm under penalty of perjury that I am exempt from the Contractors License Law for the following reason (Section 70315 Business and Professions Code: Any city or county which requires a permit to oonstrncl. aper, improve, vnolish, or repair any structure, prior to its issuance, also requires the applicam for such permit to file a signed statement that he or she licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (camma>ting with Section 7000) of Division 3 of the jusiness and Prolesaforts Code) or that he or she is exempt therefrom and IM basis for the aleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dopers )SSOO)). i I, as owner of the property or my employees with wages as that we oompensarion, will do the work, end the stnucture is not intended or offered for safe (Section 7044, Business and Professions Code: The Contractors Liomee Law does nor apply to an owner of property who bulds or improm Thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. p, however, the building or improvement is sold within one year of oompetion, the owner -builder will have the burden of proving he or she did not build or improve for the purpose of este). I, as owner of the property, am exclusively contracting with hicenaed contractus to construct the project (Section 7044, Business and Professions Code: The Contractors license Law does not apply to an owner d property who builds and or improves thereon awho contracts for such projeds with a contractor(s) licensed pursuant to The Contractors Liomse Lew). I am exerrilit /under ITS B. 6 P.C., for th' . / Ower: _ I do hereby certify A i am aware of and understand the requ ements of California Health and Safety O"i" 25505. 25533. and 25534, and Thal I or arty future building o=Wt will 1 will not (circle one) need to comply with said slate oodes and the requirements for a permit for construction or modification from the Air uua nay m-agemenr District. Residential oonstrudion appicariom am exempt from these provisions. Date: Appfirmi: WORKER'S COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of tfro following declarations; ❑ 1 have and will maintain a certificate of mneenl to self -insure for workers' compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have end will maintain workers' compensation insurance, as required by Section 3700 d the Labor Code, for the performance of the wok for which this permit is issued. My workers'S ,P.eAsall T E insurance carrier and policy number ere: Carder: 1 Policy Number: ibis section need not be completed I rhe pmrik is for one hundred dollars 157001 or bsa.J I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject 10 the workers' compensation laws of California, and agree that it f should become subjed to the woken' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with thorn provisions. Date: Applicant: Weming: Fsllure to secure woiksra' compens idon coverage is unfswfuir and shall subject an @nWloyw to criftnat panalliss and civil fines tfP to one hundred thousand dollars (SI'OQOOO), ht addltten to the cost of conWonsefior4 damages as provldod for in Section 3708 of the Labor Cods, lntsmst, and attomey's to". CONSTRUCTION LENDING AGENCY: I hereby affirm under penally of perjury that (hare A a mnstnrction lending agency for the performance of the work for which this permil is issued (Section 3097, Cir. C). LENDER'S NAME: LENDER'S ADDRESS: I certify that I have read this application and state that the above information is cored. I agree to comply with all city and county ordinances and stale laws relating to building construction and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. JACK MOHL (5151-I&WP) Whiie-Building & Safety: Green -File; Canary-Applieant; Pink-Rovenue: Gokfenrod-Assessor CITY OF COSTA MESA — BUILDING PERMIT PERM NO: P 074059 PERMIT NO: P 074059 PLAN CHECK NO: N GOVT: N SUPP: N CONSTRUCTION TYPE: 1FR SP PERMIT TYPE: PLU PURPOSE: ALT JOB DESCRIPTION : ELECTRIC WATER HEATER AT LOADING DOCK A SQ FT: CLAIM VALUE: CALC—VALUE: GROUP OCC: B-2 / COMMENTS: LEGALIZE WORK AT LOADING DOCK A ♦E �'lE � f4 iE � * �lE iF iE iE'1E � !h iE � 9E ?✓E 9F � 9E �E'lE 'IE• * �E if�'IE � � iF �E � iE iE iE -)E �F iE iF * iF 9E iE * � iE �E i[• � iE iE �)k iE iF -)(• iE 9E iE iE iE iF dE iE � iE iE iE IF FE iE iE * * � Z 0 N I N G R E Q U I R E M E N T S S E T B A C K S ------------ MAIN BUILDING ---------- --------- ACCESSORY BUILDING--------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN PARKING REQ: PROV: PARCEL: 41250102 ZNE: REF NO: PLANNING NOTES> �iE•dE*iEfEiEieiEiE��[•�*�*iEitiEiEiEiEiE*iEfEiF�EiE�i6�����**die•it•�iEiEiE*�*i4��Eitit*iFiE-IEiF��iE�fEfEiE��E�E�E�iE��3EJE->4�E�* D E V E L O P M E N T S E R V I C E S R E Q U I R E M E N T S ZONING APPROVED BY DATE: BUILDING APPROVED BY ; DATE: APPLICATION ISSUED BY: DATE: 1r LEGALIZATION:Y F E E S U M M A R Y STRUCTURAL SEGMENT:N r BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT 28,00 25% SMIP/NON—RES PLAN ISSUE FEE 20.00 BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE TOTALS ---- > 28.00 20.00 0.00 48.00 48.00 .00 REVENUE DIVISION TOTALS--> COLLECTED: 48.00 OVER/SHORT: .00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK 48.00 iE iE BE �E 3E * iE dE �E iE iE iE'lE iE'FE iL- �E iE )E iE iF �F iE 1E 1(- iE iF �E iE 1E iE i6 iE iE iE iE iE �E 9E )E )(- iE iE �F �E �E iE iE �E iF * Ji- �E iF iE iF �E iF iF iE �E �(- dE iE iE iE * jE �E i6 i(• iF � -IE -IF �r iE iE if - I N D I V I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST PLU 1 WATER HEATER AND/OR VENT 7,00 7.00 PLU 1 FIXTURE SET/TRAP W/PIPING & BACKFLOW 7.00 7.00 END OF FEES 0f. E�Q389b40-r7g1E9d40 TINT 48.09 DATE: 09106195 TIME: 11:44 AND PLANNING SOats OYALS Permit # F�Temporary ,�; PQO InspectTRUCTION or SPA APPROVALS Permit # Date Enfpecior Electrical Service or Pole , 52. Pool & Equipment Location l Pipe-Undrgrnd. 53. Steel Reinforcement r 3. Electrical Conduit Utility•Uhdrgrnd. 54. Forms 4, Electrical Conduit-Undrgrnd. 55, Electrical Bonding 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6. Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE ; 7. Footings 58. Electrical Conduit-Undrgrnd. 8'.. Foundation 59. Gas Pipe, 0 Undrgrnd., Test 9, Water Pipe-Undrgrnd. 60. Backwash Lines, P -Trap, ❑ Undrgrnd. 10. Structural Floor System - 61. APPROVAL TO DECK 11. Property Sewer Line & House Connection 62. Backwash & Receptor -Final 12; Sewer Cap 63, Heater 8t Vent -Final 13. Roof Drains 64. Plumbing System . Final 14. Rough Plumbing % .' 65. Electrical -Final 15. Rough Electrical -Conduit 66. Solar System -f=inal 16, Rough Electric Wiring 67, Fencing & Access Approval 17. Rough Wiring Sign 68, APPROVED FOR PLASTERING ) 18. Rough Electrical•T Sar Ceiling 6g. POOL/SPA SYSTEMS FINAL 19, Rough Heating & Air Conditioning ,. FERF, DEPT. REQUIREMENT APPROVALS Permit # 20, -Rough Factory Fireplace 21. Ducts, in Structure 70, Underground Hydro 22. Ducts, Ventilating 71. Product Piping C1 Gas ©ail .23. Gas Pipe -Rough & Test 72. Underground Flush 24. Roof Framing 73. Undergrnd. Storage Tank D Gas © Oil 25. Roof Sheathing 74. Overhead Hydra 26. T -Bar Ceiling (Structural) & Monocoat 75, Dry Chemical 27. Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding r 77. FIXED SYSTEM FINAL 29. Insulation 78, FIRE PREY. FINAL 30, Drywall Nailing - HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat 79, FINAL INSPECTION 32. Electrical Power Meter -Final 80. FOOD CERTIFICATE ISSUED 33. Final Electric Notes: 34. Final Heating & Air Conditioning _ /j , %Q --� YiN LCL - 35. Final Gas Pipe -Test 36. Hood or Canopy 37. Final Factory Fireplace 38. Final Plumbing - 39. Water Service -Final 40. Gas Service -Final , 41. Solar Domestic -Final 42, Backflow Preventer 43. Backflow Irrigation 44. Landscape Irrigation System 45. Sound Attenuation ` 46. Handicap Regulations ` , 47. FINAL STRUCTURE & BUILDING 48, FINAL PLANNING 49. Electric Release to Edison 50. Gas Release to Southern California Gas Co f . 51. CERTIFICATE OF OCCUPANCY No. Date F —�J 4 Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarati_ons. CITY OF COSTA MES ONSTRUCTION P RM03ePER T NO. TRACT NO. LOT NO. UNIT O. Project Address 33 Applicant's Mailing Address Owner's Name d k Phone 2 qi -!?r) Address A4 Z_ Arch/Eng. License No. Address Contractor's Name F -GT Phone i Address (mailirig) LTZ City License No. LICENSED CONTRACTOR DECLARATION I hereby affirm that I am licensed under provisions of Charter 9 (commencing with section 7000) of Division 3 of the Business and Professions Code, and my license is in fulIV,ce and effect. License Clas 1� t LI, se o.Z37 g%� Signature `- WOR•KERS' COMPENSATION DECLARATION , I hereby affirm that I have a certificate of consent to self -insure or a certificate of Workers' Compensation7.'IIn�surance, or a certified 1copy-thereof (Section Lab. `. Po800Y No. � g0�1{�P .�`t Company l2 AJ ]_ Certified copy is hereby furnished. rtif' tl cop ' Is i d with the city Buildin Ivision. Date.,,. r !�Applicant _ EXEMPTION FROM WORKERS' COMPENSATION DECLARATION (This section need not be completed if the permit Is for one hundred ($100) or less). - - I certify. that in the performance of the work for which this permit is Issued I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California. Date Signature 'NOTICE: If, after making this declaration, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall . be deemed revoked. CONSTRUCTION LENDING AGENCY 1 hereby, affirm that there is a construction lending agency for the performance of the work for which this permit is Issued (Section 3097 Civ. C.) Lender'i Name Lender's Address OWNER BUILDER DECLARATION ' I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5 Business and Professional Code: Any city or county which requires a permit to construct, alter, improve, demolish or repair any structure, prior to' its issuance, also requires the applicant for.such permit to file a signed statement that he/she is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he/she is exempt , therefrom antl the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty ofnot more than five hundred dollars ($500). ❑ 1, as owner of the property or my employees with wages as their sole compensation, will do the work, and the'structure is not Intended or offered for sale (Section 7044, Business and Professional Code: The Contractor's' License' Law does not apply to an owner of a property who builds or improves thereon, and who does such work himself/herself or through his or her own employees, provided that such,lmprovements are not intended or offered for sale. If,�however, the building or Improvement is sold within one year of com- pletlon, the owner will have the burden of proving he/she did not build or im- prove for the purpose of sale). ❑ 1, as owner of the property, am exclusively contracting with licensed con- tractors to construct the project (Section 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and _who contracts for such projects with a con- tractor(s) license pursuant*to'tha Contractor's License Law). I am aware that proof of their Worker:s Compensation insurance should be provided to me, ❑ I am exempt under Section B. & P. C. for this reason Date Owner I hereby certify that I have read this application and state that the above information is -correct. t agree to comply with all city and county ordinances and state taws relating to bUiljljng construction, and hereby authorize repre- sentatives of this 4Cityq��the above-mentioned ,property forinspection purposesrSignature Date_ 7 _�Drivers' License or 1 on TYtEEpF CONSTRUCTION NEW ADD ALTERATION REPAIR " ' VICONVERSION ❑ DEMOLISH ❑ OTHER A.P. # DESCRIPTION OF'WORKIUSE OF BLDG. Sewer Connection Clarifiers - S Main Building: TYPE OF PERMIT GRADING FOUNDATION STRUCTURAL T Front D TENANT ^ ELECTRICAL ❑ PLUMBING ❑ MECHANICAL B Urinal ❑ ,OTHER A Rear PROJECT DESCRIPTION SQ. FT. OCCUPANCY C Right CONSTRUCTION'TVPE VALUATION $ S I Left ZONE GRADING CU.YDS. ACRES Ping. Ref.+ Remarks: ' ��.` '.--� £ 2 /. /'pv Planning Notes: 2 cess 7-4 Issue Fee r Bar Sink PLUMBING Showers Backflow Preventer Service Sink Backflow Irrigation Sewer Cap Bathtubs Sewer Connection Clarifiers Solar Collectors Dishwasher Solar Piping Drinking Fountains Solar Tank Floor Drains Swimming Pool vv/Spa Floor Sinks Urinal Gas Service Outlets Water Closet Interceptors r Water Heater Kitchen Sink Water Service Lavatories P—Trap Auto -Wash Laundry Trays Roof Drains Reinspection Fee $15 Issue Fee r . j 7 Boiler Duct - Under Ground ' Duct - Structural Duct - Ventilating Exhaust System ❑ Multiple ❑ Firepl/Fact: Blt. ICBO * Heating System & Ducting ❑0-100,000 BTU ❑100,000 BT' I Reinspection Fee 1 $15 CMF 0865-46, rev. 10/84 White - Building; Canary - Applicant; Pink - Accounting; Goldenrod - Assessor Hood or Type 1 ❑ Canopy Type II ❑ Refrigeration System E10-1 00,600 BTU 1E] 100,000 BTU System Repair/Alteration Fire Dampers Registers issue Fee 2526 5/07/s� Zone Accessory Building: Z O N N G R Parking Req./Provided E _ Q M T' S FEES ELECTRICAL FEES 1 1 . Automatic Washer !.Transformer. ❑ 15-50.KW - - Construction Pole Sub. ❑ 50+ KW Reinspection Fee Cooking Unit Meter ❑up to 100amps Dishwasher Meter ❑over 100 amps FEES Dryers ❑Gas ❑Electric Sub Panel Fan Motors 00-1 HP D1% ; 6 F.A.U. , Inc. Solar El 92115 HPk16-15+ (p Date ' Date Dat _ Fixtures Microwave I Device Boxes Pole Light Z SUMMARY OF FEES $ $ $ $ $ $ Outlets Range. ! Switches Sign r Garbage Disposal ; Standing Sections Generator ❑0-5 KW ❑5-15 KW Trash Compactor ' $ 3 1 1 1 . Reinspection Fee $15 Issue Fee $ 3 FEES QEVELOPMENTSERVICESREOUIREMENTS: Zoning Approved By Building Approved By Application Issued By _ • Date ' Date Dat _ BUILDING PERMIT PLAN CHECK PLUMBING PLAN CHECK 25% ELECTRICAL PLAN CHECK 50% MECHANICAL PLAN CHECK 25% SUMMARY OF FEES $ $ $ $ $ $ SMIP $ ; PERMIT ISSUANCE $ ENERGY P.C. $ GRADING $ MICROFILM $ TOTALFEE $ o_ o $ 3 CONSTRUCTION AND PLANNING- APPROVALS Permit # Date Inspector POOL & S. r. APPROVALS Permit # Date Inspector 1. Temporary Electrical Service or Pole 52. Pool' & Equipment Location 2. Soil Pipe-Undrgrnd. 53, Steel Reinforcement 3'. Electrical Conduit Utility-Undrgrnd." 54, Forms J4;, Electrical Conduit-Undrgrnd. 55. Electrical Bonding „5. Steel Reinforcement 56. Rough Plumbing & Pressure Test t 6• Electrical UFER Grnd. 57, APPROVAL TO COVER-GUNITE '. 7. Footings 58. Electrical Conduit-Undrgrnd, j 8. Foundation I 59. Gas Pipe, ❑ Undrgrnd„ Test 9..Watgr Pipe-Undrgrnd. 60. Backwash Lines, P -Trap, D Undrgrnd. 10 -..Structural Floor System 61. APPROVAL TO DECK .11.' Property Sewer- Line & House Connection62. f Backwash &Receptor -Final .12. Sewer Cap 63. Heater & Vent -Final 1 i Roof Drains 64. Plumbing System - Final _ 14. Rough Plumbing 65. Electrical -Final 15. hough Electrical -Conduit 66. Solar System -Final 16. Rough Electric Wiring 67. Fencing & Access Approval 17. Rough Wiring Sign 68. APPROVED FOR PLASTERING 18. Rough Electrical -T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating &Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit # 20. Rough Factory Fireplace 21. Ducts, in Structure 70. Underground Hydro 22. Ducts, Ventilating 71. Product Piping ❑ Gas ❑ Oil 23. Gas Pipe -Rough & Test 72. Underground Flush ' 24. Roof Framing ,. �r 73. Undergrnd. Storage Tank D Gas ❑ Oil 25. Roof Sheathing 74, Overhead Hydro 26. T -Bar Ceiling (Structural) & Monocoat 75. Dry Chemical 27. Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding . 77. FIXED SYSTEM FINAL 29. Insulation 78. FIRE PREV. FINAL 30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat 79. FINAL INSPECTION 32. Electrical Power Meter -Final 80. FOOD CERTIFICATE ISSUED 33. Final Electric Notes, 34. Final Heating & Air Conditioning 35. Final -Gas Pipe -Test 36. Hood or Canopy 37, Final Factory Fireplace 38. Final Plumbing 39. Wa#er Service - Final 40, Gas Service -Final ' 41. Solar Domestic -Final ' 42• Backflow Preventer 1 43. Backflow Irrigation 44. .Landscape Irrigation System 45. Sound Attenuatiob 46. Handicap Regulations 47, FINAL STRUCTURE & BUILDING 48. Special Requirements Completed 49, Electric Release to Edison _ 50. Gas Release to Southern California Gas Co I t 51. CERTIFICATE OF OCCUPANCY- o. Date Applicant to fill in all spaces those within heavy border line aeq ri all appropriate declarations. , r CITY OF COSTA MESA . CONSTRUCTION PERMIT PERMi; TRACT NO. LOT NO. UNIT NO. r ,( ___ , ilV1 ` 9406- 3/15/85 IQa0" l f� .Project Addr .: r ismL - � . ` , n (i i ' - TYPE OF CONSTRUCTION NEW ADD, ALTERATION REPAIR Applicant's Mailing Address ,ST /Il'j ❑ Cl DEMOLISH ❑OTHER Owner's Name S�rP� Phone CONVERSION . q p #' Zone DESCRIPTION OF WORK/US OF BSD Address C.L S Main Building: Accessory.Building: - Arch/Eng. License No. TYPE OF PERMIT GRADING OUNDATION ❑ STRUCTURAL T Front p ❑ TENANT• ❑ ELECTRICAL ❑ PLUMBING MECHANICAL g r N Address ,' crar^7.40/yT yldma41/4)a - - I}flsi ❑ OTHER A Rear Contractor's Name— r, Phone • A�•L PROJECT DESCRIPTION 54. FT. OCCUPANCY C_ Right N Address Imailingl �Jy� I`EY� '•,/Tti'�If �'7 K G i! U - CONSTRUCTION TYPE - VALUATION $ ' S Left' R City License No.� ZONE GRADING CU.YOS. ACRES I w Ping. Ret. # Parking Req./Provided E LICENSED CONTRACTOR DECLARATION Q Thereby affirm that '1 am licensed under provisions of Charter 9 (commencing Remarks:Planning t C•\��� Notes: M with section 7000) of Division 3, of the Business and Professions Code, and 1 T my license is In full lQrcp and. effect. TO ' 1 I S License Class se No'2451 Date -s- ' Slgnatuce . Iax _ _ ___ I I I PLUMBING FEES I l ' WORKERS' COMPENSATION DECLARATION Bar Sink Showers ELECTRICAL FEES I hereby affirm that I have a certificate of consent to self -insure or a certificate , of Workers' Compensation tnsurance,.or a certified'Copy thereof (Section BackflowPreventer - Service Sink Automatic Washer Transformer ❑ 15-50 KV11 3800, La!?. r %y�/ i%T- ❑ 50'+ KW Policy Nri Company1516?h __ ' Backflow Irrigation Sewer CapConstruction Pole Sub.• ' Certified copy is hereby furnished. + Ce ifi is filed with the city vis' �•� +• Bathtubs Sewer Connection Cooking Unit � Meter ❑up to 100 amps' _cc Date �'-s -' Applicant EXEMPTION -FROM WORKES' COMPENSATION DECL ATION R Clarifiers Solar Collectors M . - Dishwasher I _ Meter Dover 100 amps.__ - (This section need not be completed if the permit is for,one hundred ($100) or"w less), Dishwasher Solar Piping ' Dryers ❑Gas . ❑Electric Sub Panel I certify that in the performance of the work for which this permit is Issued, I shall not', any in any manner so as to become subject to the Drinking Fountain's 1 Solar , employ person Workers' Compensation, Laws of California. Tank Fant Motors El 0-1 HP 0 Y - 8 Date Signature Floor Drains Swimming Pool vv/Spa v F.A.U. Inc. Solar 09-15 HP 1:116-15+ NOTICE: If, after making this declaration, you should -become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith Floor SinksUrinal = Fixtures Microwave comply with such provisions or this permit shall be deemed, revoked. , CONSTRUCTION LENDING AGENCY ' Gas Service' _Outlets Water Closet - Device Boxes Pole Light g ' I hereby affirm that there is a construction lending agency for the performance of the work forwbichr�is permit Is Issued (Section 3097 Civ. CJ - Interceptors - Water Heater, -, Outlets Range Lender's Name T _ I - Lender's Address '77— Kitchen Sink Water Service Switches Sign OWNER BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the Lavatories Auto -Wash Garbage Disposal !.Standing Sections 1 ' following r-eason (Section 7031:5 Business and Professional'Code: Any city or county which requires a permit to construct, alter, improve, demolish or repair P—Trap Laundry Trays i = Generator E10-5 KW ❑5-15 KW Trash Compactor p any structure; prior to its issuance, also requires the applicant for such permit 'to file a signed statement that he/she is licensed pursuant to the provisions of. •' - Roof Dralns + I the Contractor's License Law (Chapter 9 (commencing with Section 7000) of ) Division 3 of the Business and professions Code) or that he/she is exempt -, a 'herefrom and the basis for the alleged exemption. Any violation -of Section ' r,� ;031.5 by any. applicant for- a permit subjects the applicant to a civil - fyalty of not more than five hundred dollars ($500)• " `Reinspection $ 3 ' u I, as owner of, the Iproperty or my employees with wages as their sole Fee ,$15 Issue Fee•, compensation, will do the work, and the structure is not intended or offered Reinspection Fee $15 Issue Fee $ 3. for satee(Section 7044. Business and, Professional Code: The Contractor's '. MECHANICAL FEES License Law does not apply to an owner of a property who'builds or improves thereon, and who does such work himself/herself or through his or her own- for Boiler , Hood or Type I F-1 DEVELOPMENT SERVICES REQUIREMENTS: ' employees, provided that such improvements are not intended or offered sale. If, however, the building or improvement is sold within one year of com- - Canopy Type I I' ❑ Zoning Approved By Date pletion, the owner will have the burden of proving he/she did not build or im- Duct - Under,Ground " , ' Building Approved B 9 PP y Date • prove fpr the purpose of sale). I • I ❑ I, as owner of the property, am exclusively contracting with licensed con- Duct - Structural Refrigeration System] r ra:7 Application Issued By Dat tractors to construct the project (Section 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of who ®0-100,000 BTU iQ property builds or improves thereon, and' who contracts for such projects with a con- Duct - Ventilating - .❑100,000 -BTU - _ SUMMARY OF. FEES + tractor(.) license pursuant to'the-Contractoi's License Law). I am aware that Exhaust System ❑ Multiple ❑ System Repair/Alteration BUILDING PERMIT $ SMIP $ proof of their Worker's Compensation insurance should be provided to me. , ❑ I am exempt untler Section B. & P. C. for this reason Firepl/Fact.8lt. ICBG # Fire Dampers PIAN CHECK $ PERMIT ' ISSUANCE $ PLUMBING $ Date Owner Heating System & Ducting Registers PLAN CHECK 25% $ ENERGY P.C. $ I hereby certify that I'have read this application and state that the above information is correct. I agree to D0-100,000 BTU ❑100,0008 f 0 ELECTRICAL $ GRADING $ comply with all city,and county Ordinances and state laws relating to byllding construction, and hereby authorize repre- en sentatives of this city to ter upon the above-mentioned property for inspectionpurposes• - I PLAN CHECK 50% MICROFILM $- $ q Signature � � ^ ate•3'' r_0_j_ - MECHANICAL $ TOTAL FEE $ _. Drivers' License or SS I Reins ction Fee $15 Pe Issue Fee $ 3 PLAN CHECK 25% $ ' CMF 0865.46, rev, 10/84 White - Building; Conary _- Applicant; Pink - Accounting; Goldenrod - Assessor .POOL CONSTRUCTION AND PLANNING .or APPROVALS APPROVALS Permit # * Inspector - SPA APPROVALS Permit # Date Inspector 1 . Temporary Electrical Service or Pole 1 52. Pool & Equipment Location 2.,:Soil Pipe-Undrgrnd. 1 53. Steel Reinforcement 3. Electrical Conduit, Utility-Undrgrnd. 54. Farms ' 4, Electrical Conduit-Undrgrnd. •. 55. Electrical Bonding j 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6• Electrical UF£R Grnd. 57. APPROVAL TO COVER-GUNITE 7. Footings 58. Electrical Conduit-Undrgrnd. 8. Foundation '59. Gas Pipe, ❑ Undrgrnd., Test 9. Water Pipe-Undrgrnd. 60. Backwash Lines, P -Trap, Q Undrgrnd. 10. Structural Floor System 61. APPROVAL TO DECK 11. Property Sewer Line & House Connection 62. Backwash & Receptor -Final 12. Sevier Cap 63. Heater & Vent -Final 13. Roof Drains + 64. Plumbing System - Final 14. Rough Plumbing 65, Electrical -Final 15. Rough Electrical -Conduit 66. Solas System -Final 16. Rough Electric Wiring 67, Fencing & Access Approval 17. Rough Wiring Sign 68. APPROVED FOR PLASTERING 18, Rough Electrical -T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT, REQUIREMENT APPROVALS Permit # 20. Rough Factory Fireplace 21, Ducts, in Structure 70. Underground Hydro 22, Ducts, Ventilating 71. Product Piping ❑ Gas ❑ Oil 23. Gas Pipe -Rough & Test 72. Underground Flush 24. Roof Framing 73. Undergrnd, Storage Tank ❑ Gas 0 Oii �x 25. Roof Sheathing 74. Overhead Hydro ; 26. T_Bar Ceiling (Structural) & Monocoat 75. Dry Chemical 27. Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding 77. FIXED SYSTEM FINAL *M 29. Insulation 78. FIRE PREV. FINAL 30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31, Plaster Brown Coat 79. FINAL INSPECTION 32. Electrical Power Meter -Final 80. FOOD CERTIFICATE ISSUED 33. Final Electric Notes-, 34. Final Heating & Air Conditioning 35. Final Gas Pipe -Test 36. Hood or Canopy 37. Final Factory Fireplace 38, Final Plumbing 39. Water Service -Final _ 40. Gas Service -Final 41, Solar Domestic -Final 42. Backflow Preventer 43. Backflow irrigation ` 44. Landscape Irrigation System 45. Sound Attenuation 46. Handicap Regulations ` 47. FINAL STRUCTURE & BUILDING 148. Special Requirements Completed 49. Electric Release to Edison 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY l '4r) Date Applicant to fill in all spaces within heavy border lines and. sign all appropriate declarations. CITY OF COSTA MESA PER T NO. TRACT_ NO. LOT NO. BLDG NO. WNSTRUCTION PERMIT f / -Project Address -,2��1 1j & Z 1 4STOIV I TYPE OF CONSTRUCTION Phone Address G F_, Arch]Eng. K H ]5 EENCrINEEP-jKjLicense No. f /2.g3p(p5 Address t0 O V,AUQ,GiV AV15 Contractor (���( ,p J (Z GoN p Phoneme R- 2 Address t.,^U Q 5L, Ave,: LICENSED CONTRACTOR DECLARATION I hereby affirm that I am licensed under provisions of Charter 9 (com- mencing with section 7000) of ,Division 3 of the Business and Professions Code, and y license is In foil fort n ff Licensee C/I)rs�s r, -0 License No. Date -lyL� Signature WORKERS' COMPENSATION DECLARAT_ION I hereby affirm that I have a certlficate of Consent to self -insure or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Sect{o 3�11� t3. C.). Policy No [� (• Company. JL�Ifl}"tl�(It IruDa571a! Certified copy Is hereby furnished. Certlfled copy is filed with the City Building Division. EXEMPTION FROM WORKERS' COMPENSATION DECLARATION, (This section need not be completed if the permit is for one hundred 8$1 rt?j or.less). nt(fy that in the performance of, the work for which this permit Is Issued I shalt not employ any person in any manner so,as to become sublecl to the Workers Compensation Laws Of .r".,;;Iw :ia. Date Signature NOTICE: If after making this declaration. you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked, CONSTRUCTION LENDING AGENCY ' 1 hereby affirm that there Is a construction lending agency for the per- fgrrMnre of the work for which this permit is issued (Section 3097 Civ. C.). Lender's Name Lender's Address OWNER BUILDER DFr.LARATION_ 1 herebyy affirm th,;,t I am exempt from -the Contractor's License Law for the foll0N;;0g reason (Section 7031.5 Business and Professions Code: A^y city orCounty which requires a permit to construct, alter, improve,.demolish or repair any structure, prior to its issuance, also re- quires the applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or.that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a. permit. subjects the applicant to a civil penalty of not more than five hundred dollars ($500), ❑ I, -as owner of the -property, or my employees with wages as their sole compensation, will do the work, and the structure is not Intended or offered for -sale. (Section -7044, -Business and Professions Code., The Contractor's License Law tloes not apply to an owner of a property who •builds or improves thereon; and who tloes such work himself or through his own employees, provided that such Improvements are not Intended orofferedfor sale. If,•however, the -building or Improvement Isssold within One year of completion, the owner will have the burden of proving he- did, not build or -improve for the, purpose' of sale).' ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project. (Section 7044, Business and Professions Cade: The Contractor's License Law. does not apply to an owner of property who builds or improves thereon, and who con- tracts from such projects with a contractor(s) licesned pursuant t0. the Contractor's License law). ❑ I am exempt under Section - B. & P. C. for this reason Date Owner I hereby certify that I have read this application and state that the above information- is correct. I -agree to comply with all city and county ordinances and state laws relating to construction, and hereby authorize representatives Of this- city to enter upon the above m ntloned property for inti purpo s Signature ZINEW ❑ ADD K ALTERATION ❑ REPAIR El CONVERSION ❑DEMOLISH ❑ OTHEiR DESCRIPTION -OF WORK HYPE OF PERMIT - C1 GRADING ❑ FOUNDATION ❑ STRUCTURAL ❑ TENANT ❑ ELECTRICAL ❑PLUMBING XMECHANICF ❑ OTHER PROJECT DESCRIPTION SQ. FT. OCCUPANCY _ CONSTRUCTION TYPE VALUATION ZONE + GRADING CU. YDS. ACRES REMARKS: PLUMBING PLAN CHECK BATHTUBS-- SHOWERS - TO I LETS URINALS LAVATORIES DOUBLE LAVS KIT. SINKS - DISHWASHERS SERVICE SINKS - SUMPS FLOOR SINKS- FLOOR DRAINS DRINKING FOUNTAINS INTERCEPTORS CLARIFIERS" SWIMMING POOL PTRAP WATER SERVICE ALTERATION GAS SERVICE- OUTLETS WATER HEATERS BTU OUTPUT- UTPUTSEWER SEWERCONNECTIONS - • - - • - s ' SOLAR TANK ' ' COLLECTORS SOLAWPIPING SYS.-- YS. ---ISSUE - ISSU I -FEE - 1 MECHANICAL PLAN CHECK HEATING SYSTEM AND DUCTING 0-100,000'BTU 100,000 + BTU REFRIGERATION SYSTEM 0.100,000 BTU 100,000 + BTU BOILERS BTU . SYSTEM REPAIR, ALTERATION EXHAUST SYSTEM MULTIPLE Drivers' License or S4 ISSUE FEE CMF OS65-46 White -Building; Canary -Applicant; Pink -Accounting; Goldenrod -Assessor 7184 9/02/82 -ZONING REGULATION A.P.-*- ZONE' -' PLNG. REF. - REAR YARD (TO P/L) PKG,SPACE REQ. ' .STREET WIDTH ZONING APPROVED BY SPECIAL CONDITIONS: ELECTRICAL" PROVIDED PARK FEE $ DATE PLAN CHECK GENERATOR - TRANSFORMER APPLIANCE - 0-1 KW 1.10 KW 10.50 KW ­:„50 + KW MOTORS (INC. SOLAR) 0-1 HP 10.50'HP 1-10 HP 50 + HP FIXTURES' OUTLETS • SWITCHES GAS TUBE SIGNS - - POLE LIGHTS " SUMMARY OF FEES POLES METERED SUB W PANELS MAIN, SUB SERVICE $ AMP PERMIT ' ISSUANCE FINAL FEE $ aDb ISSUEFEE APPLICATION APPROVED BY DATE SUMMARY OF FEES BUILDING- UILDING-PERMIT PERMIT- $ •SNIP -- $ PLAN CHECK $ PERMIT ' ISSUANCE $ PLUMBING $ - GRADING S PLAN CHECK $ ELECTRICAL $ $ PLAN CHECK $ - MICROFILM $ TOTAL FEE $ MECHANICAL $ �BD LESS AD- PLAN CHECK- $ VANCE PC $ FINAL FEE $ aDb CONSTRUCTION AND PLANNING Date Inspector APPROVALS Permit # ¢ POOL•& SPA ' APPROVALS Permit.* Date " Inspector 1. Temporary Electrical Service or Pole 43. Pool & Equipment Location 2. SoilPipe-Un rgfn 44. Steel Reinforcement - - 3. Electrical Conduit Utility-Undrgrn _45.. .Forms'. i •' �' - : �� a; 4. Electrical Conduit-Undrgrn 46' Electrical Bonding_i - �._ - "' '- - �' '• 't Steel Reinforce 47. Rough Plumbing & Pressure Test'.,-` 6. Electrical UFER Grn 48. APPROVAL TO COVER-GUNITE 7. Footings 49. Electrical Conduit-Undr rn 8. Foundation 50. Gas Pipe,' ❑ Undr rn; Tbsi'- 9. Water Pipe-Undrgrn 51. Backwash Lines P-Tra - ❑ndr-rr-�. 10. Structural Floor System 52. APPROVAL TO DECK 11. Property Sewer Line & House Connection 53. Backwash & Receptor -Final 12. Street Sewer Connection 54.- Heater & Vent -Final 13. Rough Plumbingui�- " % 14. Rough Electric -Conduit - 7,58.- ' Electrical -Final-' 15. Rough Electric -Wring _ 57. Solar System -Final ' 16. Rough Heating & Air Conditioning encing & Access Approval 17. Ducts in Structure . APPROVED FOR PLASTERING 18. Ducts, Ventilatiog 60. • POOL/SPA SYSTEMS FINAL 19. Gas Pipe -Rough &Test 20. Roof Framing 21. Roof Sheathin NOTES: ._ 22. Frame and Flashing 23. _ Insulation -- - - -- 24. Lathing & Siding 25. Drywall Nailing " 26. - . Plaster Brown Coat 27. Electrical Power Meter -Final _ 28. Final Electric 29. Final Heating & Air Conditioning y 30. Final Gas Pipe -Test 31. Final Plumbing 32. Water Service -Final 33. Gas Service -Final 34. Solar Domestic -Final + r 35. Landscape Sprinkling System 36. Sound Attenuation 37. Handicap Regulations 38. FINAL STRUCTURE & BUILDING 39. Special Requirements Completed 40. Electric Release to Edison - •- 41. Gas Release to Southern California -Gas -Co. 42. CERTIFICATE OF OCCUPANCY T No� Date I Applicant 10 fill in all spaces within heavy border lines and sign all appropriate declarations. \ CITY OF COSTA MESA FP?ZRIT NO. TRACT NO. LOT NO. -SLOG. O. 7185 9IO2I8� ��•Qd CONSTRUCTION PERMIT �-- k Protect Address _ TYPE OF CONSTRUCTION - Owner +�pU �.} G S A ne NEw ❑ADD �1 t Address g,GiNj i✓i ❑ REPAIR _.0 CDiVV RSION� ❑DEMOL€SH + > ❑ OTHER ZONING REGULATIONS. , 1. ArchlEng..(lKj.+� � �t�lC:�S1d�,�y�;censeNo. j S ' , - Address .100)09! LAUiL�I�-AVS DESCRIPTIO O _ WOR R:P. :P_ r _ _ j% ZONE PLNG, REF. !P-,' , Contractor_ !C Y +�� GoN D. Phone 94L__,zz YPE'OF P>= IT _ _ - ���L WYING'. _ SETBACK T. E TY -LINE Address i 0 j_,^UF_eL- V ❑ GRADING' ❑ FOUNDATION- Q STRUUCCT"U�RAL- IDF YARD LICENSED CONTRACTOR DECLARATION ❑ TENArvT ❑ ELECT,RICAL ❑PLUMBINGxvCHANIGA - I£EpE Y - 1 hereby affirm that'1 am licensed under provisions of Charter 9 (CE3 mencing with Section 7000) of Division 3 of the Business and ❑ OTHER Professions Code, d license is In full farce n effect PROJECT fl> SCRIPTION } REAR YARD (TO P/L) License C 55 License ho. y ,PKC. SPACE REQ. �PROV IOED Date g�� Signature _ SQ. FT. I'' WORKERS' COMPENSATION DECLARATION OCCUPANCY CONST_RUCTiON TYPE STREET WIDTH PARK FEE. S I hereby affirm that I have a certificate of condont to"self-Insure or -.a ZONING -APPROVED BY —7— Insure certificate lot Workers' Compensation insurance, or a certified copy YALLtAT1ON ` ZONE thereof (Sect os�}y 3 Q�0,,�.., b C.). RAIDING CU. YDS. ACRES SPECIAL CONDITIONS-- Pnl€cy No�'�CSFIRS� W _Company �A1Dil.S�+4i! lscacMu _ ertlfled copy is hereby turnlshed, '-REMARKS: ertif€ed copy is filed with the city Building Dlvislon, EXEMPTION FROM WORKERS' COMPENSATION DECLARATION74; 7, - (This section need not be completed if the permit is for one hundred (5100) or less). e ^ ' cert fy that n the performance of the work for which this permit is _ Issued, i shall not employ any -person in any manner so as to become PLUMBING PLAN CHECK ELECTRICAL PLAN CHECK subject to the Workers' Compensation Laws of California. GAPAGF NL Date Signature BATiiTUBS SHOWERS50 F -1- V NOTICE: if after making this declaration, you Should become subject "TOILETS URINALS GENERATOR '0-1 KW 1.10 KW 1 to the Workers' Compensation provisions of the Labor Code, you must TRANSFORMER forthwith comply with such provisions or this Permit shall be deemed LAVATORIES DOUBLE LAYS APPLIANCE 10-50 KW=50 + KW + ri revoked. CONSTRUCTION LENDING AGENCY' KIT. SINKS DIS4WA5HERS MOTORS 0.1 HP -' 1.10 HP I hereby affirm that there Is a construction lendingagency for the per {INC. SOLAR3 10-50 HP.:_ 50 + HP — „ - tdrmance of the work for which this permit is 15uec! (Section 3G97 SERVICE SINKS L• SUMPS' Civ. C.). _ - _ FLOOR SINKS FLOOR DRAINS ' 'FIXTURES' _' -OUTLETS --SWITCHES Lender's Name Lender's Address' DRINKING FOUNTAINS GAS TUBE SIGNS' OWNER BUILDER DECLARATION INTERCEPTORS CLARIFIERS- ?OLE LIGHTS € hereby affirm that 1 am exempt from the Contractor's License Law for the following reason, (Section 7031.5 Business and Profession% Code: SWIMMING POOL P TRAP Any city or county which requires a permit to construct, alter, POLES METERED SUB improve,. demolish or repair any structure..prior_to its is5uance, also re- WATER SERVICE ALTERATION 'PANELS- MAIN - 5U6 autres the applicant for such permit to file a signed statement that he v. is licensed pursuant to the provisions of -the -Contractor's License.L.aw 'GAS SERVICE OUTLETS - SERVICE _ AMP {Chapter 9 (commencing with Section 7000) of Division 3 of the Business and ProTessions Code) or that he is exempt therefrom and the WATER HEATERS - BTU OUTPUT paSIS for the alleged exemption. Any violation of Section 7031.5 by !€cant for a permit 5ubjects_the applicant to a civil penalty -SEWER CONNECTIONS ore than five hundred dollars ($500), owner of the property, or my employees with -wages -as their- SOLAR TANK COLLECTORS sole compensation, will do the work, and the structure €5 not Intended or Offered for sate. (Section 7044, Business and Professions Code: The SOLAR PIPING SYS. ISSUE FEE Contractor's License Law does not apply to an owner of a property who buifels or improves thereon, and who does such work hilnseff or - ISSUE FEE APPLICATION APPROVED BY DATE through his own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement - MECHANICAL PLAN CHECK iL'Drirs'License-0 sld within one year of completion, the owner wilt have the burden ' SUMMARY OF FEES - proving -he -did not -build or Improve for the purpose of sale). HEATING SYSTEM 0.140,444 BTU BUILDING I, as owner of the property, am exclusively contracting with ANQQUCTlNG PERMIT $ 'SMIPsed contractors to construct the project (Section 7044, Business 100,000 +,6TU PLAN CHECK S PERM17L Professions Code-. The Contractor's L{cense.L.aw does not apply to - 1SSVA T wner of property who build$ or Improves thereon, antl who con• REFRIGERATION 0-100,000 BTU PLUMBING $ts from such projects with a contractors) Ilcesned pursuant toSYSTEM - GRADINGContractor's License Law). 104,004 + BTU PLAN CHECK S am exempt under Section B. & P. C, for triis BOfLERS BTU EL! CTRICAL $ on SYSTEM REPAIR, RLTERAT{ON PLAN CHECK $ MiCROf'iL.M $ e Owner MECHANICAL' I Gt9TOTAL FEE $ reby certify that I have read this application antl state that the above EXHAUST SYSTEM MULTIPLE L.ESS'AI]- rmation Is correct. 1 agree to comply with 2M city and county PLAN CHECK S VANCE PCinances antl state laws relating to construction and herepyauihprizaA ix esentatives of this city to enter upon tete above ment€p ed perty for 1 Ction our a atureFiNAL FEE Sers'L License or 5 ISSUE.FEE O CMF 0865-46 White -Building; Canary -Applicant; Pink -Accounting; Goldenrod -Assessor - CONSTRUCTION AND PLANNING Date APPROVALS Permit# .- • POOL & SPA" _ `_ - ._ I .. Ins ectbr y Date Inspector P APPROVALS Permit# - •' '_ 1. Temporary Electrical Service or Pole - 43.• Pool & Equipment Location - 2. SoilPipe-Undrgrn 44. Steel Reinforcement 3. Electrical Conduit. Utility-Undrgrn 45. Forms 4. Electrical Conduit-Undrgrn _ 46.- Electrical Bonding_ - : ' -. •. , 5. Steel ein orae 47. Rough Plumbin &`Pressure Test - 6. Electrical LIFER Grn - 48. APPROVAL TO COVER-GUNITE - 7. Footings 49. Electrical Conduit-Undr rn " 8. Foundation _ 50. -.Gas Pipe; ❑ Undr rn', Test '- 9. . Water Pipe-Undrgrn 51. Backwash Lines P-Tra - El 06dign ^' 10. Structural Floor System , - 52. _ APPROVAL TO DECK _ 11. Property Sewer Line & House Connection 53. Backwash & Receptor -Final " 12. Street Sewer Connection - 54. Heater & Vent -Final, 13. Rough Plumbing -56. Pludnb6na System -�Final 14. Rough Electric -Conduit - - '•56. Electrical -Final • " 15. Rough Electric -Wiring - 57: Solar System -Final 16. Rough Heating & Air Conditioning - - - - encing & Access Approval - 17. Ducts in Structure 59, APPROVED FOR PLASTERING 18. 19. . 20. Ducts, Ventilating - Gas Pipe -Rough & Test . Roof Framing- 60. - - POOL/SPA SYSTEMS FINAL 21. 22. Roof Sheathing- Frame and Flashing - - - NOTES: 1-23. Insulation - - - - - - -- - - 24. Lathing & Siding - - 25. Drywall,Nailing ' ' 26.' Plaster Brown Coat 27. Electrical Power Meter -Final 28. Final Electric 29. Final Heating & Air Conditioning y - 30. Final Gas Pipe -Test 31. Final Plumbing 32. Water Service -Final 33. Gas Service -Final - { 34. Solar Domestic -Final 35. Landscape Sprinkling System ` 36. Sound Attenuation 37. Handicap Regulations - - - 38. FINAL STRUCTURE & BUILDING 39. Special Requirements Completed 40. Electric Release to Edison 41. Gas Release to Southern California Gas Co. 42. CERTIFICATE OF OCCUPANCY No - Date 1 J Applicant to fill In all spaces except those within heavy border lines and sign all appropriate declarations. - _ - _ f U� f� CITY OF COSTA MESA. t CONSTRUCTION PERMIT PERMIT ^�° TRACT NO. ' LOT NO. B F, Applicant's Mailing Add - '° n - R� j��'L� i Project Address-_' -- - TYPE QF CQNSTRUCTION NEW ADD ' ALTERATION REPAIR j CONVERSION ❑ DEM LISW ❑OTHER l I i ' -'• ! hone Owner's!Name 'e DESCRIPTION F WORK o S k I G 2s I Address' ' r ft / + T,YPE OF PEfi I _ GRADING FOUNDATION STRUCTURA�Cpi� f A. P. qW ZONE t I 1 'T -LicenseNo.' Arch/En' 9� ❑TENANT ELECTRICAL ❑,PLUMBING ❑ ME HANICAL �r PLNG. REF.'* v BUILDING -+ (ir w 1 I` I Address! ❑,'OTHER + C `- T4 BUILDING REAR YARD (TO P/L) , U Contractor's Nam ¢ hone S3�7.53 P . PROJECT DESCRIPTION. SQ. FT.' OCCUPANCY P PE Y I - Address(mailing)_�r( L' 1_ _ /T ,n J _ e v.J G ;9 f9 1,V Z; CONSTRUCTION TYPE -SALUATION $ LEFT SIDE YARD RIGHT SIDE YARD + License No. ZONJ= GRADING CU.YDS: ACR PKG•SPAC@;REQ. PROVIDED t ', i LICENSE=D CONTRACTOR DECLARATION I Remarks: �S , 1 3 L �, L i + STREET WIDTH ', i PARK FEE.$ ! `� l��hereby' affirm that I am licensed under provisions of Charter 9 (commencing wEth'section 7000) of Division 3 of the E3uslness and Professions Code, and ' , • ! ! A� r ' C -.I SPECIAL CONDITIONS: ONS - I my license -is in full force and effect. F Llcen Class *- Llcens No. y ( ''xr , � ' i PLUMBING _ Datet' SlgnaWre WORKERS' COMPENSATION DEC RA I Bar Sink I ; Sewer Cap 1 i ELECTRICAL hereby:affirm that I have a -certificate of.cnnsent to $0114niure or.a certlficate- i ;' Backflow Preventer - - Sewer Connection' - _ _ Automatic.Washer-- _ _ jMeter over 100,amps,l '1 if Workers' Compensation Insurance,' or a certified' copy thereof (Sec on 3800, Lab. C) 1 /� �• Backflow irrigation � Soler Cdllectors i~ Construction Pole ;Sub Panel' Policy No, f T 39 � � ' Company�r� 1 ertified copy is hereby furnished, r 1 r ' i Bathtub5 I I - Soler Piping I Cooking Unit � i ' { Sub Pole ) , I Ce r. tied cop yjj filed with the city Bu ng Dlvisiorl„ I Date - Er �[ ^-� t , Clariiier_s i Solar Tank 1 Dishwasher + Motors ❑0-1 HP ❑ 1 h$ Applicant; EXEMPTION FROM WORKERS' COMPENS_AT*ory flE ARATION for ~I �~ Dryers ❑Gas' ❑Electric �' Ine.Solar ❑9 15 HP ❑16-15+ 1 Dishwasher { Swimming Pool w/Spa (Thissection need not be completed if tha permit is ons hundred ($100) or I less): I I I certify,that in the performance of the work far which this permit Is Issued I f + prinking Fountains Urinal F r Fan ; t r f iMicfowaV¢ I shall, not employ any person In any manner so 'as to become subject. to tNe ; - F.A.U. Pole Light Workers" Compensation Laws of California., Floor Drains Water Closet' l Date Signature -NOTICE. If; after making this declaration, you shouid-become-subject to -the- - Floor•Sinks-' r- --Water Heater.-^ - - Fixtures _ -'Range _ -}• -- - - g Workers', Compensation provisions of the Labor. Code, you. must forthwith. comply with) such ,provisions :.or ;,this,?_permit 1 shall be . tleemed revoked; , ,. _ _. i Gas Service. ' OutlBts - - - ' < ,Water S2rvice G _ Device Boxes .Sign I CONSTRUCTION LENDING.,AGENCY t I hereby affirm that there is a'construction tending agency,for theiperformance• Interceptors j �_' _ - - i r; r- Outlets • Standing Sections of the work for which this' permit is fiysued (Section .3097„ Civ. C.)_ Lender's Name ` i 1 '. KiiclienlSink' I - -_ Switches I = 4 Trash Compactor f Lender's Address - -- _- _ i Lavatories• I ' Garbage Disposal i O]� d✓< 047 OWNEWBUILDER DECLARATIQN + _ I hereby affirin'that I am'exempt•from the iContractor's.Llcense Law for the following reason 7031.5 Business Professional Code: Any city or ' Generator, 00-5 KW 05-15 KW P -Trap: p• (Section and county which requires a permit to'conStruet', atter Improve, demolish or, repair any Structure; prior to its'Issuance, also requites file applicant for such permit Trensforrrier 1-115-50 KW , r ' + - � Roof Diains; to file a signed statement that he/she is licensed pursuant to the provisions of the Contractor's -License Law (Chapter 9 (commencing•with Section 7000) of " ,f ❑5U+ KW { + Reinspection Fee $75' `Ivision +3 -of the Business and Professions Code) -or that' he she Is exempt erefrom and thea basis for the alleged exemption. Any violation -of, Section ) Showers 7 r _ ' Reinspection Fee $15 Meter ❑up to 100 031.5 by ;any - applicant for a 1 permit -Subjects the applicant toy a civil t penalty of not more than five hundred dollars ($500). -r_ ' I 'ds,OWnEr 'my y f Service Sink + ,• , G i - j Issue Fee $ 3 amps I Issue Fee ' Zoning Approved By 'Date '• I, oft the:property or employees_,wlth wages as their sole compensation' will,do the work; and the struLture is not intentletl or offered I - - , I 1 r MECHANICAL �_ Application Approved By Date for sate ; (Sec{Ion 7044; Business and Professional Code:' The' Contractor's License Law tloes not apply to an owner of a property who builds or improves ; ; 1 Refrigeration System I I 1 i thereon, and who does such work himself/herself or through hEs or her own I Boiler ; ! Application Issued By , v :Date_ employees, provided that such improvements orcinol Intended or offered for sale. If however, the building or improvement Is sold within one year of cam- i 1 DUct = Under Ground I ❑0.100,000870 ❑100,000BTU ' Pietlon, the owner;wlll have the burden of proving he/she dltl not build or fm- rove for the purpose otlsale)'. I t Duct - Structural I System RepairrAlieiation SUMMARY OF FEES + $UI LDING PERMIT $; SMTP I $ , r' f 1, as owner of the property, am exclusively contracting'with licensed con- ;_tractor$to con structJhe project (Section 7044, Business and. Professions, Code:. The Contractor's Ll cense Law does not apply to an owner of property who Duct--Ventila_ ting- _ _I -� ,._( I ; PLAN CHECK! CK: $' I PERMIT t builds or Improves' thereon, and who contracts for such projects with a con- Exhaust System ❑ Multiple ❑ j { ,PLUMBING $ ISSUANCE $ i� V tractor(s) license pursuant to the Contractor's License Law), { 1 ❑ I'am exempt under Section B. & P. C. for this reason I ; PLAN CHECK` $ GRADING $ I o i Firepl/Fact, Bit. ICBO # \ I ELECTRICAL, $ f oO I $ N Date r Owner ,•i• -hereby •certify -that -1' have read- this�applicatlon••antl-state-that the^above ' II Heating System & Ducting ❑0.100,000 BTU•❑100,0(10 I { f f - - - - - - r (PLAN CHECK $ i MICROFILM $ t ' + i Information Is correct. I agree to comply with. cltyiand county ordinances and'state laws' rela g to ding construct ,and he by authorize repre- / 1 Hood or Type I ❑ ' MECHANICAL $' I TOTAL FEE' $ Sentatives of �thi t to ent u th bove-mentioned property for i Y p Inspection p I/ r } - Y Cann T e II ❑ ! Rainspectian Fee; $15 PLAN CHECK{ $ l I : LESS ADVANCED,PC # $ , X S[gnature f LI40 4 eg' R islets I 1 , ; Issue Fee ! $ 3 ► I- i { - t Drivers' or SS �� i I I FINAL FEE j $ 1 CMF 0865-46 rev. 12/82 ~White - w k - Accounting; Goldenrod -Assessor ' + r �3CONSTRUCTION.ANQJPLAN 1 G ' `` ' "-, �. _p ^ ^.; r -POOL SPA ,_ _ _ ` ` ;� t Date zAPP,ROVALS Permit* - _ I nspector W _ �, APPROVALS• Permit# Date 1 nspector ' ` Temporary Electrical Service or, Pole +> L - .'52'- Pool &Equipment Location ' �+ 2� rnd. :4' ' �, _ '; _ 53.. Steel Reinforcement :Soil'Pipe-Undrg ~ 3' Electrical Conduit Utility-Undrgrnd. + `• , �= - _ `54.: , 4• Eleeirical Conduit-Undrgrnd: - + B 55= Electrical=Bonding - r,i - - 5: �5teel'Reinforcement I r ' - ^ - ; 56.- Rough Pluri�bing &Pressure Test f, 6: !Eiactric'I LIFER Grnd.i `-;• ^ .. o.. - 57' APPROVAL'TO-COVER-GUNITE, i f! 7. Footings t + ` a' :' m 58: Conduit-Undrgrnd. .-Electrical- 8. Foundatiori {+ i ' : i ? s " �" 'S9. 6as!Pipe;_f],fJntirgr,nd., lest - 9. Water Pipe{Uridrgrnd, X60. Backwash Lines,'P-Trap, 0 Undrgrnd.: ' 10. Structural Floor System f L ,+Y "^ 1 -61. APPROVAL` TO'DECK 11. Property Sewer Line & House'Connection - `� = 62. Backwash &-fiecepfar Final=: S' 12.Cap ! i r {Ir B , '63. .Sewer ; Heater & Vent -Final 13. Roof•Drains I Plumbing System ; Final, i A' +1 14. Rough Plumbing' ' i i 1 " T { 65. Electrical -Final' -- 15:- Rough'Electr1cal=Conduitfir_ �I' 'F _ : - r` "� - ;66.f SoIWSVs`tem-So • r `- # -'I r i16." Rriugh-EleaRric,Wir•ing, , 1 : I rl f ; -�: i a;+F _7' �; ��- ' -67. 3 encing & Access, ,, 17, _RoughLWiring`Sign.' •� 1 + I L4 i I ` 6$.1 APPROVED FOR PLASTERING y i� 18. *Rough Elee'trical'TtBar Ceiling fl i j # ' i 69.I POOL/SPA SYSTEMS FINAL Y- 19.'Rough Heating &Air Conditioning FIRE DEPT. REQUIREMENT + 20. 'Rough- Factory Fireplact ; i t APPROVALS Permit x 21. Ducts, in Structure. ' ,` i j Underground Hydro l ,!I X70. '22.Ducts%Ventilating r,, 3 I 71 Product Piping ©Gas ❑Oil a ; i t 4 i • Y.23. Gas Pipe -Rough & Test .72.; Underground Flush 1 24. (Roof Framing; Undergrd. StorageTank-❑ . Gas ❑ Oil, 25. Roof Sheathing i t r' ' ' : 74.• Overhead Hydro } 26. -Bar Ceiling (Structural}, & Monocoat' + 1 n �.: - ' 75.` Dry Chemical • t •T , ; _ r 27. Frame and Flashing t 4 i i! T { I 76.i Dry Standpipe 28. ;�Lsthing &Sidings i; ' ! +. { 37.1 FIXED SYSTEM FINAL Y 29.:Insulation ^, ! I + ; = j X78. FIRE PREY. FINAL , 30. �D`ryvvall Nailing,., ;Notes:, X31. ;01aster Brown Coat !'32. iElectrical,Power Meter -Final „ + 33. final Electrics 34. Final ing &,Air Conditioning ,,eat :I 35. FinalGas�Pipel-estl v� ' r ,=i r ;� Epi 4 }4'; `;I I'''P I� I .; Y�; i•.. _: rI I f i 36. Hood or 6n�opy?;n 37. Final Factory Fireplacem 1 7 38. Final Plumbing I. i - 39. Water Selvice-Finall 1 it • I I14 , I 40. Gas Service -Final I 41. Solar Domestic -Final L; t ; i i t `moi 42. Backflow Preventers = =� r ' ' - �•7 f i - -' - - - --l--r-i - - 43. Backflow irrigation' '' r , 44. Landscape Irrigation System 7,t 1-* I ! �; , - _ '' 45. Sound! l y ! + 1 1 # �Attenuation I i _ , , i t, 46. Handicap Regulations r } _ I • '' ' i 47. FINAL STRUCTURE & BUILDING = + i 1- 48. Special Requirements Corripleted i 49. Electric Releasejto Edisonl i i i r -- -- ;` 50. Gas Release to Southern California Gas Co r I i ; + ► 51. CERTIFICATEOCCUPANCY No. -- Date - 4 CITY OF COSTA MESA BUILDING DIVISION > 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 7544856 www.ci.costa-mesa.ca.us 1- �.� FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER E07-00700 PERMIT TYPE ELEC STATUS: ISSUED DATE ISSUED: 07/27/2007 ISSUED BY: " r r JOB ADDRESS: 3333 BRISTOLST-CM. SuitelUnit: Vicinity: NEAR LOADING DOCK,C #\x SCOPE OF WORK: ELECTRICAL PERMIT FOR THE INSTALLATION OF A NEW 2000A;BREAKER IN'AN (E) MAIN SWITCH BOARD LOCATED NEX TO LOADING DOCK "C" AT "SOUTH COAST PLAZA". ✓ OWNER: SOUTH COAST PLAZA ; ' Address: Unit:COSTA MESA CA PHONE: f CitylstatelZip: 3315 FAIRVIEW ROAD APPLICANT: SANDOVAL, SAM I Address: Unit: PHONE: 714-936-3974 CitylStatelzZip: CONTRACTOR: A J KIRKWOOD AND ASSOC INC = - F . 'License No. 724633 Address: 2752 WALNUT AVUnit: PHONE: 714-505-1977 City/State: TUSTIN,CA . ZipCode: 92780- — _ . - CELL: ELECTRICAL PERMIT FEES. - Electrical Plan Check Fee: $0.00 Electrical Permit Fee: "$1.97.30, - Reinspection 97.30. Reinspection Fee $0.00 TOTAL FEES �$493.30 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE -1. INSPEc'nON TYPEA¢AT INTITIAL CODE / INSPECTION TYPE pig INTMALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical i U 201 Final BlocklRetaining Wall 212 Final Fire Prevention 202 Final Factory Fire Piave 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Buildingloccupancy WORKERS' COMPENSATION DECLARATION:% I hereby affirm under penalty of perjury one of the tt„ ..,wing declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy number are: QSa�rfler:_ MA ���� G I� CD {7h s section need not be competed d the perms 4 va)ued atone hundred doNars ($100) or less.) Poli umber: �7 d ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Califomia, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labo e, 1 shall fo th co with these provisions. Appkant13 Signature pates L� WARNING: FAILURE TO SECURE WORKI RS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONS HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. �[ #f Clas # - C— 10 ntractor's Signature Dat' e� CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: S,gnature T Dale OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to Tile a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ' ❑ I,.as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature Date 3057-46 (3117) Owner ID verified by driv. ase. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION bF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation Five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high, (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Dale Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? []Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feel of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4, If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? []Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If "yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. • . ' Signature Dale CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection, ignalure of La er(s Date 7 Aft Authorized Apdicanl-Date CITY OF COSTA MESA BUILDING DIVISION * 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 • vwvw.ci.costa-mesa.ca.us FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: /BX07-00045 PERMIT TYPE B MISC STATUS: ISSUED DATE ISSUED: 08/30/2007 ISSUED BY: BJK JOB ADDRESS: 3333 BRISTOL ST CM - ; . Suite/Unit: Vicinity: AREA ADJACENT TO STES 3000; 30028, 3002D.,. - Primary Occ: Const Type :?? SQ. FT: 0 valuation: $8,000.00 {. SCOPE OF WORK: 150SF`INTERIOR DEMOLITION OF THE NONBEARING FRONT WALL ADJACENT TO SUITES 3000, 30028 AND 3002D TO ACCOMODATE THE EXPANSION OF THE PUBLIC AREA. OWNER: SOUTH COAST. PLAZA Address:':" Unit COSTA MESA CA City/State: 3315 FAIRVIEW ROAD Zip Code: ' 92626 Phone: APPLICANT: SNEDEN, KENT Address: Unit: City/State: Zip Code: Phone: 714-350-2415 CONTRACTOR: SNEDEN AND BOWERS INC _ License No'" 811856 Address: 1081,ST REGIS PL Unit. City/State: SANTA ANA, CA . Zip Code: 92705 Phone. 714-838-4112. Cell: 714-350-2415 ARCHITECT: TIM DOSS License No. C23447 Phone 714-728-7284 ENGINEER: _ License No. Phone FEE SUMMARY Building Plan Check: $99.61 Building Permit: $153.25 Electrical Permit: $0.00 SMIP Residential $0.00 SMIP Commercial $1.68 $1.68TOTAL FEES $254.54 NOTICE. The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE :, INSPECTION TYPE DATE INTMAL5 CODE / INSPECTION TYPE DATE NTMAL 1615 Fixed System Final Fre Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Etectrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign p mi� 222 Final Site 204 Final Demolition y,� / 9 ©p 250 Final Building/Occupancy WORKERS' COMPENSATION DECLARATIONO I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' Compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by s tion 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: -,S e [� (This section need not be oamprered if p�emr�t is valued stAhe hundre d dAaarrs (5100) or (ess.) Policy Number:l�`l ❑ I certify t at in the perfo of the work for which this permit is Issued, I she not employ an erson ' any manner so as to become subject to he wro rs' componsati n laws of California, and agree that if I should b a subject to the work r$' compensation provisio s of Se ion 37pp of abor t I these provi ions. . �/)__ Ap cant's orale WARNING: FAILUR TO SECURE WORKERS' COMPEN TION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL. PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), 1N ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. INTEREST, AND ATTORNEY'S FEES. LICENSED C NTRACTORS DECLARATION: I hethat I am licensed under provisions of Chapter 9 (commencing KBeipsoe"i, 7000) of Divis' of th Business and Professions Code, and s in full force d effectClass# ra ignatvre tate CONSTRUCTIO tLLEENDING AGENCY: [31 hereby a that there is a construction tending agency for the performance of the rk for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sac. 7031.5. Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Cade) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds of improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ i am exempt under sec. Business and Professions Code for this reason: signature 3057.46 (3+07) Date F Owner ID verified by dri nse. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ t hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec, 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division, AppliCanl'$ Signature Division of Industrial Safety Permit Number: Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at arty one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. tf an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential !wilding permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If 'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purpWs. f agree o occupy or allow occupancy of any building autho 'zed b tfSSls permit 11 final ASpection. Signa a r(s) Date �a D or Aut Applicant Date (714)754-5273 • Fax(714)754-4856 1 _ � CITY OF COSTA MESA f BUILDING DIVISION DEVELOPMENT SERVICES DEPARTMENT PERMIT ,lob Address: 3333 BRISTOL ST Suite No Vicinity: COOLING TOWER Parcel Nunmber: 41250106 Applicant: GRIMM, DAN Address: ELECTRICAL PERMIT Phone: Zip: owner: , SEARS, ROEBUCK & CO Address D/768TAX,B2-116A HOFFMAN ESTATES,,IL Phone: 3333 BEVERLY RD. - Zip: 60179 Contractor: GRC ELECTRIC INC/WIRED RITE ELECTRIC Address: 1300 GARDENA AV Phone: 818-242-9891 GLENDALE, CA Zip: 91204 License: 735615 PERMIT NUMBER E99-00355 77 FAIR DRIVE, COSTA MESA, CA 92626 Status: ISSUED Applied: 04/29/1999 Issued: 04/29/1999 ISSUED BY: �� M SCOPE OF PERMIT 1 MOTOR UPTO 50 HP & 1 VARIABLE SPEED DRIVE FOR COOLING TOWER. M99-00160. COMMENTS 1 SPECIAL CONDITIONS NOTICE: The worts authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION. This permit shall automatically expire and become void if work is not commenced within 160 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754.5626 A FEE SUMMARY Quantity Quantity ISSUE FEE $22.00 Temp Dist System / Lighting $0.00 0 Temp service test $0.00 Busway /100 ft $0.00 0 Res. a/c package $0.00 Standing Section $0.00 0 New Res (1-2 units) $0.00 0 Misc Electrical Equipment $16.25 1 New Res (3+units) $0.00 0 Transformers up to 1 kva/kw $0.00 0 Pool / Spa $0.00 0 ................up to 10 kva/kw $0.00 0 Lighting Fixts $0.00 0 .................up to 50 kvalkw $0.00 0 Recept Outlets $0.00 0 ....up to 100 kva/kw $0.00 0 Switches $0.00 0 ..................over 100 kva/kw $0.00 0 Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0 Res Appl $0.00 0 Low Volt Wiring System / Ckt $0.00 0 Service to 200a $0.00 0r Misc. Conduit $0.00 0 Service to 1000a $0.00 0 Misc. Conductor $0.00 0 Service over 1000a $0.00 0 Circus ( gen or ride) $0.00 0 Motors to 1 hp $0.00 0 Circus (mech ride or lights) $0.00 0 Motors to 1 Ohp $0.00 0 Christmas Tree Stand $0.00 0 Motors to 50hp $22.00 1 Fireworks Stand $0.00 0 Motors to 1 00h $0.00 0 Other Electrical Fee $0.00 Motors over 1 00hp $0.00 0 Communication drops $0.00 0 Investigation Fee $0.00 Sub panel to 200a $0.00 0 Plan Check Fee $0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $0.00 0 Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $60.25 Intermed Pole $0.00 0 COMMENTS 1 SPECIAL CONDITIONS NOTICE: The worts authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION. This permit shall automatically expire and become void if work is not commenced within 160 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754.5626 A WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury orae of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the tabor Code, for the performance of the / work for which this permit is issued. I have and will maintain works cgmpensation Ins nee, as required by section 3700 of the Labor Code, for the perfomianee of the work for which this permit is issued. M wo m n- n In r nce carder and i number are: Carder:y r _ d'/ (9OA[78•-r' �� ^, Policy Number: O (77tis section Head n be completed it the permit Is ed at one hundred dollars ($f00) or less.) ❑ I certify that in t edormance f e wo for hich this permit is Issued, I shall not employ any person in any manner so as to become subject to the workers' compensation Is Calif ml agree at i E should become subject to the workers' Compensation provisions of Section 3700 of the Labor Coda, I shall forthwith comply with these rov ons. - Applicant Signature: Data: –� WARNING: FAILURE TO SECURE ORKERS' COMPENSA COVERABE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($106,000), (N ADD(T(ON TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR (N SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACT RS DECLARATION: I hereby affirm that I am li nsed under pr ions of a er 9 (commencing with Section 7000) of Division 3 of the Business(It Prof Bions Code, and my license is in Tutt force and effect. Lic. # Class # r! f- r Contractor's Signature: V Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: -- -- - -- Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjt4ry that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, altar, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chaplet 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than fire hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (See. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contraclor(s) license pursuant to the Contractors License taws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby Certify that no excavation five (5) or more feet in depth into which a person Is required to descend, will be made In connection with work authorized by this permit, and that no building structure, scaffofding, falsework, or demolition or dismantling thereof, w4l be more than thirty-six (36) feet high, (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industria! Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Numtaer: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Masa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure)_ _ 2 Does or will rho applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity Of acutely hazardous materials equal 10 or greater than a weight of 500 pounds, or a volume of 65 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication aggermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes I__l No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Cade Section 42303 been made? ❑ Yes ❑ No 8 (it yes , attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: - — Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the Information given is correct. I agre to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above -describer rty for Ins fr Ion pu es. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Slg tura Le al Owners) An Or Authorized Applicant Date CODE r. INSPE012NTYPE pM Jam$ CODE$ INSPECTION TYPE am 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 - Final Planning Approval 203 Final Sign 222 Finaf Site 204 Final Demolition 250 Final Building/Occupancy 244646 Job Address: 3333 BRISTOL ST Status: ISSUED Suite: Applied: 0511612007 Vicinity: Issued: 05/16/2007 Primary Occ7 Type of Construction: Parcel Number: 41250107 Zoning: PDC Applicant: MIKE PAZ Address: 3315 FAIRVIEW ROAD Phone: 714-546-0110 COSTA MESA, CA J .,,_ 1>-_ Zip:: 92626 - _ ISSUED BY: Owner: SOUTH COAST', -PLAZA - Address COSTA MESA CA, Phone: , 3315'FAIRVIEW ROAD .'Zip: 92626._ ' • �'\�` Contractor': " 'OWNER-BUILDER.', Address, Phone: Zip: �!, License: 000000 Arch Eng: Address: / ( Address: \ Phone: G. Phone, ' Zip: ., 1 License: License': SCOPE OF PERMIT INSTALL 2 HANDICAP PARKING SPACES LOCATED IN Z TEJAS PARKING LOT. FEE SUMMARY ' Plan Check: $45.01 %'T % - } ��Calc Valuation: $2,000.00 Permit: $69.25 _ -`-`� ' _ ��' ` Claim Valuation: L $2,00000 T SMIP Res: $0.00 ; SMIP Com: $0.50 Other: $0.00 Inspection: $0.00 Total: $114.76 4 PLANNING & ZONING ; SETBACKS. t it MAIN STRUCTURE Front0-0 Rear, ;;0-0 '; ' Left 0-'0''"',.� Right 0-D�-`�'���� ACCESSORY Front, 0-.0A Rear 0-0, - ��> Left 0 0 Right.';:O 0 PARKING Existing. o� - �' J �✓ Required`. 0: Proposed: 0 �� \, ����'r �vi�� ,. t. � .,� •.-yam ��V/1`'' %� / NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained, Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446.46 (6W) DECLARATIONS WORKERS' COMPENSATION DECLARATION: ' I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a cenificate 01 consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Coda, for the performance of the work for which this permit is issued. ❑ I have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. My workers' compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed if the permit is valued at one hundred dollars ($100) or lass.) -0-1 certify that In the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if l should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisions. Applicant Signature: Date: i' WARNING: FAILURE TO SEC RE WORKERS' COMPENCOVERAGE is UNLAWFUL AND SHALL SUaJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED AADDITION THOUSAND DOURE ($100,000), IN TO THE OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LA9OR CODE. INTEREST, AND ATTORNEI"S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license Is In full force and effect. Llc. q Class fr Contractor's Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for safe (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not Intended or offered for sale. If, however, the building or Improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ' I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractors) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: ~Slgnature: Date: S D -Owrigr ID verified by drivers anse. ❑ Yes ❑ No FDriver•s License Expires: Verification of Ownership by (type of document, i.e, -property tax bill or dead):" DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby cartify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-bullder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Dale: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION - 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic fact of compressed gas at standard temperature and pressure). _.—..... ._....... ----.................... — ..... _... .._................... - _ - _.. ..................._................................................- ... _....._ .._ . - .............................�................. 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? C] Yes ❑ _... No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registratlon with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 2DO cubic feet of compressed gas at standard temperature and pressure). .D.o"----------------t'h........pp'l'i'c"...........p.t'.s-ei..........................uI'I'd-i'..........................................................................---•Pki-s..........................._............--•--...............enP'r,_g-T'a.......'o*'r*.........._................................a'to**.......)'?.__. 3 Does or will the applicant Or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous matedals)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Liepartment of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ...... ............................................................................................................................................................................. ........-.............. ....................... ,....,.......,..............,...................... ............................................ ................................... ....... 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes [I No _............ ........ _..................... ---................................................... ............... ....---__._..................... . �........................................ ..__ - .................................................... ................ .... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification lrom the South Coast Air Quality Management District or from any other air pollution control district or agency? lU Yes ff No (Section 65850.2 of the California Govammant Code requires that the requested information be furnished on applications for non-residential building permits). -...........................................................................-- - .......__ .......................--....................................................................................................._........................................................ _.................. -- 6 Will any part of the faci l to be constructed under this permit he within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). .............__..................................... -_.......................... ,........................ _................................................................................................. - ......._................ ...-.._.............. 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes {] No ----- .................................................................................................................... _.............................. ............................. --................................................... ........................_..........................._..._................................ B (It yes", attach certificate of Compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. r Signature Of Legal Ownor(s) Date ( And/Or Authorized Date CODE 1. INSPECTION TYPE pSI€ INTmAL,4 CODE It INSPECTION TYPE 2M ifs 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Fina! Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final BuildinglOCcupancy-LS" ` CITY OF COSTA MESA BUILDING DIVISION DEVELOPMENT SERVICES DEPARTMENT J• PERMIT (714)754-5273 • Fax(714)764-4856 ,lob Address: 3333 BRISTOL ST Suite No Vicinity: Parcel Nunmber: 41250106 Applicant: BRADLEY Address: Owner: SEARS, ROEBUCK & CO Address D1768TAX,B2-116A HOFFMAN ESTATES,. IL 3333 BEVERLY RD Contractor. SOUTHLAND INDUSTRIES Address: 01661 E. 32ND ST LONG BEACH CA ELECTRICAL PERMIT Phone: 562-424-8638 Zip: Phone: Zip: 60179 Phone: Zip: 90809 License: 114040 PERMIT NUMBER L/ I E99-00341 77 FAIR DRIVE, COSTA MESA, CA 92626 ISSUED BY: Status: ISSUED Applied: 04126/1999 Issued: 04/26/1999 SCOPE OF PERMIT ROOF CHILLER REPLACEMENT, RE:B99-00484., REPLACE 1000 TON CHILLER, 1-416OV, 1-480V, 1-208V OUTLETS & 1 LOW VOLTAGE. ELECT WORK INCIDENTALTO MECH , RE:M99-00200. COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § i, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 FEE SUMMARY Quantity Quantity ISSUE FEE $22.00 Temp Dist System 1 Lighting $0.00 0 Temp service test $0.00 Busway 1100 ft $0.00 0 Res, a/c package $0.00 Standing Section $0.00 0 New Res (1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0 New Res (3+units) $0.00 0 Transformers up to 1 kvalkw $0.00 0 Pool / Spa $0.00 0 ................up to 10 kvalkw $0.00 0 Lighting Fixts $0.00 0 :................up to 50 kvalkw $0.00 0 Recept Outlets $0.00 0 .................up to 100 kvalkw $0.00 0 Switches $0.00 0 ..................over 100 kvalkw $0.00 0 Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0 Res Appl $0.00 0 Low Volt Wiring System 1 Ckt $25.00 1 Service to 200a $0.00 0 Misc. Conduit $0.00 0 Service to 1000a $0.00 0 Misc. Conductor $0.00 0 Service over 1000a $0.00 0 Circus ( gen or ride) $0.00 0 Motors to 1hp $4.25 1 Circus (mech ride or lights) $0.00 0 Motors to 10hp $11.00 1 Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 0 Fireworks Stand $0.00 0 Motors to 100hp $0.00 0 Other Electrical Fee $0.00 Motors over 100hp $66.50 1 Communication drops $0.00 0 Investigation Fee $0.00 Sub panel to 200a $0.00 0 Plan Check Fee $0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $0.00 0 Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $128.75 Intermed Pale $0.00 0 COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § i, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 M DECLARATIONS WORKERS' COMPENSATION DECLARATION-. I hereby affirm under penalty, of perjury o of the following declarations: ❑ 1 have and will maintain a certiflcat of Consent to self -Insure for w ars' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is Issued. I have % {Il maintain workers' pensation Insurance as •red section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My cornpensati nsura carrier and poll are: Carrier: Policy Number: (This sectl n need not leted If Vw-ork a! rdred d ars (S 1 no)or lass.) ❑ I ce ty that in the rformancei this reit is Issued, I shall not employ any person in any man er so as to become subject to the workers' Com ensatfon taws o1 Callfamia; e subject tLthewvlkers' oompensatlon provisions v} Se tion 3700 f the Labor Cade, I shall forthwith corn ly with these provisions. Applicant Signature: Date: WARNING: FAILURE TO SECURE WOWJ1RA."WdI&T1Vz6iAAGE IS UNLAWFUL D SHALL SUBJECT AN EMPLOYER TO CRIW4 ENALTIES CML FINES UP TO ONE: HUNDRED THOUSAND DOLLARE ($100, ),1N TO THY OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CO 5 DECLAAATiO I hereby affirm that I am tic dynder i of 1 9 (co d th Section 7000) of Division 3 of the Busi essf r asst ed my license is in full force and effect. Lic. # ��i Class # Contractors Signature: Date: CONSTRUCTION LENDING GENC ❑ I hereby affirm that then tructi ending agency for the performance of the work for which this permit is Issued. (Sec. 3097, Civil Code), Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Coda: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors Uoense Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption, Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more then five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not intended or offered for sale. if, however, the building or Improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not appy to an owner of property who builds or Improves thereon, and who contracts for such project with a oontractogs) license pursuant to the Contractors License taws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's Ucense No. Expires: Verification of Ownership by (type of document. i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet In depth into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more then thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, Califomia Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one Ume during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight o1 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutety hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, ceddication and flling with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP Is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication aggermlt for such construction or modification from the South Coast Alr Quality Management District or from any other air pollution control district or agency? (i Yes I I No (Section 65850.2 of the California Government Coda requires that the requested information be furnished on applications for non-rosidential building permits). 6 Will any part o1 the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yos ❑ No (If 'yes', the fac lity must meet the re9direment of.Sections 25534 and 42303 of the California Health and Safety Code), 7 If a permit fron the South Coas it Ouaiity,Management District or other air pollution control district or agency Is required for the work which is the subject of this application, ha all of the disciures pr cubed by Califomia Health and Safety Code Section 42303 been mads? ❑Yes ❑ No 8 (if 'yes", attach rtificate of II rom a appropriate air pollution control officer). CERTIFICATE rtify t under on ve is cornet . agre to omp y w a sae ordinances regard g H dous M rials re: CERTIFIC OF D UTHORIZATI OF ENTRY: I certify under penalty of perjury that I have read thl application and state that the information given is correct. I a roe to comply state laws and city ordinances relating to building construction, and authorize represen lives of the City of Costa Mesa to enter upon the above -des bed Pr r inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final Inspection. Sign r Of Le e ) r7, Qate An r utharizad Applicant Date CODE �. 1j�g �y]� CODE! INSPECTION TYPE 1616 ystem Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing fT1 • /!,f�7�7 200 Final R.Root 210 Final Electrical 201 Final Block/Retaining Well 212 Final Flre Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Buitding/Occupancy 2448.48 (714)754-5273 • Fax(714)754-4656 CITY OF COSTA MESA BUILDING DIVISION DEVELOPMENT SERVICES DEPARTMENT PERMIT MECHANICAL PERMIT Job Address: 3333 BRISTOL ST Suite No Vicinity: ROOF Parcel Number: 41250106 Applicant: KING, ROSCOE FEE SUMMARY . Address: 1300 GARDENA AVE " Quantity r Phone: 323-245-1111 ISSUE FEE GLENDALE, CA Zip: 91204 Owner: SEARS, ROEBUCK & CO Inst FAU <100 k BTU $0.00 Address: D/768TAX,132-116A $0.00 . Inst FAU >100 k BTU HOFFMAN ESTATES, IL , Phone: Ventillation System $0.00 3333 BEVERLY RD Zip: 60179 Contractor: M & D PLUMBING INC DBA PRC MECHANICAL Address: 1300 GARDENA AVE $0.00 0 Commercial Incinerator $0.00 Phone:. 323-245-1111 $0.00 GLENDALE, CA Zip: 91204 0 Ref rig Sys >100 k BTU License: 311690 Arch/Eng: Gas Piping, Address: 0 Up to 3 hp l 100 k BTU $0.00 Phone: Zip: License: PERMIT NUMBER M99-00160 77 FAIR DRIVE, COSTA MESA, CA 92626 ISSUED BY: Status: ISSUED Applied: 04/08/1999 Issued: 04/08/1999 SCOPE OF PERMIT DEMO'D EXISTING COOLING TOWER & INSTALLED NEW UNIT ON ROOF WITH ENCLOSURE. TOTAL CALCULATED FEES $38.15 COMMENTS ! SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 FEE SUMMARY . Quantity Quantity ISSUE FEE $22.00 Repair 1 Alt Absorbtion Unit $0.00' 0 Inst FAU <100 k BTU $0.00 0 Repair I Alt Refrigeration Unit $0.00 0 Inst FAU >100 k BTU $0.00 0 Ventillation System $0.00 0 Repair I Alt Cooling/Heat $0.00 0 Evaporative Cooler $0.00 0 Inst / Rep. Recess Wall Htr $0.00 0 Commercial Incinerator $0.00 0 Ref rig Sys <100 k BTU $0.00 0 Domestic Incinerator $0.00 0 Ref rig Sys >100 k BTU $0.00 0 Compressors / Absorption Systems Gas Piping, $0.00 0 Up to 3 hp l 100 k BTU $0.00 0 Factory Fireplace $0.00 0 3 To 15 hp / 500 k BTU $0.00 0 Hood w/Mech Exhaust $0.00 0"" 15 To 30 hp 11,000 k BTU $0.00 0 VAV Box $0.00 0 30 To 50 hp 11,750 k BTU $0.00 0 Vent Fan / Single Duct $0.00 0 Over 50 hp 1 Over 1,750 BTU $0.00 0 Appliance $0.00 0 Boilers Fire Dampers $0.00 0 Up to 3 hp $0.00 0 Smoke Dampers $0.00 0 3 To 15 hp $0.00 0 Inst or Relocate Appl Vent $0.00 0 15 to 30 hp $0.00 0 Air Handlers < 10000cfm $0,00 0 30 to 50 hp $0.00 0 Air Handlers > 10000cfm $16.15 1 Over 50 hp $0.00 0 Floor Furnace $0.00 0 Other Mechanical Fee Floor or Suspend Heater $0.00 0 Investigation Fee $0.00 Plan Check Fee $0.00 Reinspection Fee $0.00 TOTAL CALCULATED FEES $38.15 COMMENTS ! SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under Penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed if the permit is valued at one hundred dollars ($100) or lass.) ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labgt-code. I shall forthwith comply with these provisions. Applicant Signature: Date: —� WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS U FUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSA DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed underpr v ns of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Uc. p Class a Contractor's Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: 1 hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the aiiegad exemption. Arty violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: ^, Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or dead): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet In depth into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP {Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 if an RMPP is presontly required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ El No 5� Does or will the applicant or resent or future building occupant require for the i hes subject of will the work which is the subject of this a plication aPertnit for such construction or modification from the South Coast Air Quality Management District or from an other air pollution control district or agency? U Yes j No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (it "yes', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for tate work which is the subject of this applicaflon, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (If "yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: l certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions, Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of parjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection.. And/Or Authorized Applicant Date CODE A, [NSPECTIONTi1PE 12A1E INTITIALS CODE t INSPECTION TYPE 1616 Fixed System Rinal Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy 2446-46 CITY OF COSTA MESA y BUILDING DIVISION DEVELOPMENT SERVICES DEPARTMENT PERMIT (714) 754-5273 • Fax (714) 754-4856 FIRE SUPRESSION PERMIT Job Address: 3333 BRISTOL ST Suite: Vicinity: Parcel Nunmber: 41250106 Zoning: PDC PDC Applicant: TOM PONTOLILLO 198-00095 PERMIT NUMBER 77 FAIR DRIVE, COSTA MESA, CA 92626 Status: ISSUED Applied: 0412411998 Issued: 06/22/1998 Address: - Zip: //��✓�- ti � � � � � /tom' � ���., ^� Owner: f Address Dt768TAXB2-,1,16A �.� S_D- t_ / fj ►.� t Lit- HflFFMAN ESTATES,IL- =-.�+ t?hone;� Al3 �� �� \� BEVERLY,RD Zip: 60179 ntractor. TRI COLIN,—,F,IRE address: 23881 VIR'i=ABRECANTE x <\ �� Phone: 1 �MISSION•VIEJO CA Zip:s'92692 License:' 659326 ( ri �• �`'"� ���;;;, " r"`-,�!SCOPE`•OF PERMIT j I UNDERGROUND FIRE'LINE.REPAIR'REF-P-C#i586-98� :.. ��-•_ e-�� � �r-\•'��G�/ �� ��� 1 FEE SUMMARY ..� _ r� P,lan•ChecK $373.59 �� ti n - 'r _- —� - ��,�� f,� r,i Calc Valuation $0.00, ;.f /�.�I', �fl oT�I`� i Permit: 1''$574.75 v . }� �� _� ,_�i;; 1?,C. �,��,`;,C, _i! �,-.� ..' Claimed Valuation: $5o,000.00 1 Other: 'Id $0.00 � 1 ti Ef �''. t ,Total• t`�$948.34 3 , �� ` /� � � \ �E.� � _�-. (1 In • r:�..� �.�`• <J;fl��'. v ` ` r �-ir/ `� ,L�/ � � {� �� '�� .� ��•C,R'• ��i •�1 r:,�'�S",. 4/ S���Y cam/ i ✓ EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or If work is suspended or abandoned for a period of 180 days. , INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain Inspectlons and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 DECLARATIONS 111—k, i i WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a cerilficate of consent to sett -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. ❑ t have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. My workers' compensation Insurance carrier and policy number are: Carrier: I Policy Number. (This section need not be completed it the permit Is valued at one hundred dollars ($100) or less.) ❑ I certify that In the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation taws of California, a ae that If I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisions. Applicant Signature: Date: " 2 2- ` 97 WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL_ SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section] -000} of Division 3 of the Business and Professions Code, and my license is in full farce and effect. Lic. # / class # C - (o - to .S 9112- 6 Contractor s Signature: ��, --L _ _ _ _ _ _ Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there Is a construction lending agency for the performance of the work for which this permit is Issued. (Sec. 3097, CMI Code). Lender's Name: Lander's Address: Signature: Date: OWNER-13UILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the fallowing reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their We compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or Improves thereon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not intended or offered for sale. If, however, the building or Improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, Le. - property tax bill or dead): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made In connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolitJon or dismantling thereof, Will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, 71tis 8, Catifomla Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Data: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 WIII the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ............. will ......app..................................................................................................................................................................a.1's .............................................................-........ 2 Does or will the appl€cant or present or future building occupant need to fits a registration form for acutely hazardous materials? ❑Yes ❑ No (Section 25533 of the Califomia Health and Safety Cade, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of Compressed gas at standard temperature and pressure). -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutety hazardous materials)? ❑ Yes ❑ No LSection 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, Certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an W0P. Is presently required, has Section 25534 of thi. e Calif- omia Health and Safety Code been fully complied with? ❑ Yes ❑ No ........................................................................... o. r. t'........................'s"I'h................................... a. t ............. n"d-...................................... ''o. d.."c.a.i...... 5 Doas or wi11 the applicant ar present or future building occupant require for the work which is the subject of this a plication a�ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested Information be furnished on applications for non-residential building permits). ....................................................................................................................................................................................................... 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). .................................................................................................................................................................................................................................................................................... 7 -If a permlt from the South Coast Air Quality Management District or other air pollution control district or agency Is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ................................................................................................................................................................... 8 (If yes", attach certificate of compliance Pram the appropriate a€r pollution control officer). CERTIFICATE OF COMPLIANCE: I Corti that under penalty of perjury the information given above Is correct I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final Inspection. �1—Sli;neture Of Legal ner(s) Date = An Or Authorized Applicant —( Date COO_ L IMSPECmONTYPE CODE MSPECTIONtYPE DAIS R1imALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 7- b��a 202 Final Factory Fire Place 220 Final Planning Approval „ 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy 2446.48 r' CITY OF COSTA MESA o A 1W s BUILDING DIVISION AL i 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 - www.ci.costa-mesa.ca.us r ` �. FOR INSPECTIONS CALL: (714) 754-5626 F10-00007 FIRE SUPRESSION PERMIT Job Address: 3333 BRISTOL ST Suite: Vicinity: BEHIND WET SEAL AND NATRULIZER SUBTYPE: OVERHEAD' Parcel Nunmber: 41250107, Applicant: a DE BOS,,WYBRAND Address: Phone: ' 714-712-3672 Zip: Owner: SOUTH COAST PLAZA Address 3315 FAIRVIEW RD Phone: COSTA MESA, CA Zip: 92626 Contractor: SIMPLEX GRINNELL LP Address: 1701 W SEQUOIA AV Phone: 714-870-1010 ORANGE, CA Zip: 92868 License: 802591 Status: APPROVED Applied: 01/12/2010 Issued: 01/12/2010 SCOPE OF PERMIT: FIRE SUPPRESSION PERMIT ADD 3 FIRE SPRINKLER HEADS AND RELOCATE 3 FIRE SPRINLER HEADS IN CONJUNCTION WITH THE EXTENSION OF CORRIDOR AREA BEHIND WET SEAL AND NATURALIZER AT CLUBHOUSE LOCATION, Ref BC09-00476, FEE SUMMARY Add'I Inspection Fees: $0.00 Total Fees: $118.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE t. INSPECTION TYPE D1; INTMALS CODE A INSPECTION TYPE DATE INTMALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy numb�e r�--� { ri m+7G Lfati cw rLKf w3, Co, PITT'. �---rTha need not be completed if the permit LS valued at one hundred dollars (S100) or less) i umber: kIG 011. 0 — 1,& — 874-0 ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code I shall fort 'th comply with these provision 7ziIle jppiQ� ure Date WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. 0 Z lass C ~ (t5 Co ignature Dai CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature Date 3057.46 (3x07) Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Dale Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the Califomia Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes . ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and Ming with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? C1 Yes [:1 No 8. (If "yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: 1 certify under penalty of perjury that I have read this application and stale that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described properly for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Suye at Legal Own"5) Date/ / W�iJjr /w3ci`r 1 /D AndJo A i scant_ to CITY OF COSTA MESA BUILDING DIVISION t77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 www.ci.costa-mesa.ca.us FOR INSPECTIONS CALL: (714) 754-5626 F10-00011 FIRE SUPRESSION PERMIT Job Address: 3333 BRISTOL ST Suite: 2820 Vicinity: SUBTYPE: OVERHEAD Parcel Nunmber: 41250107 Applicant: APODACA, DENNIS Address: 130 HIGHLAND AVE Phone: 714-680-5174 FULLERTON, CA Zip: 92832 Owner: SOUTH COAST PLAZA Address 3315 FAIRVIEW RD Phone: COSTA MESA, CA Zip: 92626 Contractor: R T SHELTON Address: 130 HIGHLAND AVE Phone: 714-680-5174 FULLERTON. CA Zip: 92832 License: 869383 Status: ISSUED Applied: 01/2012010 Issued: 01/20/2010 SCOPE OF PERMIT: FIRE SPRINKLERS FOR "WET SEAL". REF: BC09-00439. 1 SYSTEM AND 14 HEADS. FEE SUMMARY Add'I Inspection Fees: $0.00 Total Fees: $167.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1. 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE M• INSPECTION TYPE QM tNTMAlS �M INA -n N M DATEN� 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Raaf 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention �Q 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the icti.nt3700 ance of the work for which this permit is issued. ave and will maintain workers' compensation insurance, as required by of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number ar {This section need not be compteted A rha,berm t is vahfed at one hundred dolars (S 100) OF ILSs, j ��r: wCsg�'�o7Cn ❑ I certify that in the performance of the work for which this permit is issued, t shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Sect' n 3700 of { abor Code. I shall forthwith comply with these pro sions ��1 1 2_��(] e ppliCarrt�$�¢talure Del } WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP Tp ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed un(ier provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. r o CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Dale OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuaht to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption, Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of safe.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractus License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature 305746 (3/071 Date Owner ID verified by driver s license. ❑ Yes j] No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code), ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Division of Industrial Safety Permit Number: Dale HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of Compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department, 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No S. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction of modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safely Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If "yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. f agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Dale CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY, I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. ignature of Legal Owner(s) Date �Zq c7 !81�6(2—Apphcan, F C__Vte_ 4 CITY OF COSTA MESA BUILDING DIVISION r DEVELOPMENT SERVICES DEPARTMENT PERMIT (714) 754-5273 • Fax (714) 754-4856 BUILDING PERMIT .lob Address: 3333 BRISTOL ST Suite: Vicinity: SECOND FLOOR STAIRS Parcel Nunmber: 41250106 Zoning: PDC PDC L Applicant: DAVIES, OARA Address: Zip Phone: License: Zip: PERMIT NUMBER B99-00316 77 FAIR DRIVE, COSTA MESA, CA 92626 Status: ISSUED Applied: 03/08/1999 Issued: 03/08/1999 Phone: License: Phone: CONSTRUCT NEW CONCRETE STAIR WAY @ SECOND FLOOR (SEE SHEETS A-202 a A-252). STAIR IS AT SECTION Zip: Sov 1 H ZXA,��- PLftzA -- Mfi IN Owner: SEIR Address r£",-1 RD. $112.25 - - .� / Claim Valuation: S+5,500.00 0-- M. CA. Phone: $0.00 C1.c-p2fo Zip: 60179 Contractor: BASELINE CONSTRUCTION Address: 20201 SW. BIRCH ST $0.00 Phone: $113.40 N.B. CA Zip: 92660 License: 429501 Arch Eng: Address: Address: Zip Phone: License: Zip: PERMIT NUMBER B99-00316 77 FAIR DRIVE, COSTA MESA, CA 92626 Status: ISSUED Applied: 03/08/1999 Issued: 03/08/1999 Phone: License: PLANNING & ZONING SETBACKS MAIN STRUCTURE Front 0-0 Rear 0-0 Left 0-0 Right 0-0 ACCESSORY Front 0-0 Rear 0- 0 Left 0-0 Right 04 PARKING Existing: 0 Required: 0 Proposed: 0 NOTES: EXPIRATION: This permit shall automatically expire and become void if work Is not commenced within 160 days, or if work is suspended or abandoned for a period of 180 days. 'INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result In the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 SCOPE OF PERMIT CONSTRUCT NEW CONCRETE STAIR WAY @ SECOND FLOOR (SEE SHEETS A-202 a A-252). STAIR IS AT SECTION E-20 AREA, FEE SUMMARY Plan Check: $0.00 Calc Valuation: $5,500.00 Permit! $112.25 - - .� / Claim Valuation: S+5,500.00 SMIP Res: $0.00 SMIP Com: $1.15 Other: .$0.00 Inspection! $0.00 Total: $113.40 PLANNING & ZONING SETBACKS MAIN STRUCTURE Front 0-0 Rear 0-0 Left 0-0 Right 0-0 ACCESSORY Front 0-0 Rear 0- 0 Left 0-0 Right 04 PARKING Existing: 0 Required: 0 Proposed: 0 NOTES: EXPIRATION: This permit shall automatically expire and become void if work Is not commenced within 160 days, or if work is suspended or abandoned for a period of 180 days. 'INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result In the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 DECLARATIONS WORKERS' COMPENSATION DECLARATION: .. hereby affirm under penalty of perjury one of the following declarations: have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. My workers' compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed it the permit is valued at one hundred dollars ($100) or less.) ❑ I certify that In the performance of the work for which Phis permit is issued, i shall not employ any person in any manner so as to become subject to the workers' compensation la s of California, and I;gree th It I should become subject to the workers' compensation provisions of eCti n 3700 of the Labor Code, I shall forthwith comply with thea p i Applicant Signature:-L7.� �lh�� _ _ Dater 1 WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: hereby affirm that I am ilcenge5�un�gr pro i rs of Chapter 9 (commencing with Section 7000) of Division 3 of the tress and Professions Code, and my license is In full force and effect. Lic. # - L�d y 1 N Class # Contractor's Signature: 1% F_>11 E't U-5, Date: CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is Issued. (Sec. 3097, Civil Code), Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE.LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to Its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Seo. 341, Title 8, California Administrative Cade). ❑ As owner-builder, I will not employ anyone to do work which would require a Hermit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic fest of compressed gas at standard temperature and pressure). ................................................................................ .............. ................................................. ................... ............................................................................................... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ..........................................................................................................................................................................................................................................................I..................... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ Na (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. .. ...... ......5pl... ....................... .......................................................................................................... .......... ......................... I......................... 4 It an RMPP 1s presently required, has Section 25534 of the Califomia Health and Safety Code been fully complied with? ❑ Yes ❑ No ................................................................................................................................................................................................................................................................ 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? lU Yes LJ No (Section 65850.2 of the California Government Cade requires that the requested information be furnished on applications for non-residential building permits). ......................................................................................................................................1­11- ....................................................................................................................... 6 Will any part of the fadlity to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'fres", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a Permit from the South Coast Air Quality Management District or other air pollution control district or agency is regwiofred for the work which Is the subject this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑Yes ❑ No ............... ....... ................................... ............... .............................................................................................. .............................................. ......... ............................ ...... jres", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given Is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for Inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final Inspection, eget Owner(s) � t +1 AndtOr Authorized Applicant Imte CODE INSPECtiON TYPE DAIS UQIIIALS CODE ! INSPECTION TYPE DAIS IHIIDALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Flnal Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (.ti2-6-1Z 2446-46 1 i CITY OF COSTA MESA•- �` BUILDING DIVISION 10 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 www.ci.costa-mesa.ca.us r FOR INSPECTIONS CALL: (714) 754-5626 4m'd` PERMIT NUMBER: BC10-00375 PERMIT TYPE: B_COMBO STATUS: ISSUED Sub Type: COM—ALT DATE ISSUED: 09/1512010 ISSUED BY: RMD JOB ADDRESS: 3333 BRISTOL ST CM APN: 41250107 Vicinity: 2ND LEVEL - WEST ENTRY Const Type: I -A SQ. FT: Suite/Unit: Zoning:PDC, , Primary Occ: 0 Valuation: $50;000.00 SCOPE OF WORK: 2ND LEVEL ,'WEST ENTRY. REMOVE EXISTING ENTRY DOORS AND FRAMES. INSTALL NEW AUTOMATIC SLIDING DOOR AND SWINGING DOORS. ONE ELECTRICAL OUTLET OWNER: SOUTH COAST PLAZA Phone: APPLICANT: SIEBERT, PHIL Phone: 949-338-7126 CONTRACTOR: HURST AND SIEBERT Phone: 949-361-0111 Cell: ARCHITECT: ENGINEER: COMBINATION PERMIT FEE SUMMARY Building Plan Check: Building Fees: Electrical Fees: Mechanical Fees: Plumbing Fees: SMIP Residential: SMIP Commercial: Bldg Std Admin Fund TOTAL FEES: Address: 3315 FAIRVIEW RD Unit: City/State/Zip: COSTA MESA, CA Address: Unit: CitylState/zzip: License No. 622681 Address: 2377 SO EL CAMINO REALUnit: SUITE 103 City/State; SAN CLEMENTE, CA ZipCode 92572 License No. PHONE: License No. PHONE: $104.69 $644.25 $24.60 $0.00 $0.00 $0.00 $10.50 $2.00 .$786.04 'Refer to fee receipts for alt fees paid for pr9ject HOURS FOR CONSTRUCTION ACTIVITY: EFFECTIVE 3/1812010 - PER CMMC Sec. 13-279 Monday thru Friday - 7:00 am thru 7:00 pm. Saturdays- 9:00 am thru 6:00 pm. Prohibited all hours - Sundays and the following Federal holidays: New Years Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day and Christmas Day NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF (LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE 1. INSPECTION TYPE 1616 Fixed System Final Fire Prevention 1266 Pool Spa Final 200 Final Re -Roof 201 Final Block/Retaining Wall 202 Final Factory Fire Place 203 Final Sign 204 Final Demolition DATE INTMALS CODER INSPECTION TYPE 206 Final Mechanical 208 Final Plumbing 210 Final Electrical 212 Final Fire Prevention 220 Final Planning Approval 222 Final Site 250 Final Building/Occupancy DATE INTITIALs x ji -1 -lo R_6 aQ-- -,( 10 -29 -ID P8 WORKERS' COMPENSATION DECLARATION. I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: oV (Thos secton need not be foompleted A the R rs valued at one hundred dollars (S100) or less) Policy Number: / i� ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should became ubfect to the workers' corppensation provisions of Section 3700 of the L I sh i fortith co ly with these provision rn (J A=15mver6i / f te' WARNING: FAILURE TO SECURE WORKER$' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic. CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Cade: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he Or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of not more than five hundred dollars {$500).): ❑ I, as owner of the property. or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of Completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature 3057-46 (3/07) Date Owner ID verified by driver's license. j] Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). C] As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above. unless such person has a permit to do such work from the division. Applicant's Signature Dale Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the Califomia Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No S. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? []Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If "yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon t e above-described property for inspection purposes. 1 agree not to occupy r allow occupancy of any building authorized by this permit u 'I final ' spe ' g eat {s ale Andlor-AuMcin- ed Applicant C:. le' CITY OF COSTA MESA BUILDING DIVISION e * 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 www.ci.costa-mesa.ca.us �. FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BC08-00235 PERMIT TYPE: B_COMBO STATUS: ISSUED Sub Type: COM—ALT DATE ISSUED: 07/1812008 ISSUED BY: J013 ADDRESS: 3333 BRISTOL ST CM'" StiitelUfait: APN: 41250107 Zoriing:PDC; - , Vicinity: Primary,Occ: M Const Type: I -A SQ,iFT: 0 Valuation: $750,000.00 SCOPE OF WORK: REMOVE EXISTING ESCALTOR AND CONSTRUCT NEW ELEVATOR IN THE MALL LOBBY LOCATED' BETWEEN SEARS AND MACYS. 7 LIGHTS 2 OUTLES 4 SWITCHES., -1 MOTOR 100 HP 1 AC UNIT < 100K BTU 1 AIR HANDLER.. OWNER: SOUTH COAST PLAZA Address: 3315 FAIRVIEW RD' Unit: Phone: —1 f City/State/Zip: COSTA.MESA, CA APPLICANT: JOHN PRICE Address: Unit: Phone: 949-716-8258 City/State/zZip: CONTRACTOR: HURST AND SIEBERT License No. 622681 Phone: 949-361-0111. ` Address: 2377 SO EL CAMINO REALUnit: SUITE 103 Cell: City/State: SAN CLEMENTE, CA ; ZipCode 92672 ARCHITECT: License No. PHONE: ENGINEER: PEYTON - TOMITA AND ASSOCIATES License No.3304 PHONE:714-245-4931 COMBINTATION PERMIT_ FEE SUMMARY Building Plan Check: $7.1$:45 Building Fees: $4,421.25 _ Electrical Fees: $87.30 Mechanical Fees: .$48.95 Plumbing Fees: SMIP Residential: $0.00 SMIP Commercial: $0.00 TOTAL FEES: $5,275.95 "Refer to fee receipts for all fees paid for project NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with -all applicable codes, and all required Inspections and ffnaf approval must be obtained. Failure to obtain inspections and final approval wiif result in the expiration of this pe it. C9QE /. 1NSPECrONTYPE DTE INTIMAL S CQQEa INSPECr011 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1 1206 Pool Spa Flna! 208 Final Plumbing C� 200 Final Re•Roof 210 Final Electrical 201 Final BlooklRetaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final BuildinglOccupancy WORKERS' COMPENSATION DECLARATION:' 1 hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the 0p ormance of the work for which this permit Is Issued. " 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy rIUMEFFMw Carrier: ¢T'c�+r±b_ section need not be oorrtpleted C o9e pemW is valued atone hundred dollars ($100) or less.) Policy Number: 1606 BB I ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject t the k s' compensation provisions of Section 3700 of the Cod s fo It comply with these provisio lirant's Sign re Date WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my ' se is in full force and effect. L' 6 Z 68 ! lass Cont lor's nalurie D e CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure. prior to its issuance, also requires the applicant for such permit to rile a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement, is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property. am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Owner ID verified by driver ....cense. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title B. California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division, Applicant's Signature Division of Industrial Safety Permit Number: Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to rile and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No S. (If 'yes", attach certificate of compliance from the appropriate air`pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above,is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date , CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all slate laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. ti T—liicinfu'mNLewi r(s) Dole Signature Dale 30576 (3107) Andlur tulhonzed Appli nl ate QUALITY CONSTRUCTION MANAGERS, INC. June 12, 1985 Mr. Burt Morgan CITY OF COSTA MESA Post Office Box 1200 Costa Mesa, California 92628-1200 RE. SOUTH COAST PLAZA ELEVATOR ADDITION South Coast Plaza, California QCM, Inc. Project No. 81450 Dear Mr. Morgan: Per your request, please find the "Permit to Operate an Elevator" sent by South Coast Plaza as verification of an approval by the State Elevator Inspection Agency. If we can be of further assistance, please do not hesi- tate to call. Sincerely, Don Gause Construction Manager DG:kv Enclosure 10005 MUIPLANDS PKWY, UNIT A • IRVINE, CA 92718 + ( 714) 770-3460 VORM No. $-I 32A (REV. 10-781 STATE OF CALIFORNIA ae202-50i iG-G210M39PT0Woar 58M � DEPARTMENT OF INDUSTRIAL RELATIONS DIVISION OF OCCUPATIONAL SAFETY AND HEALTH PERMIT TO OPERATE AN ELEVATOR 4-12-85 /aa (Sections 7200-7322 of the lAbcn Code) TX1 E47085-1SD/ South Coast Plaza c/o Office of the Building 3333 Bristol Street Costa Mesa, CA 92626 Attention: Rick Landau vw A, I'W.� - row ---tkWrK, "MCI lye W momww STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS .SION OF OCCUPATIONAL SAFETY AND HEALTH ERMIT MUST BE POSTED IN ELEVATOR CAR % .1 A d., V :.,. 41 r L -4. - AY. -N-3 =V, VORM No. $-I 32A (REV. 10-781 STATE OF CALIFORNIA ae202-50i iG-G210M39PT0Woar 58M � DEPARTMENT OF INDUSTRIAL RELATIONS DIVISION OF OCCUPATIONAL SAFETY AND HEALTH PERMIT TO OPERATE AN ELEVATOR 4-12-85 /aa (Sections 7200-7322 of the lAbcn Code) TX1 E47085-1SD/ South Coast Plaza c/o Office of the Building 3333 Bristol Street Costa Mesa, CA 92626 Attention: Rick Landau vw A, I'W.� - row ---tkWrK, "MCI lye W momww STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS .SION OF OCCUPATIONAL SAFETY AND HEALTH ERMIT MUST BE POSTED IN ELEVATOR CAR CITY OF COSTA MESA BUILDING DIVISION 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 - Fax (714) 754-4856 www.ci.costa-mesa.ca.us FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BC08-00147 PERMIT TYPE: B_COMBO STATUS: ' ISSUED Sub Type: COM—ALT DATE ISSUED: 05116/2008 Mechanical Fees: ISSUED BY: YH . - $0.00- JOB ADDRESS: 3333 BRISTOL ST.CM, °' p ,a StiitelUn'it•;,: APN: 41250107 Zohing:PDC, - $42.00 F TOTAL FEES: Vicinity: 2ND AND 3RD FLOOR P�UBLIC'AREAS ` f - '- ,PrimaryOcc:.M Const Type: I -A ,' F SQ FT 1500 Valuatioft: $200,000.00 SCOPE OF WORK: PHASE,4'.'I.COMMON'AREA AT "SOUTH COAST PLAZA." WORK INCLUDES REMOVAL OF PLANTERS, REAILINGS ON THE 2ND AND 3RD FLOORS. INSTALLATION OF NEW RAILING, GLASS PANE_ L.FLOORING, BACK FIT LOGOS AND FLOORING. NO PLUMB. OR MECH ELECT IS 40 FIXTURES ONLY.-,! a ' OWNER: SOUTH COAST PLAZA,`, . ", Address: 3315 FAIRVIEW RD " ' -• t°. ; n Unit: ' Phone: City/State/Zip: COSTA MESA, CA: .r APPLICANT: PRICE, JOHN Address: ;Unit: Phone:949-716-8256° . CitylStatelzZip: CONTRACTOR: SNEDEN AND,66WERS INC - License N6. 811856 I ' Phone: 714-838-4112= - Address: 1081 ST REGIS PLUnit: Cell: 714-350-2415{'' t.:, City/State: SANTA ANA, CA ZipCode 92705 ARCHITECT: JOHN BRYAN-PRICELicense No.C30696 ENGINEER: MARK TOMITA=`PEYTON-TOMITA AND ASSOC. PHONE: 714-245-4931 COMBINTATION PERM_ IT•FEE SUMMARY Building Plan Check: $252:49, PHONE: 949-716-8258 License No.S3304 Building Fees: $1,553.75 Electrical Fees: Mechanical Fees: MOO:, Plumbing Fees: - $0.00- SMIP Residential: $0.00 t 47 SMIP Commercial: $42.00 F TOTAL FEES: $1,908.34 "Refer to fee receipts for all fees paid for project NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with al! applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. COog 1. INSPECTION TYPE DATE INTIW, T1AL5 CODE! INSPECTION TYPE DATE INTMALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy E WORKERS' COMPENSATION DECLARATION: 0 I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. Lhave and will maintain workers' compensation insurance, as required by `section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number � I (Cartier: 756M V w (This sedbn need not be Completed d the permd is valued al one hundred dollars ($100) or less ) Policy Number: ❑ I certify tha in the performance of the work for which this permit is issued, I shall employ an on in any manner so as to become subject to the wo compens Ion la of California, and agree that if I should 4be u t to the rkers' compensation provisionspit Section 3700 of abor C h these provisi s. can re WARNING: FAIL RE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL ND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND IVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license infull force and effect. `Cie.. r / 1 Class :# r a tract S� re - Date CONSTRUC ION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lenders Name: Lender's Address: Signature Dale OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature Date 3057-46 (3!07) Owner ID verified by drive A ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Division of Industrial Safely Permit Number: Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (It 'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify. that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date r CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY. I certify under penally of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purpo es. I agree upy or allow occupancy of any building authoriz9d by Is permityltil final inspection, Date . —Date- V CITY OF COSTA MESA BUILDING DIVISION 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 www.ci.cw ta-mesa.ca. FOR INSPECTIONS CALL: (714) 754-5626 F07-00353 FIRE SUPRESSION PERMIT .lob Address: 3333 BRISTOL ST Status: ISSUED Suite: t Applied: 11/19/2007 Vicinity: Issued: 11/28/2007 Parcel Nunmbec 41250107 Zoning: PDC PDC Applicant: CHRIS GUTIERREZ. ' I Address: 18102 SKYPARK Cl " SUITE B Phone: 949-221-0194 IRVINE, CA Zip: 92614 owner: SOUTH COAT PLAZA-. Address I, „ . COSTA MESA CA Phone: 3315 FAIRVIEW ROAD Zip: 92626 Contractor CORUM CAPITAL CORP DBA GENTECH CONTROLS Address: 18102 SKYPARK Cl _ SUITE 6 Phone: 949-221-0194 IRVINE, CA- Zip: 926114 License: 811297 SCOPE OF PERMIT FIRE ALARM FOR NEW GLASS ELEVATOR AT "SOUTH COAST PLAZA" NEAR JEWEL COURT. REF.: B06-00543 Plan Check: $29.15 Permit: $44.85 Other: $0.00 Total: $74.00 FEE SUMMARY Calc Valuation: $1,200.00 Claimed Valuation: $1,200.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE p• INSPECTION TYPE OAST INTMAL CODE # INSPECTION TYPE DATE 1NTMALS 1616. Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Stock/Retaining Wall _ 212 Final Fire Prevention � !, 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final BuildinglOccupancy WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided fbr by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor.Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are, r !1 MGamier:_ rs sktw nerd nW ed Arhe perrrvt is valued at one hundred ".-Is ($ 100) a' less) P-olicy.Number: ❑ I certify that in the pertormance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should becom u 'ect to the workers' c pensation provisions of Section 3700 of th a r e, I shall fort ply with these provisions. L'�Appffea 5 Segnaturj � re^ ---^F WARNMG: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL_ SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION,3746 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licenged under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. uw—#y ; Class JV �wrdactarsZ9_144NDat CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (Commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her awn employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Co(Je for this reason: Signature _._. Date 3057-4613107) Owner ID verified by driver's Iii. .. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building stnicture, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, Califomia Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Division of Industrial Safety Permit Number: Dale HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4, If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If "yes", attach certificate of compliance from the appropriate air pollution control officer), CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions, Signature Dale CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: f certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authoried y this permit u til fi I inspection. Signature Le I e(s) rDale {� ti I I 291 I Anttf�..AulfriSrrpliCanl� • Dole (714) 754-5273 • Fax (714) 754-4856 • www.cl.costa-mesa.&jFsCTRICAL PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Suite No Vicinity: WALK WAY BETWEEN BLOM AND CLUB HOUSE Parcel Nunmber: 41250107 Applicant: BOB FERNANDEZ Address: 3315 FAIRVIEW ROAD ISSUED BY: Phone:` Zip: ! } License:000000 Al. i SCOPE OF PERMIT 'ADD 19 NEW LIGHT, FIXTURES AND 1 ILLUMINATED PEDESTRIAN SIGN ON EXISTING WALKWAY BETWEEN BLOOMINGDALES AND CLUB HOUSE RESTAURANT. Status: ISSUED Applied: 12/06/2006 Issued: 02/27/2007 50.00 -Phone' '714.438.3222 isc ectncal Equipm1.ent Transformers u to•1 kva/kw�- COSTA MESA CA `� , ' Zip~ . 92626 -, i- ., f ~ -, V, ; -- Quantity ISSUE FEE $23.50 ,! ;: r Temp Dist Systern-1,Lighting $0.00 0 Owner: SOUTH COAST PLAZA 1 Address Res. a/c package l Standing Section' COSTA MESA CA Phone;- / . 3315 FAIRVIEW ROAD "f Zip: 92626 $0.00 0,, Non Res Appl Contractor: 'OWNER -BUILDER Low Voltage'Equipment $0.00 0 - Res Appl, , $0.00 i Address: Low Volt Wiring System 1 Ckt ;$0.00 0 l ISSUED BY: Phone:` Zip: ! } License:000000 Al. i SCOPE OF PERMIT 'ADD 19 NEW LIGHT, FIXTURES AND 1 ILLUMINATED PEDESTRIAN SIGN ON EXISTING WALKWAY BETWEEN BLOOMINGDALES AND CLUB HOUSE RESTAURANT. Status: ISSUED Applied: 12/06/2006 Issued: 02/27/2007 New Res (3+units) 50.00 FEE SUMMARY isc ectncal Equipm1.ent Transformers u to•1 kva/kw�- $0-00 0 $0.00 0 ; Quantity -, i- ., f ~ -, V, ; -- Quantity ISSUE FEE $23.50 ,! ;: r Temp Dist Systern-1,Lighting $0.00 0 Temp service test $0.00 _ _ - Buswayl100 ft i $0.00 0 Res. a/c package $0.00 , Standing Section' $0.00 0 New Res (1-2 units) $0 00 0 M; EI ............ "..over 100 kvalkw New Res (3+units) 50.00 0!^• ~ isc ectncal Equipm1.ent Transformers u to•1 kva/kw�- $0-00 0 $0.00 0 ; Pool /Spa $0.00 i F• 0_.,_ ""� - _= C� •: - : =up to ii&Walk+nr �- $0,00 0 Lighting Fixts $20.90 ` • 19 - .v c up.to 50 kvalkw - $0.00 0 ! r Rece t Outlets p $0.00 0 up to 400 kvalkw $0.00 0 Switches $0.40 , 0 ............ "..over 100 kvalkw $0.00 0,, Non Res Appl $0.00 0 Low Voltage'Equipment $0.00 0 - Res Appl, , $0.00 i 0 Low Volt Wiring System 1 Ckt ;$0.00 0 l Service to 200x• ,• $0.00 0 , Misc:•Conduit 10.00 "/0/ Service to 1000a $0.00 0 Misc.'Conductor $4.00 ;! 0 Service over 1000a '�� $0.00 0; �, Circus (-gen,or. ride)$0.00 ,'0 Motors to 1 hp $0.00 0 Circus (meth ride'or lights) $0.00-1' ' 0 i Motors to 10hp $0.00 0 �, Christmas Tree Stand °' -'` " $0.00 D Motors to 50hp Motors 100hp $0,00': � 0 ' Fireworks Stand ;$0.00 , 0 to ,' $0.00•X , ���� 0 - Other- Electrical Fee -$0.00'_/"' Motors over 100hp� $0.00 '�0�:,. �� ;�. Communication drops- $0.00. �0 Investigation $0.100- Sub panel to 200a $0.00 0 �- _ -,:Plan Check Fee ' : '-$0.00 Pole Light Pkg ` '� ` , $0.00 % �` ' , 10 -. �' --Reins_pection-Fee-"�� �� 10.00 Sign Circuits :$0.40 0 Temp Pwr Pole $0.00. ; ; 0 TOZAL'CALCULATED FEES $44.40.'', Intermed Pole $0.00,'.0--: ' , � , -,Q, _� l' -COMMENTS 1 SPECIAL CONDITIONS` NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) . EXPIRATION: This permit shall automatically expire and become void if work Is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the w%k authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 244848 (M) JMLARATioms WORKERS' COMPENSATION DECLARATION: hereby affirm under penalty of perjury one of the following declarations, ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. [] 1 have and will maintain workers' compensation Insurance, as required by section 37DO of the Labor Code, far the performance of the work for which this permit Is issued. My workers' compensation Insurance carrier and policy number are: Carrier: Policy Number: (This s tion need rot be completed if the permit is valued at one hundred dollars ($100) or less.) I comity that in the performance of the work for which permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and th ould become subject to the workers' componsatlon provisions of Section 3700 f the Labor Code, i shall forthwith complywith these provisi Applicant Signature: Date: WARNING: FAILURE TO SECURE WORKERS' NSATION COVERAGE IS UNLAWFUL AND SHALL SUELIECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic. q Class f1 Contractor's Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is Issued. (Sec. 3097, Civil Code). Lender's Name: Lendor's Address: Signature: Data: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to Its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Divislon 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exomption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work hi It or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. It, however, the building or improvement is ld within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Coda: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursua�Gontractorssa Laws.). I am exempt uBusiness and Professions Code for his reason: Signature: Date: Owner ID verified by drivers I rise. ❑ Yes ❑ No Driver's License No Expires: Verification of Ownership by (type of document, i.e. - property tax bill or doed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than Ihlrty six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Coda). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Data: Division of Industrial Safety Permit Number. HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 o1 the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 50D pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 20D cubic feet of compressed gas at standard temperature and pressure). -- —..—._._.. _ _ _ _ _ . _. _ .............. .---�.._................ _� . �.. __.......— 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 tf an RMPP is presently required, has Section 25534 of the California Health and Safety Coda bean fulty compiled with? ❑ Yes ❑ NQ 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a6rmil for such construction or modification from the South Coast Air Quality Management District or from any other air poltution control district or agency? LJ Yes LJ No (Section 65650.2 of the California Government Code requires that the requested Information be furnished on applications for non-residential building permits). — —---......_.....__....__._.......................... _ ........... 6 Will any parohe facilityto.—constructed ....._..—._....... _ ... _--...--- under this permit be within 101X1 feet from the outer boundaries of a school? ❑ Yes ❑ No (If ryes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 11 a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which Is the subject of this application. have all of the disdosures proscribed by California Health and Safety Code Section 42303 boon made? ❑ Yes ❑ No 8 (If 'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above Is correct. I agree to comply with ail state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for Inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. n e �/_.. / 7 And/Or Authori ppl cant /`i �f/[� ate CODE 1. jNSPEC-nQ.b,p'PE WE INTITIALS CODE I INSPECTION TYPE 2M 1!{[IDALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1268 Pool Spa Final 208 Final Plumbing a` 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Placa 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 - Fax (714) 754-4856 - www.ci.costa-mesa.efALDING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Suite: Vicinity: Primary Occ: M Display/Sale Merchandise Type of Construction: I -FR Parcel Number: 41250107 Zoning: PDC Applicant: WOODRUFF, JOHN Address: 2121 ALTON PARKWAY SUITE 150 A IRVINE, CA Phone: 949-608-3474 Zip: _ 92606 Status: ISSUED Applied: 04/12/2006 Issued: 06/16/2006 ISSUED BYE AV 0 YV Owner: SOUTH COAST PLAZA - Address COSTA MESA CA • ' — Phone:, 3315 FAIRVIEW ROAD 1 Zip: 92626; -- , HOWARD S'WRIGHT.CONSTRUCTORS L P �:.� `. ���� Contractor., _ �," , > Address:. _ 2121 ALTON PARKWAY SUITE 150 A Phone: 949-608-3474 IRVINE, CA Zip: 92606 License: 860938 Arch : GRUEN AND ASSOCIATES Address: 6330 SAN VICENTE BLVD SUITE 200. Phone: 323-937-4270 LOS ANGELES, CA Zip: 90048 License: C8379 - Eng: ` Address: Phone: License: SCOPE OF PERMIT._ 137,409 S.F. INTERIOR TENANT IMPROVEMENT THROUGHOUT PUBLIC SPACES FOR "SOUTH COAST PLAZA". WORK TO INCLUDE: REAPiACE 1 STAIR (NEAR MACY'S MEN'S STORE), ADD OBSERVATION ELEVATOR (NEAR JEWEL COURT) AND REPLACE GUARORAILIHANDRAIL. `• _ 1-7"• �r �r :, -FEE�SUMMARY Pian Check: $4,766.74 77 - - Calc Valuation: $7,500,000.00 Permit: $29,333.75 Claim Valuation: $7,500,000.00 SMIP Res: $0.00 ^' SMTP Com: $1,575.00 Other: $0.00 - Inspection: $0.00 - Total: $35,675.49 _ SETBACKS MAIN STRUCTURE Front , 0- 0 ACCESSORY PARKING Front - 0- 0 Existing: 0 _•-PLANNING & ZONING Rear 0- 0 Left . 0-0 , Right ,/0 - Rear ,0 -Rear 0- 0 Left,' 0-0 Right,- --O' 0,� Required: 0 Proposed: 0- V NOTICE: The work authorized by this permit shad comply with all applicable handicap access requirements under California and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This perrnit shall automatically expire and become void it work Is not commenced within ISO days, or,4wwo�rk is suspended or abandoned for a period o1 180 days. V INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with an applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will resuil In the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446-46 (MM F-1 DECLARArIONS WORKERS' COMPENSATION DECLARATION: hereby affirm under penalty of perjury one of the following declarations: ❑ i have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. �E]—1 have and,will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for•the performance of the work for which this permit is issued, My workelrs' compensatlo Insura ce carder and policy numb "re: Carrier: Afr /7�21',LZ�/� �/Ls(>%AZ,C Polio`yNumhe���`t����Qa!—�t� (This section creed not be completed it the permit is valued at one hundred dollars f$100) or less.) ❑ 1 certify that in the pert rmance o e work for which this permit is iss I nl not employ any person in any manner so as to become sub' C to the workers' compensation laws of alifomi d a e at I I shout become ec workers' compensation provisions of Section 370 of the I r Code, I shall forthwith comply with these pr 8 �� Applicant Signature: rDate r WARNING` FAILURE TO RE WORKERS' COMPENSA ON COVERAGE IS UN L ANQ SHALL SUEUECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($1 ,000J, iN ADDITION TO THE COST OF COMPENSATION AMAGES AS PROVI DED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am Iicens er pro ions Chapter 9 (commencing with Section 7000) of Division 3 of the.Business a Professions Code, and my license Is in full force and effect. Lic. # class,#: l+ r.,.'4•.,. ` P Contractor's Signature: Date: -� CONSTRUCTION LENDIN AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors license Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the properly, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certity that no excavation five (5) or more feel in depth into which a person is required 10 descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition Or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division, Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ..................................................................................................................................................................................•----.........---.......................................................................................... _. 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .............................................................................................................................................................................................................................................................................................................................................................................. 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ......................................................................................................................................................................................................................................................... .. ........................................ ........",.............. 4 If an RMPP Is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No ....................... ...................... .... ........... ................................................................................... -................................................ ........................................ .................................................................................................................................... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a6rmlt for Such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? El Yes L I No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ............................................................................. ..........................._............................................. _ _... 6 Will any part of the facility to be constructed under this permit be within 1000 teat from the outer boundaries of a school? [:]Yes ❑ No (If 'yes the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Coda). ...........................••..................................................................................... .................................. --..................................................... ........................;.............................................................................. ................................................................... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (If yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree t0 comply with all state laws and city ordinances regarding Hazardous Materials and `:missions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above -des `bed prop for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. gni O e l w ZD -4 0� 7ndlOr Au orized Appfficrlz Date JQQLV mpg INTMALS CODE it INSPECTIONTYPE 114ITIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266' Pool Spa'Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final BuildinglOccupancy d (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.p,us,MBING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Suite No Vicinity: PUBLIC AREA AT SCP Parcel Nunmber: 41250107 Applicant: GAINES, CLABE Address: 2121 ALTON PARKWAY SUITE 150 A IRVINE, CA Phone: 949-608-3474 Zip: 92606 Owner: 'SOUTH COAST PLAZA AMT Address •' 0 AMT COSTA MESA CA Phone: --'WT 3315 FAIRVIEW ROAD Zip: 92626 Contractor: , HOWARD S WRIGHT CONSTRUCTORS L P Address: 2121 "ALTON PARKWAY Backflow irrigation $0.00 SUITE 150 A Phone: 949-608-3474 IRVINE, CA Zip: 92606 P -Trap License: 860938 ISSUED BY: Status: ISSUED Applied: 1012412006 Issued: 1012412006 ' . SCOPE OF PERMIT PLUMBING TO INCLUDE: 2 FLOOR DRAINS AND 1 DRINKING FOUNTAIN, WATER CAP PIPING FOR REMOVAL OF DRINKING FOUNTAINS AND FLOOR DRAINS. WATER RE -PIPE IN SOME AREAS. REF: 806-00543.137,409 S.F. INTERIOR TENANT IMPROVEMENT THROUGHOUT PUBLIC SPACES FOR "SOUTH COAST PLAZA". WORK TO INCLUDE: REAPLACE 1 STAIR (NEAR MACY'S MEN'S STORE), ADD OBSERVATION ELEVATOR (NEAR JEWEL COURT) AND REPLACE GUARDRAILIHANDRAIL. MISC PLBG, ELEC AND MECHANICAL. Interceptors (Sand Auto ) $0.00 -0 QTY AMT FEE SUMMARY 0 AMT QTY _ _ - '-- __ _ - --'WT ISSUE FEE - $23.50 0 Laundry Tub/ Washer. - $0.00 Backflow irrigation $0.00 0 Landscape Irrigation $0.00 Backflow Preventer, $0.00 0 - P -Trap $0.00 Bathtub "1 $0.00 0, Pressure Regulator = $0.00 Clarifier System , ., $0.00 0, Process Piping (per 10 ft) $0.00 Connect (Ice,Soda,etc) 's$0.00 0 Receptors m $0.00 Dental Units _ $0.00 0 Septic Tank. $0.00 Dishwasher,' $0.00 0 Sewer Cap for Demo $0.00 Drain, Floor.- $19.60; 2 Sewer Connect $0.00 Drain, Rainwater $0,00; \ 0 5 t) Sewer Private Line $0.00 Drain, Roof' , �� ti� $0.00 �o v = � Shower, " $D.DO Drinking Fountain - 1 $9.80 1: __, Sink, bar $0.00 Expansion Tank', ` ' $0.00 -0 `" .,Sink; commercial $0.00 Gas Earthquake Valve $0.00 ' 0 ,�Sink,.Floor $0.00 Gas (1-4 outlets) - \$0.00 0", Sink, kitchen $0.00 Gas (Over 4 outlets) 'I, $0.00 Sink, service/mop $0.00 Gas Repipe x•$0.00 0, Spa (private) $0.00 Gas Service $0.00- 0 Spa (public) $0.00 Interceptors (Grease, Oil) $0.00 0 Interceptors (Sand Auto ) $0.00 -0 QTY AMT QTY 0 Sump Pump $0.00 0 0 Swimming Pool $0.00 0 0 Trap Primer $0.00 0 0 Urinal $0.00 0 0 Vacuum Brkr.Bkflow(1-4) $0.00 0 0 Vacuum Brkr•Bkfiow(5+) $0.00 0 0 Wash Basin . I 1 $0.00 0 0 Wash Basin Set $0.00 0 0 Waste and Vent System $0.00 0 0 : , • z_ "'= * Water 'Closet (Toilet) $0.00 0 0 -Water Heater 1 vent $0.00 0 0 - Piping,(Inst or Rep.) $29.40 3 0 _'Water Water Re -pipe $29.40 3 0 Water Service $0.00 0 __0 'Water Softener $0.00 0 0 OTHER $0.00 '0 VIOLATION $0.00 0 PLAN CHECK $0.00 REINSPECTION $0.00 0 COMMENTS 1 SPECIAL CONDITIONS TOTAL CALCULATED FEES: $111.70 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) t, EXPIRATION: This permit shall automatically expire and become -void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446-46 (6/00) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the w for which this permit Is issued. I have and will maintain workers' compensation I surance, as required by section 3700 of the tabor Code, for the performance of the work for which this permit is Issued. My wo rs ompensatlon Incur nce carrier policy number are: I� (� 76 /� I71 �_ Carrier: l/'Y" 1 Policy Number: lhJ`.'f�� / f! LL11 (This section ne root bid a completed if the permits valued at one hundred dollars ($ 100) or fess.) ❑ 1 certify that in the performance of the work for which this permit Is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Secti n 3700 of the labor Code, I shall forthwith comply with these provi / Applicant Signature: _/VI�C� �G1.�� Date: WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL P TIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE (S100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions y1 Chapter 9 (commencing with Section 7000) of Division 3 of the Busines d Professions Code, and my license is in full force and effect. Lic. # #0 Y60CI 3 Class # Contractor's Signature: /� �, v� Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is Issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that f am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, after, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License law (Chapter 9 (Commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant fora permit subjects the applicant to a civil penalty of not more then live hundred dollars ($500),): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.), ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ t am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Driver's License No. Expires: Verification o1 Ownership by (type of document, i.e. - property tax bill or dead): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person Is required to descend, will be made In connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title B, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _..............__...................--.............................................. 1111.... .........................._.......................... ._............ ............ .................... ...................................................... ................_......................... -.1.11.1........................ 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ........................................................................................ ........................... ...................... .................................... ................................................................................................._................................... ............... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fre Department. ..................................................................................................................................... ...............---...................................................... .................................................................................. ................. ................... .............. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No ............ .......................................................................... ................ ............................................ ................................................................................... ................................................................................ 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this a plication agermit for such construction or modification from the South Coast Air Ouality Management District or from any other air pollution control district or agency? Yes tJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ...... .._..................... ----•-•--................................... - - _ 1111.....-• ..... .._._.... _....... . —_........................................................ --- ......... _.............. . .............. .......... —.... 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if 'fres-, the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 1111..._ .......... __._.............._._...._..-- ----..__.._...__..._.. __.. __ 1111. _ _1111. _............. .. .._ _..-........._ _ ..... ........� -- 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (if 'yes% attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. AU at01 LegalOwner(s) j �� yy+ Due �� ( 09 - And/Or Authorized Applicant Date CODE !l. INSPECTION TYPE PAU INTITIALS CODE r INSPECTION TYPE PATE lTlIIDAL$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final ,208 Final Plumbing 100-y7 , 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval , 203 Final Sign 222 Final Site 204 Final Demolition 250. Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 - www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 MECHANICAL PERMIT .lob Address: 3333 BRISTOL ST Suite No Vicinity: GENERAL PUBLIC AREA SCP Parcel Number: 41250107 ISSUED BY: Applicant: GAINES, CLARE Address: 2121 ALTON PARKWAY SUITE 150 A Phone: 949-608-3474 IRVINE, CA Zip: 92606 Owner: SOUTH COAST PLAZA Address: COSTA MESA CA ' Phone: 3315 FAIRVIEW ROAD Zip: 92626 Contractor. HOWARD S WRIGHT CONSTRUCTORS L P Address: 2121 ALTON PARKWAY SUITE 150 A Phone: 949.608-3474 -IRVINE, CA Zip: 92606 License: 860938 Status: ISSUED Applied: 10/24/2006 Issued: 10124!2006 SCOPE OF PERMIT MECHANICAL TO INCLUDE: 1 COOLING SYSTEM, < THAN 100K BTU, ON BACK OF ELEVATOR FOR COOLING, REF: B06-00543. 137,409 S.F. INTERIOR TENANT IMPROVEMENT THROUGHOUT PUBLIC SPACES FOR "SOUTH COAST PLAZA". WORK TO INCLUDE: REAPLACE 1 STAIR (NEAR MACY'S MEN'S STORE), ADD OBSERVATION ELEVATOR (NEAR JEWEL COURT) AND REPLACE GUARDRAILfHANDRAIL. MISC PLBG, ELEC AND MECHANICAL. TOTAL CALCULATED FEES $37.20 COMMENTS I SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92.28, g 1, 12-21.92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced wlihin 180 days, or it work Is suspended or abandoned for a period of 160 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure'to obtain inspections and final approval will result In the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 2446-46 (aroo) FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 Repair/AltAbsorbtion Unit $0.00 0 Inst FAU <100 k BTU $0.00 0 Repair I Alt Refrigeration Unit $0.00 0 Inst FAU >100 k BTU $0.00 0 Ventillation System $0.00 0 Repair/ Alt Cooling/Heat $13.70 1 Evaporative Cooler $0.00 0 Inst / Rep. Recess Wail Htr $0.00 0 Commercial Incinerator $0.00 0 Refrig Sys <100 k BTU $0.00 0 Domestic Incinerator $0.00 0 Ref rig Sys >100 k BTU $0.00 0 Compressors / Absorption Svstems Gas Piping • • $0.00 0 Up to 3 hp/ 100k BTU $0.00 0 Factory Fireplace $0.00 0 3 To 15 hp / 500 k BTU $0.00 0 Hood w/Meth Exhaust $0.00 0 15 To 30 hp / 1,000 k BTU $0.00 0 VAV Box 1$0.00 0 30 To 50 hp / 1,750 k BTU $0.00 0 Vent Fan I Single Duct / ; '$0.00 0 Over 50 hp / Over 1,750 BTU $0.00 0 Appliance $0.00 • 0 Boilers Fire Dampers $0.00 :; 0. Up to 3 hp $0.00 0 Smoke Dampers' $0.00 0 3 To 15 hp $0.00 0 Inst or Relocate Appl Vent $0.00 0 15 to 30 hp $0.00 0 Air Handlers < 10000cfm $0.00 0 30 to 50 hp $0.00 0 Air Handlers > 10000cfm $0.00 0 Over 50 hp $0.00 0 Floor Furnace 50.00 0 Other Mechanical Fee Floor or Suspend Heater $0.00 `0 , Investigation Fee - $0.00 Plan Check Fee $0.00 Reinspection Fee $0.00 TOTAL CALCULATED FEES $37.20 COMMENTS I SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92.28, g 1, 12-21.92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced wlihin 180 days, or it work Is suspended or abandoned for a period of 160 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure'to obtain inspections and final approval will result In the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 2446-46 (aroo) DECLARATIONS WORKERS' COMPENSATION DECLARATION: _ I hereby affirm under penalty of pedury one of the following declarations: ❑ ave and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued, t have and will maintain workers' compensation insurance, as required by section 3700 Of the Labor Code, for the performance of the work for which this permit is issued. My wemVoompensatign I renco car,"r and policy number are: �7 Carrier: _ � 24 2 �:d Policy Number: V�'fv �� % ! A (This section need not be completed it the permlf is valued at one hundred dollars ($100) or less.) ❑ 1 certify that in the performance of the work for which this permit is Issued, t shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that It I should become subject to the workers' compensation provisions of Section 700 of th Labor Code, I shall forthwith comply with e: provisigfts. Applicant Signature: CC!/L"Z/'� Date: WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($700,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed urWor provislions of Chapter 9 (commencing with Section 7000) of Division 3 of the Busines a rofessions Code, and my license is In full force and effect. LIc. # 6 4' 3 Class # Contractors Signature: _ 9ol_ Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is Issued. (Sec. 3097, Civil Code). Lenders Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires B permit to construct, alter, improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation o1 Section 7031.5 by any applicant fora permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or Improves thereon, and who does such work himself or herself Or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or Improvement Is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner Of property who builds or Improves thereon, and who contracts for such project with a contractors) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or dead): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby cenity that no excavation five (5) or more feet in depth into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater then a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutety hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic toot of compressed gas at standard temperature and pressure). - 1 .............1....... ....... _.....---._...._........................ _.................................................................................... ...............,........,,............................................. ............_..._.............. __......... —....... 3 Desorwill the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? 10 (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If anRMPP is presently required, has Section 25534 of the California Health and Safety Coda been fully compiled with? ❑ Yas ❑ No 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this a plication agermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agent}? B Yes L1 No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). __.........._ r__ ................_...---------. _....._. ....... _................._...............................-_•------•-••----••--.....----............................... ......_...........----........................................ ............ Will any part of the facility to be constructed under this permit be within 1000 lset from the outer boundaries of a school? ❑ Yes 0 No (11 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). _. _...---------...-..._........ _.... ......................... ........_.................................................................._...._....._._._.._..................----- �....... - - 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No _._................. __...... __ ----......_.........-----..................... --- ..... B {If yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the Information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection, i Btu Of Legal Owner(s) �� n C to cry L 7' And/Or Authorized Applicant ate COBE 1. INSEgCTION TYPE CODE 0 INSPECTION TYPE jam, 1616 Fixed System Final Fire Prevention 206 Final Mechanical D- -O 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy . (714) 754.5273 • Fax (714) 754-4856 • www.cl.costa-mesa.ca.us Job Address: 3333 BRISTOL ST Suite: Vicinity: CONCIERGE CORRIDOR AREA Parcel Nunmber: 41250107 Applicant: APODACA, DENNIS Address: 130 HIGHLAND AVE FULLERTON, CA Owner: SOUTH COAST PLAZA Address -11 60STA MESA CA 3315 FAIRVIEW ROAD Contractor: R T SHELTON Address: 130 HIGHLAND"AVE 77 FAIR DRIVE, COSTA MESA, CA 92626 Status: ISSUED Applied: 1 011 712 0 0 6 Issued: 10/17/2006 Zoning: PDC PDC ISSUED BY: Phone: 714-680-5174 Zip: 92832 Phone: Zip: 92626 Phone:" 714-680-5174 FULLERTON, CA Zip: 92832 License: 869383 SCOPE OF PERMIT RELOCATE 6 (E) FIRE SPRINKLERS IN THE CONCIERGE CORRIDOR AREA ON FIRST FLOOR (NEAR CARROUSEL) FOR A 137,409 S.F. INTERIOR TENANT IMPROVEMENT THROUGHOUT PUBLIC SPACES FOR "SOUTH COAST PLAZA". REF#: B06-00543 Plan Check: $29.15 Permit: $44.85 Other: $0.00 Total: $74.00 , FEE SUMMARY 10 Calc Valuation: $1,200.00 Claimed Valuation: $1,200.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 44646 IBM) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of Consent to sell -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My/�v}orkers' compensation 119surance carrier and civ number era: + , Carrier: �1`]�"� f - `� Policy Number: W C= S 9 o -7(,)-o3 Lints secrron need nor be completed rf the perrart is valued at one hundred dollars ($100) or less.) ❑ I certify that in the performance of the work for which this permit is Issued, I shall not employ any person In any manner so as to become subject to the workers' compensation t California. and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the labor Cade. I shall forthwith comply wlIPes pr visions. 1 Applicant Signatu�: i' -WARNING: FAILURE T SECURE WORKERS' COMPENSATION covERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CAVIL FINES UP TO ONE HUNDRED ,THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am ILC nsed under p Ions of Chapter 9 (commencing with Section 7000) of Division 3 _f1he`Busin ss and Professions Code, and my license is in full force and effect. LK. # tClass e- + - ,Can�acfo�sSignatur�: Data. "! 7^ O CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a Construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031 .5, Business and Professions Code: Any city or county which requires a permit to construct, after, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for We. 11, however, the building or Improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Data: Owner ID verified by driver's license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, I.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high, (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, i will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? Cl Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ........ ................ _............................................................ ....._—........................................ ....................... ............................... ........................ ................................................................. .............................W..._ ................. __............. 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ ka (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ........................... .._... —_.... _.. . ................. ..w..._...... .. _ . .._ _........... _........................_..... ............................................................. ......_.... ............. __....__._—...--- 4 If an RMPP 15 presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No ....................... _ ...... __....._.......... .._....... ....................................... .................- ...........- �. _.... —.. 5 Does or will the appiioant or present or future building occupant require for the work which Is the subject of this application a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes No (Section 65850.2 of the Califomia Government Code requires that the requested Information be furnished on applications for non-residential building permits). ..................................._..__....._..._....--- _- ..._.............—........................ ........................ ......_....................................................__..0--No .... -- — --- 6 W III any part of iiia iacitity to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If "yes", the faciiity must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). _.. ..... •..... "----..._...............-----.._._..... _........ _.__.......... _...._"-"""""""""...._............................. .......... ......................................................................................... _ _..._ ._..... _.. 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which Is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No e (If yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I cetfy that under penalty of perjury the information, given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final Inspection. I Signature 01 Legal Owner(s) Date And/Or Authorized Applicant ` Q_Date�� - CODE +. INSPECTION TYPE Ma IIfTITIA CODE M INSPECTION TYPE DAIS 1NTITIALff 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Root 210 Final Electrical 201 Final Block/Retalning Wall 212 Final Fire Prevention P _ CO � 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesaEL&TRICAL PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 33331 BRISTOL ST Suite No Vicinity: PUBLIC AREA SCP Parcel Nunmber: 41250107 Applicant: GAINES, CLABE Address: 2121 ALTON PARKWAY SUITE 150 A Phone: 949-60B-3474 IRVINE, CA Zip 92605 " w Owner: SOUTH COAST PLAZA Address COSTA MESA CA Phone: 3315 FAIRVIEW ROAD Zip: 92626 Contractor: HOWARD S WRIGHT CONSTRUCTORS L P Address: 2121 ALTON PARKWAY Sl11Tl+ 150 A Phone: 949-608-3474 IRVINE, CA Zip: 92606 License: 860938 ISSUED BY: Status: ISSUED Applied: 10124/2006 Issued: 10/24/2006 SCOPE OF PERMIT ELECT TO INCLUDE: 175 LIGHT FIXTURES, 42 OUTLETS, 3 SWITCHES 17 COMMUNICATION DROPS, 1 SUBPANEL TO 200 AMP FOR ELEVATOR. REF: B06-00543. 137,409 S.F. INTERIOR TENANT IMPROVEMENT THROUGHOUT PUBLIC SPACES FOR "SOUTH COAST PLAZA". WORK TO INCLUDE: REAPLACE 1 STAIR (NEAR MACY'S MEN'S STORE), ADD OBSERVATION ELEVATOR (NEAR JEWEL COURT) AND REPLACE GUARDRAILIHANDRAIL. MISC PLBG, ELEC AND MECHANICAL. FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 Busway 1100 ft Temp service test $0.00 Standing Section Res. a/c package $0.00 Misc Electrical Equipment New Res (1-2 units) $0.00 0 New Res (3+units) $0.00 0 Pool/ Spa $0.00 0 Lighting Fixts $135.15 175 Recept Outlets $38.06 42 Switches • $3.30 3 Non Res Appl 1$0.00 0 Res APpi $0.00:, s ,4 O;. " Service to 200a, `. ` j'$0.00y�:. 0 �k Service to 1000a ; $0.00 , 0 Service over 1000a- MOO 0 Motors to 1 hp $0.00. 0 ' Motors to 1Ohp $0.00 0 Motors to 50hp$0.00' ; �` �. ; 0- , Motors to 100hp , $0.00 J/ 0 ' Motors over 1 00h $0.00, 0, Communication drops $18.70- 17 Sub panel to 200a $30.50 1 Pole Light Pkg $0.00 0 Sign Circuits $0.00 0 Temp Pwr Pole $0.00 0 Intermed Pole 50.00 0 FEE SUMMARY Quantity -- - Temp Dist System 1 Lighting $0.00 0 Busway 1100 ft $0.00 0 Standing Section $0.00 0 Misc Electrical Equipment $0.00 0 Transformers up to 1 kva/kw $0.00 0 ................up to 10 kva/kw $0.00 0 , -• . .................up to 50 kvalkw $0.00 0 ...............-up to 100 kva/kw $0.00 0 ..................over 100 kva/kw $0.00 0 Low Voltage Equipment $0.00 0 Low Volt Wiring System / Ckt $0.00 0 Misc. Conduit $D.00 , 0 Misc. Conductor` $0.00 ', 0 Circus (gen or ride) $0.00 ,' 0 Circus (mech ride or lights) $0.00 0 Christmas Tree Stand $0.00 0 Fireworks Stand $0.00 , 0 Other Electrical Fee $0.00,- 0.00,- Investigation Investigation Fee $0.00 Plan Check Fee $0.00 Reinspection Fee $0.00 TOTAL CALCULATED FEES $249.21 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit sttall automatically expire and become void if work Is not commenced wiihin 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and fIrnal approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 2"6-48 (6=) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Coda, for the performance of the Xrk for which this permit is issued. A I have will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. My r s' compensatio Insur��c�ar_eenr a_nd policy number are: wC q,:)-/ 7Q9 U Carrier: V�^– r'�N �r�^+r 1 Policy Number: (This section need not be completed if the permit is valued at one hundred dollars ($100) Ar less.) ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner So as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Secion 3700 of the Labor Code, I shall forthwith Comply with these provic4 - Applicant Signature: �— Date' 0 WARNLNG: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL 6NALTLE1 AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE (St D0,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed nder pr visio of Chapter 9 (commencing with Section 7000) of Division 3 of the Business a ofessions Code, and my license is in full force and effect. Lie. #{� Class # Contractor's Signature: fl— Date: CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, on my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Drivers License No. Expires: Verification at Ownership by (type of document, i.e. - property tax bill or dead): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, fatsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 6, California Administrative Code). ❑ As owner -builder, I will not employ anyone to dA work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Hate: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 W III the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous materlal7 ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .........or ................................. ............ .. . .....................u.p' .....t, r'................'1'e'----------------------...1,0"'r.....lio,"r.....................a, z"ii'd-.........................I's"?,...................................................................................... ... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater then a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ........................................................................................................................................................ ................................................ .......................... --............. --.............---.....-----............................................................................................. 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. .................................................. ............I ................ -----...................................................................................................................................................................................................................................... 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No .--�----- 1......................................................-............................................----••------.................................................................................................................------.............................................................................................._.......... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution controt district or agency? U Yes U No (Section 65850.2 of the California Government Coda requires that the requested information be furnished on applications for non-residential building permits). .............................................................................................................................................................................................................................................................................................................. 6 Will ..... any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). .......................................................................................................................�-......................................................................................................................".................................................................................---•----............................. 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ..............................................c'e,......'r_a.................................e, f'.........t'h"'............................a"ir, .po. 1.......................,0.1................................................................................................................................................................................................. 8 {If 'fires", attach certificate Af compliance from the appropriate air pcilution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Si ature Qf Legal Owner(s) at r - I U N 114 And/Or Authorized Applicant 10ate CODE N, INSPECTION TYPE - .RATE lNiffiAL CODE f INSPECTION TYPE Qat [ice 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204,. Final Demolition 250 Final Building/Occupancy 40 BUILDING PERMIT .lob Address: 3333 BRISTOL ST Suite: 2 Vicinity: 2ND FLOOR COMMON RESTROOM Primary Occ: R Eat<50/ Office/ Bar<50 Type of Construction: I -FR Parcel Number: 41249107 Zoning: PDC Applicant: WATSON, DUSTY Address: 1260 LOGAN AVE. B-2 COSTA MESA, CA Owner: SOUTH COAST PLAZA Address 3315 FAIRVIEW RD III COSTA MESA, CA Contractor: WATSON CONSTRUCTION INC. Address: 1260 LOGAN AVE. B-2 COSTA MESA, CA Zip: 92626 Arch : Address: Zip: Phone: License: Phone: (714) 662-7933 Zip: 92626 Status: FINALED Applied: 09125/2000 issued: 09/25/2000 ISSUED BY: (!n .I Phone: Zip: 92626 COPY Phone: (714)662-7933 License: 705797 Eng: Address: Phone: License: SCOPE OF PERMIT EXPIRED. 3-24-01 ENLARGE EXISTING; PUBLIC RESTROOM IN COMMON AREA OF "SOUTH COAST PLAZA" (2ND FLOORIOLD "EDDIE BAUER" CORRIDOR). 'ALL INTERIOR WORK - NO ADDED SQUARE FOOTAGE. FEE SUMMARY Plan Check: $206.99 Permit: $1,273.75 SMTP Res: $0.00 SMIP Com: $31.50 Other: $0.00 Calc Valuation: $150,000.00 Claim Valuation: $150,000.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRA77ON: This permit shall automatically expire and become void if work Is not commenced within 160 days, or if work Is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446.46 (&W) i DECLARATIONS WORKERS' COMPENSATION DECLARATION: hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. ❑ I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. My workers' compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed i7 the permit is valued at one hundred dollars ($100) or less.) ❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisions. Applicant Signature: Date: WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE (51 00,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic. # Class # Contractor's Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and or he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the ap an five hundred dollars ($500).): ❑ !, as owner e y to ea h wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sac. 7044, Busi and Pr a tractors License Law does not apply to an owner of property who builds or improves Thereon, and who does such work himself or ell or thr ph ployees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of comple I , the 0 r -builder will have the burden of proving that he or she did not build or improve for purpose of safe.). ' ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ i am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Drivel's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, 1 will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .................................................................................................................................................................. ... ..................... 1.11.1....................... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume o1 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .............................................................................................................................. ............................................... I ........... ................... ............................... ........................................................... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. .............................................................aail.....airid --efi--................................................................................... ..e........................................................................................ 4 Ii an RMPP is presently required, has Sactipn 25534 of the Celifomia Health and Salety Code been fully complied wiSh7 ❑Yes ❑ No 5 oes Dor 11 willhe tapplicant or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modiffcatlon from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes No (Section 65850.2 of the California Government Cade requires that the requested information be furnished on applications for non-residential building permits). 'a'n................................. hit"..................... 's. t.......................a, r"'h"i------.................................................t"ir"........ h'a'.........................................................._................ ........................................................................................... fi Wiil any part at the facility to ba constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ............................................................................................................................................................................................................................................................................................................................................................................................ 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which Is the subject of this application, have all of the disclosures prescribed by California Health and Safety Coda Section 42303 been made? ❑ Yes ❑ No .............................:................. ..................._.....-----........................................................................_.--11......................................................_...............__............................................................._................................................... 8 (If yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature Of Legal Owner(s) Date And/Or Autho6zod Applicant Date CODE ; INSPECTIOTXPE DATE IRMIALS CODE # IUSPECTION TYPE IIS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Well 212 Final f=ire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy e- PROJECT ADDRESS: 3333 BRISTOL ST UNIT: OWNER'S NAME: C J • SEGERSTROM & SONS ADDRESS: D15 FAIRVIEW RD COSTA MESA CA92626 (714)546-0110 ARCHIENGINEER: JOHN A. MARTIN & ASSO. REO.ND.: 610 ADDRESS: 1800 WILSHIRE BL UNIT: LOS ANGELES CA 90057 PERMITTEE: C.J. SEGERSTROM & SONS (714)546-0110 ADDRESS: 3 315 FAIRVIEW RD COSTA MESA CA 92626 LICENSED CONTRACTOR DECLARATION: ,l hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code. and my license is In lull force and effect. CITY EIC.: STATE UC.: CLASS: Date: Signature: WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to selt•insure or a certificate al Workers' Compensation insurance. or a certified copy thereof (Section 3800, Lab. CO. POLICY NO.: EXP. DATE: COMPANY: ! Certihed copy is hereby:umished. ❑ Certified Copy is filed with the city Building Division. Date: ..Applip3l,_ EXEMPTION FROM WORXERS' COMPENSATION DECLARATION: I Certify that in the performance of the work for whichtfus p subject to t O rke ' Compens lioq,L aws,pf Cali:orniar J+ Date: Signature:: NOTICE: Il, after making this eclaration, you shodld Code. you must forthwith comply witch provisiai CONSTRUCTION LENDING AGENCY: I hgreby affirm'tilal which Ihis permit i5 issued {Section 3097,'Civ. Q. LENDER; ADDRESS: -ed not be comp' int is for one hundred (SIOD) or less). I shag r$l efiftloy pe n in arty, manner so as tncomE .coA subject to the Workers' Compensation provisions of the or this permit shall be deemed revoked. 04 fere is a construction lending agency for the performance of the work for OWNER BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractors' State License Law for the following reason (Section 7031,5 Business and Professional Cade: Any city of county which requires a permit to Construct, after, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that helshe is licensed pursuant to the provisions of the Contractors' State License Law (Chapter 9 (commencing with Section 7010) of Division 3 of the Business and Professions Code) or that heyshe is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than live hundred dollars {5500). I, as owner of the property or my employees with wages as their sole compensation, will do the work, and the ❑ structure is not intended or offered for sale (Section 7044, Business and Professional Code: The Contractors' State License Law does not apply to an owner of a property who builds or improves thereon, and who does such work hlmstilherself or through his or her own employees, provided that such improvements are not intended or otlered lar sale. 11, however the building or improvement is sold wtihin one year of completion, the owner will have the burden of proving he/she did not build or improve for the purpose of sale). I, as owner of the property, am exclusively contracting with licensed contractors to construct the pro;ect (Section 7044, Business and Professions Code: The Contractors' State License Law does not appy to an owner of property who builds or improves thereon and who contracts for such projects with a cOntractor(SO license pursuant to the Contractors' Slate License Law). I am aware that proof of their Workers Compensation insurance should be provided to me. ❑ 1 am exempt under Section: B. d P. C. tort this reason: Date: to Ju�A — — Owner: T do hereby Certify that I am a re of and understand the requirements of Calilornia,Heahh and Safety Code Sections 25505, 25533, apA 25534 and that I o+ any future building occupant willlwill not (circle one) need to comply with said state codes and the requirements A6K permit [or construction or modification from theAir�uahty Management District. Residential construction applications are exempt from these provisions. Date: Applicant I hereby cerlify that I have read this application and state the abW information is t. I ree to comply with all city and county ordinances and slate laws relating 10 building Construction a TrIze re ese lives hi city to enter upon the above-mentioned property) lar innsppeecctio)n purposes.LAI /� Dale: O � � L Signature:. �— Driver's License or Social Lunly sr: 164146 While—Bu ddmq; Grean—Code Enforcement: Canary—Applicant; Pink—Revenue: GDldenrod—ABsassnr CITY OF COSTA MESA — BUILDING PERMIT PERM NO: B 05811 PERMIT NO: 8 058116 PLAN CHECK NO: 02585-92 S GOVT: N SUPP: N CONSTRUCTION TYPE: IFR SP PERMIT TYPE: STR PURPOSE: NEW JOB DESCRIPTION : NEW EXTERIOR ELEVATOR SHAFT & CAR SQ FT: 125,000 CLAIM VALUE: 125,000.00 CALC—VALUE: 125,000.00 GROUP OCC: B-2 / COMMENTS: LOACTED AT THE FORMER "NORDSTOM" BLDG, Z 0 N I N G R E Q U I R E M E N T S S E T B A C K S ------------ MAIN BUILDING ---------- ---------- ACCESSORY BUILDING--------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN PARKING REQ• PROV: PARCEL: 41249102 ZNE: CI—S REF NO: PLANNING N TES> INSTALL AN ELEVATOR ATTACHED TO THE EXTERIOR WALL OF THE > EXISTING TIFFANY'S STORE — TO GO UP 3 STORIES, ���*1t•�c•�***���-�-�•��•�F*�*��•-��l•-��-x•-�+��*�•��*��l-�l••��•�•�c���•*������•�•�E�•�*�••�i�������E�•�•*�•���1•���c� D E V E L O P M E N T S E R V I C E S R E Q U I R E M E 'N ..T S ZONING APPROVED BY :14 DATE: BUILDING APPROVED BY : DATE: APPLICATION ISSUED BY:r DATE: * iE iF if• OK• iE,X T4• IF iE iE 3E dE iE it• i(• ♦!E � #E iE � � iF •lE � it iF iE •1E ii- * �F•ii'i• • �(• ik iE TE •14 �E Ct � �(• Of dE 1f !F 9F iF 3E T(• �F it• � !E'►F iE * �!' � � iF !{• �' iE i4 IE �(• � 3F iF it• iI! it• �F ' iE IF #f � �F iF �• x• it• 3E iF �E 9i•'1F it•14 * ik ;+t T!• �(• iE iF TF �(• iE i{• * �( �(• iE * dt• 3F iF i(• LEGALIZATION:N F E E S U M M A R Y STRUCTURAL SEGMENT:Y BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT 727,00 , SMIP/NON—RES PLAN 472.55 !. ; 26.25 ISSUE FEE BUILDING—DIV—> PERMIT ISSUE :-PLAN—CHECK TOTAL PAID DUE TOTALS ---- > 753.25 0,00 472,55 1225.80 1225.80 ,00 REVENUE DIVISION TOTALS--> COLLECTED: 1225.80 OVER/SHORT•00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK 727.00 26.25 472.55 ,07 *******************T4•*-IETE********TkTt••!Ft********1{********is*1Eft•it•*1i•*if•***it•*******)Efir•** I N D I V I D U A L F E E B R E A K D O W N TYPE QTY SFC 125000 ALTER BY VALUE I O N COMMERCIAL NOZONE END OF FEES UNIT COST TOTAL COST 1,00 125,000,00 DATE: 01l0 111 _11"11 CONSTRUCTION AND PLANNING : APPROVALS Permit # Date Inspector PO,SPA APPROVALS Permit # Date Inspector 1. Temporary Electrical Service or Pole. . 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd, 53. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. 54. Forms 4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding S. Steel Reinforcement ,itfJ'�Lr j [ 7 Z 56, Rough Plumbing &Pressure Test 57. APPROVAL TO COVER-GUNITE 58. Electrical Conduit-Undrgrnd. 59. Gas Pipe, 0 Undrgrnd., Test 6, Electrical UFER Grnd. 7. Footings 8". Foundation 9. Water Pipe-Undrgrnd. 60. Backwash Lines, P-Trap, 0 Undrgrnd. 10. Structural Floor System 61. APPROVAL TO DECK 11. Property Sewer Line & House Connection 62. Backwash & Receptor-Final 12. Sewer Cap 63. Heater & Vent-Final 13. Roof Drains 64. Plumbing System - Final 14. Rough Plumbing 65. Electrical-Final 15. rough Electrical-Conduit 66. Solar System-Final 16. Rough Electric Wiring 67. Fencing & Access Approval 17. Rough Wiring Sign 68. APPROVED FOR PLASTERING 18. Rough Electrical-T Bar Ceiling 69. POOLfSPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT : APPROVALS Permit # 20. Rough Factory Fireplace 21. Ducts, in Structure 70, Underground Hydro 22. Ducts, Ventilating 71. Product Piping 0 Gas 004 23. Gas Pipe-Rough & Test 72. Underground Flush 24, Roof Framing 73. Undergrnd, Storage Tank 0 Gas D Oil 25. Roof Sheathing 74. Overhead Hydro 26. T-Bar Ceiling (Structural) & Monocoat 75. Dry Chemical 27. Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding 77. FIXED SYSTEM FINAL 29. Insulation 76. FIRE PREV. FINAL 30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat 79. FINAL INSPECTION 32. Electrical Power Meter-Final 33. Final Electric 80. FOOD C£PTIFICATE ISSUED Notes:�l� 34. Final Heating & Air Conditioning 35. Final Gas Pipe-Test 36. Hood or Canopy 37. Final Factory Fireplace 38. Final Plumbing 39. Water Service-Final 40. Gas Service-Final 41, Solar Domestic-Final 42, Backflow Preventer 43. Backflow Irrigation 44. Landscape Irrigation System 45. Sound Attenuation 46. Handicap Regulations 47. FINAL STRUCTURE & BUILDING 48. FINAL PLANNING y 49'. Electric Release to Edison 50. Gas 'Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY No. Date PROJECT AGGRESS: ' UNIT: OWNER'S NAME: 3333 BRISTOL ST ADDRESS; C J. SEGERSTROM & SONS 3;15 FAIRVIEW RD COSTA MESA CA 92626 ARCNlENGINEER: (714)546-0110 REG.NO.: ADDRESS: UNIT: PERMITTEE: ADDRESS: ROBERTS ELECTRICAL (714)495-3541 12 SAND -POINTE NTE A q F T n1,r1thtA N1Tr.1 Rmr �jfrdv fs?1 7 LICENSED CONTRACTOR'MARATION: I hereb�I that t am licensed untler isio o C pier 9 ting wi ection 7000) of Elmdon 3 of the Business and Professions Code. and my license is " full force and of e , CITY LIC.: 0 1 4 STATE LIC.: 38011 6 SS: 1 ' Ste: Signature: WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate at consent to sell -insure or a certificate of workers' Compensation Insurance. or o certified copy thereof (Section 3800. Lab. Q. POLICY NO.: EXP. DATE: COMPANY: ❑ Certified copy is hereby furnished. ❑ Certified copy is filed with the city Building Division. Date: Applicant EXEMPTION FROM WORKERS' COMPENSATION DECLARATION: (This sectioPall be completed iithe p is tar one d ($100) or less). I certify that in the performance of the work tar which this permit is ,ss not empl gggaaa 11tn an n so as to become subject to 1 SWorkers" Compensation Laws of California. �a e: Signature: NOTICE; If. atter making this declaration, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked, CONSTRUCTION LENDING AGENCY; I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (section 3097. Civ. C). LENDER: ADDRESS: OWNER BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractors' Slate License Law for the following reason {Section 7031,5 Business and Professional Code: Any city of county which requires a permit to construct, alter, improve, demolish, or repair any structure. prior to its issuance, also requires the applicant for such permit to file a signed statement that he/she is licensed pursuant to the provisions of the Contractors' Stale License Law (Chapter 9 (commencing with Section 7000) of Division 3 o1 the Business and Professions Code) or that he/she is exempt therefrom and the basis for the alleged exemption, Any violation of Section 71131.5 by any applicant tar a permit subjects the applicant to a civil penalty o1 not more than five hundred dollars (S5DO). I, as owner of the property or my employees with wallas as their sole compensation, will do the work, and the ❑ structure is not intended or offered for sale (Section 7044, Business and Professional Code: The Contractors' Stale License Law does not apply to an owner of a property who builds or improves thereon, and who does such work himsefllhersetl or through his or her own employees, provided that such improvements are not intended or offered for sate. If, however the building or improvement is sold within one year of completion, the owner will have the burden of proving he/she did not build or improve for the purpose at sale). I, as owner of the property, am exclusive)y contracting with licensed contractors to construct the project (Section 7044, Business Eland Professions Code: The Contractors' State License Law does not apply loan owner of property who bUtIOS or improves thereon and who contracts for such projects with a contractors) license pursuant to the Contractors' Stale License Law). I am aware that proof of their Worker's Compensation insurance should be provided to me. ❑ 1 am exempt under Section: B. i3 P. C. lar this reason: Date: Owner: I do hereby certify that I am aware of and understand the requirements of Caldornia,Health and Safety Code Sections 25505. 25533, and 25534 and that I w any future building occupant willlwill rlrrt (circle one) need to comply with Said state codes and the requirements for a permit for construction or modification Irom the Air Quality Management District. Residential construction applications are exempt from these provisions, Date: — Applicant: I hereby certify that I have read this application and state that the above ordinances and state laws relating to budding construction and hereby auto property for inspection purposes. Dale: Cl —.1-4 L -- Driver's -Driver's License or Social Security N. is correct. I 1641-46 Whae—Building: Green—Code Enforcement,. Canary—Applicanl; Pink—Revenue; Goldenrod—Assessor county CITY OF COSTA MESA — BUILDING PERMIT PERM NO: E 058479 PERMIT NO: E 05$-479' PLAN CHECK NO: N GOVT; N SUPP: N CONSTRUCTION TYPE: IFR SP PERMIT TYPE: ELE PURPOSE: OTH JOB DESCRIPTION : 400 AMP METER & ONE MAIN SQ FT; CLAIM VALUE; 3,000,00 CALC—VALUE; GROUP UCC: B-2 / COMMENTS: LOADING DOC 8 NEAR CHANNEL # #tE">F >�ae•>E �F#� �E#�t *##*->f*st*•>E**X-**_X E�">E���#fF��###r��"�#r�aF•1E"K#*��#�!�##">fa�*x�#��>4�#�� Z 0 N I N G F E Q U I R E M E N T S S E T B A C K S ------------ MAIN BUILDING ----------- --------- ACCESSORY BUILDING ---------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RIGHT, FT IN LEFT: FT IN RGHT: FT IN PARKING RE • PROV: PARCEL; 00000000 ZNE; REF NO; PLANNING N T£S> > f} WJE if aF •1! i!• •K' iE• 3E iP #'1f- li• # # # ih 3F iE •IF iE 9f fit• tit• �• it• ii• # •K• iE �f• #,�f• i4- aE• TE •!!• iE ft- !E iiif• if }F if• TE •>N # X• ik i6 # it• TF 3(• �c iF• 3i• # # K• �L 9k •!f• # i(• iF � T{• k * .� if # # # �(• 3F iK# D E V E L O P M E N T S E R V I C E S. R E Q U I R E M E N T S ZONING APPROVED BY 1 DATE: BUILDING APPROVED BY : DATE: �y APPLICATION ISSUED BY: DATE: tt x f� #r Jf Fix c ib �I• iE !f it # x # # # !f S 14 LEGALIZATION:N F E E 5 U M M A R STRUCTURAL SEGMENT:N BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT 37.50 50% SMIP/NON—RES PLAN ISSUE FEE 15.00 BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTALS ---- > 37,50 15.00 0.00 REVENUE DIVISION TOTALS--> COLLECTED: BLDG PMT PLUMBING ELECTRIC MECHANIC 52,50 TOTAL PAID DUE 5.2.50 52.50 .00 52.50 OVER/SHORT: .00 FIRE SMIP/TOT GRADING PLAN—CHECK #9t #Tt•ie9f ##kt'iF1(*# �E#bf *X* # kF#*##yr* ####***#kF *#***#*3Fkt•*** ii•****}f•****##9t•#dl•-le#it**#**##*#TF#al-# I N D I V I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST ELE I SERVICES BELOW 600 V & 201— 1000 AMP 37.50 37.50 END OF FEES L tfi1-.• lei _�!�'� r._. r1,I7• CONSTRUCTION AND PLANNING APPROVALS Permit # Date r Inspector POI 4 SPA APPROVALS Permit # Date Inspector 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location 2, Soil Pipe-Undrgrnd. c f' 3. Electrical Conduit Utility-Undrgrnd. 53. Steel Reinforcement 54. Forms 4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6. Electrical UFER Grnd. 57. APPROVAL TO COVER•GUNITE 7. Footings 58. Electrical Conduit-Undrgrnd. , S. Foundation 59. Gas Pipe, ❑ Undrgrnd., Test 9. Water Ripe-Undrgrnd. 60. Backwash Lines, P -Trap, ❑ Undrgrnd. 10. Structural Floor System 61. APPROVAL TO DECK 11. Property Sewer Line & House Connection 62. Backwash & Receptor -Final 12. Sewer Cap 63. Heater & Vent -Final 13. Roof Drains 64. Plumbing System • Final 14. Rough Plumbing 65. Electrical -Final 15. Rough Electrical -Conduit 66. Solar System -Final 16. Rough Electric Wiring 67. Fencing & Access Approval 17. Rough Wiring Sign 68. APPROVED FOR PLASTERING 18. Rough Electrical -T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit # 20. Rough Factory Fireplace 21. Ducts, in Structure 70. Underground Hydro 22. Ducts, Ventilating 71. Product Piping ❑ Gas ❑ Oil 23. Gas Pipe -Rough & Test 72. Underground Flush 24. Roof Framing 73. Undergrnd. Storage Tank ❑ Gas ❑ Oil 25. Roof Sheathing 74. Overhead Hydro 26, T -Bar Ceiling (Structural) & Monocoat 75. Dry Chemical 27. Frame and Flashing 76. Dry Standpipe 28. i-athing & Siding 77. FIXED SYSTEM FINAL 29, Insulation 78. FIRE PREV. FINAL 30, Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat 79, FINAL INSPECTION 32. Electrical Power Meter -Final ! 80. FOOD CERTIFICATE ISSUED 33. Final Electric 1 Notes: 34, Final Heating & Air Conditioning 35, Final Gas Pipe -Test 36. Hood or Canopy 37. Final Factory Fireplace 38. Final Plumbing 39. Water Service -Final 40. Gas Service -Final 41. Solar Domestic -Final 42. Backflow Preventer 43. Backflow Irrigation 44. Landscape Irrigation System 45. Sound Attenuation 46. Handicap Regulations 47i FINAL STRUCTURE & BUILDING r 48, FINAL PLANNING 49. Electric Release to Edison t , 54. Gas Release to Southern California Gas Co 51, CERTIFICATE OF OCCUPANCY No. Date r PROTECT ADDRESS: 3333 BRISTOL ST UNIT: 1 STFL OWNER'S NAME: C J SEGERSTROM ADDRESS: 3� I t FA I RV I EW RD COSTA MESA CA 92626 (714)546-0110 ARCHIENGINEER: LAMPERT/LANG ARCH REG.NO.:C10583 ADDRESS: 199 TECHNOLOGY UNIT: 110 IRVINE CA 92714 PERMITTEE: S & S ELECTRIC (714)788-1411 ADDRESS: 393 LA CAD ENA 16 RIVERSIDE CA 92504 LICENSE% CONTRACTOR DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of %Nlsion 3 of the Business and Prolessions Code, and my license is in fun force and effect. CITY LIC.: 0 4 78 7 3 STATE Lic.: 4 9 8 7 1 cLAs : C —1 fi � Dale: 12 — 11i - 9 Z Signature: WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure or a certificate of Workers' Compensation ktrapct, Oj A r�rylieQ copy ihereaf (Section 3BOD, Lab. L►� / 1 0 i 9 3 POLICY NO.: 11 (] 18 if ]l EXP. DATE: 1 POMPANY: CANAD IAN INSUR . 1 Certified copy is hereby furnished. CJ Certified copy is filed with the city Building Division. Date: 12 - I'- -q� - -- — _ Applicant: & . !t!y . LQ, EXEMPTION FROM WORXERS' COMPENSATION DECLARATION: (This section need riot be completed if the permit is for one hundred Sl DOJ or less). I certify that in the performance of the work far which this permit is issued, I shall not employ any person in arty manner so as to become subject to the Workers' Compensation Laws of California. Date: Signature: NOTICE: If, after making this declaration, you should become subject to the Workers' Compensation provisions of the Labor Code. you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency Ior the performance of the work for which this permit is issued (Section 3097. Civ. Q. LENDER: ADDRESS: OWNER BUILDER DECLARATION: 1 hereby affirm that I am exempt from the Contractors' State License Law for the following reason (Section 7031.5 Business and Professional Code: Any city of county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance. also requires the applicant for such permit to file a signed statement that he/she is licensed pursuant to the provisions of the Contractors' State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that helshe is exempt therefrom and the basis for the alleged exemption. Arty violation at Section 7031.5 by any applicant for a permit subjects the applicant to a cW penalty of not more than five hundred donars (5500). I, as owner of the property or my employees with wages as their sole compensation, will do the work, and the 0 structure is not intended or offered tar sale (Section 7044, Business and Professional Code: The Contractors' State License Law does nor apply to an owner Of a property who builds or improves thereon, and who does such work himselllhersell or through his or her own employees, provided that such improvements are not intended or offered for We, If, however the building or improvement is sold within one year of completion, the owner win have the burden of proving he/she did not build or improve Ior the purpose of sale). I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Section 7044, Business © and Professions Code: The Contractors' State License Law does nor apply to an owner of property who builds or improves thereon and who contracts lar such projects with a contractors) license pursuant to the Contractors' State License Law). I am aware that proof of their Worker's Compensation insurance Should be provided to me. I am exempt under Section: B. E P. C. Ior this reason: Date: Owner: I do hereby certify that I am aware of and understand the requirements of Cakforrga Heatih and Safety Code Sections 25505, 25533, and 25534 and that I or any luture building occupant wiWwi9 not (cirde one) need to comply with Said state codes and the requirements for a permit Ior construction or modification from the Air Duality Management District Residential construction applications are exempt from these provisions Date: Applicant: I hereby certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. , n n w ,1 Z Date:nnal Driver's License or Social Security =a" 1641.46 White—Buitdina: Green—Code Enlorcement: Canary—Aoolicant: Pink—Revenue: Goldenrod—Assessor CITY OF COSTA MESA — BUILDING PERMIT PERM NO: E 0603 PERMIT NO: E 060323 PLAN CHECK NO: N : CONSTRUCTION TYPE: IFR SP PERMIT TYPE: ELE PURPOSE: OTH JOB DESCRIPTION : REROUTE IHR CORRIDOR (BEHIND SP#1872) SQ FT: CLAIM VALUE: CALC—VALUE: GROUP OCC; B-2 / COMMENTS: RE: B60137 PRIMARY BUILDING PERMIT, Z O N I N G S E T B A C K SR E Q U I R E M E N T S ------------ MAIN BUILDING ---------- --------- ACCESSORY BUILDING--------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN PARKING REQ: PROV: PARCEL: 41050105 ZNE: REF NO: PLANNING N TES> > lE1l1!!11E�E�l�t�f�il•#94'k1EiE#��lflEdliE�k�E�Eif�t�tiE��lf**�****fit•it•ildE*#9FititlFiE�iFitifiFif�*lEiE***�t���iEiEiE9E��TEit�EdE D E V E L O P M E N T S E R V I C E S R E Q U I R E M E N"T S ZONING APPROVED BY DATE: BUILDING APPROVED BY : DATE: APPLICATION ISSUED BY: DATE: 4'1141 F2 !t•�FiF��Fit•1Eif�titf4ib*dtiE�E*iI•�*TES �it•iE�****it it• cif **�F94'IIiEiflffrt�l�i6�9f�fIEIt�tiFiFfrtiF1!lfTElE�E�!*it�,7fMF*k�iE1EiE�t'JfiFif*9!�l9E��9F�ki6if�li4ir�***if�FlE�d!*�iE1t•iETt*ir•���ia* LEGALIZATION:N F E E S U M M A R Y STRUCTURAL SEGMENT:N BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT 32 25 X01 SMIP/NON—RES PLAN ISSUE FEE 15,00 BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE TOTALS ---- > 32.25 15,00 0.00 47.25 47,25 ,00 REVENUE DIVISION TOTALS--> COLLECTED: 47.25 OVER/SHORT: ,00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK 47.25 �1E'�!!!!!E!ElflEiFflf�flf'1lflfll��#�*9!lFiF�f�F�FilililiflF��FdEiElE*iElf1llE�liFiflfik#E**��iflE9k�lfiEiE�Fi>E�*!t !f*�FirdE�!!*it•it*�EiF�lit I N D I V I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST ELE 19 FIXTURES LIGHTING 1 ST 20 EA, ELE 11 RECEPT/OGTLET I ST 20 EA, .75 18.25 ELE 5 RECEPT/SWITCH 1 ST 20 EA, 75 3,75 ELE 1 NON—RES APPLIANCE NOT OVER 1.0 HP 3,00 3.00 ELE 1 MOTOR/POWR APPARATUS 0,0 — 1.0 HP 3,00 3.00 END OF FEES CONSTRUCTION AND PLANNING APPROVALS Permit # Date inspector PO SPA APPROVALS Permit # Date Inspector 1. Temporary Electrical Serve or Poles, 52. Pool & Equipment Location +Z. Soi�Pipe-Undrgrnd.c 53. Steel Reinforcement ec`tcic,Y1 CgZuit,Utility-L7ndrgrnd, j 54. Forms ' 4. EIi3 trtcal-Co7iouit•--t-�ndrgrr)d. 55. Electrical Bonding r�•JStee1 Ftelnf�rcdqxknt , 56. Rough Plumbing & Pressure Test z .J.6aElectF► M'GF HFitzmd. -= 57. APPROVAL TO COVER•GUNITE 27:�ooti2)v= yt .. 58. Electrical Conduit-Undrgrnd. ' L 1 8,-Foundattofn * 59. Gas Pipe, © Undrgrnd., Test 9. Water Pipe-Undrgrnd. 60. Backwash Lines, P -Trap, ❑ Undrgrnd. 10. Structural Floor System 61. APPROVAL TO DECK 11. Property Sewer Line & HoZise Connection .r _ 62. Backwash & Receptor -Final 12. Sewer Cap _ y 63. Heater & Vent -Final 13. Roof Drains- 64, Plumbing System - Final 14, Rough Plum6l,69 65. Electrical -Final 15. Rough Electrical•Conduit i 66. Solar System -Final -16. Rough Efectrie.Wiring 67. Fencing & Access Approval ��17. Rough IA7iNng Sign I 68. APPROVED FOR PLASTERING _.18. Rough Electrical -T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning _ FIRE DEPT. REQUIREMENT PPR IP -S. 71 �Pthit 20? Rough Factory Fir6place r 'ti - fi 7._ 21; Dulcis, iL*StrUcturjpr =-I�; X. I r 4 ,. a -4;,1 r r 370. UndergrdC!hd Hydro i 22. Dins, Clntiratirig•{ *71. ProducPikng C9 G3s Coil 23k..Gas l'ipexRau'9 h i R;L9 a• In ► e 72, Underground Flush)tj- 24. Rob? Framing 73, Undergrnif. Storaoe`7ank'C7 Gas © 61' 25. Roqf Sl Bathing Z:y ti t= 7ZOverheaAydreC, r 26.:T -Bar Ceiling (Structural) &Vonocoat * ti G r+:�. 75.Dry Chemical * A: ` 27"Frame and F1asi�in$ ;. _ x 76.� Dry Stan 4#pl;pe _ -�28. Laihing• Siding- a •� '• 770' FIXED SYSTEii�)�1NAL� r' - `29. Insulation `- S • t rJ 78s FIRE PREY. FINAL r30. Drywall Nailing } L' HEALTWDEPT: R•EQUIREM T '31. Plaster $town Coat; •� i r - { x _ 79 FINAL Il SP�I_CTIOI`f. ' r` ` C32 -Electrical Power (leten-Firtal ±::; x •: n80?'FOOD CERTIFIGAT'E ISSUED .33.-FiA5l Electric ' ;x ' , ` r'Notel:- ,434F.Firlal H"tin & •. ii Conditioning ~35"'Finial Gas Pipe -Test x36:THood oT.Canopyr - ^37. r n -Finis Factory Fir'eslace_ Or -38. Final Plumbing .:39. Water Seivice-Final, `40. Gas Service -Final - M'41. Solar Domestic -Final. -t 42. -Backflow Prevented �* > 43. Backflow Irrigation a H + x t _ •� _44, Landscape IuigatiQn System :-'-) ;;.45 -.:Sound Attenuation r r I Ti .7 3 C 7' •1 -46.'-Handic$p Regulatigns 47:-.ftNAL STRUCTURE & BUtLDING 46: FINAL PLANNING .::49. Electric Release to -Edison 50.- Gas Release to Southern California Gas Coy ' 51. CERTIFICATE OF:.00CUPANCIf No Date r 0 PROJECT ADDRESS: 3333 BRISTOL ST UNIT: 1STFL OWNER'S NAME: C J SEGERSTROM ADDRESS: 3K S FAIRVIEW RD COSTA MESA CA 92626 (714)546-0110 ARCHIENGINEER: LAMPERT/LANG ARCH REG.NO.: C10583 ADDRESS: 199 TECHNOLOGY UNIT: 110 IRVINE CA 92714 PERMITTEE: HURST & SIEBERT (714)361-0111 ADDRESS: 2377 S EL CAMINO REAL 103 SAN CLEMENTE 72 LICENSED CONTRACTOR DECLARATION: I hereby affirm tnai 1> ice ed p islmrs Of pier 9 (commencing with Section 7000) of Division 3 01 the Business and Professions Code. my lice a full o e CITY LIC.: 054 075STATE LIC.: 6 2 2 Date: Z L� / Signature: WORKERS' COMPENSATION DECLARATION: I hereby affirm tharr to self -insure or a ertilicate of WorkersCompensation s}u�r�qcY�. Qjc led copy thereof (Section 38POLICY NO.: U U1 7 i r EXPCOMPANY: TRANSAMERICA 7 Cert+tied copy is hereby lumished. IN Cerufcopy is 1snan. Date: /Z ��Lr Applicant: EXEMPTION FROM WORKERS' COMPENSATION DECLARATION: {This section need not be completed d the permit is for one hundred [5100) or iess). I certify that in the performance Of the work for which this permit is issued, l shall not employ any person in any manner so as to become subject to the WorkefS)Compensation Laws of California. Date: Signature: NOTICE: If. aher,making this declaration, you should become subject to the Workers' Compensation provisions of the Labor Code. you must)prthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Section 3097. Civ. Q. LENDER: ADDRESS: OWNER BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractors' State License Law for the lollowing reason (Section 7031.5 Business and Professional Code: Any city of county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance. also requires the applicant Ior such permit to file a signed statement that he/she is licensed pursuant 10 the provisions of the Contractors' State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Prolessions Code) or that he/she is exempt therefrom and the basis for the alleged exemption, Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a cM penalty of not more than five hundred dollars (5500♦. I, as owner of the properly or my em loyees with wages as their sole compensation, will do the work, and the ❑ structure is not intended or offered for sate (Section 7044, Business and Professional Code: The Contractors' State License Law does not apply to an owner of a property who builds or improves thereon, and who does such work himself/hersell or through his or her own employees, provided that such improvements are not intended or Offered for sale. II, however the building or improvement is sold within one year of completion. the owner wig have the burden of proving he/she did not build or improve for the purpose of sale). 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Section 7044, Business ❑ and Professions Code: The Contractors' State license Law does not appy to an owner of properly who builds or improves thereon and who contracts for such projects with a contractors) license pursuant to the Contractors' State License Law), I am aware Ihat proof of their Worker's Compensation insurance should be provided to me. ❑ I am exempt under Section: B. & P. C. for this reason: Date: Owner: I do hereby certify that I am aware of and understand the requirements of California.Heallh and Safety Code Sections 25505, 25533, and 25534 and that I or any future building occupant will/will not (circle one) need to comply with said state codes and the requirements Inr a permit ler construction or modification Irom the Air Duality Management District. Residential construction applications are exempt from these provisions. — Dale: Appkanh I hereby certify that I have read this application and state that the ordinances and state laws relating to building construction and her property for inspection purposes. Date/ —/ 3- 22— Sig re: Driver's License or Social Security N 1641-46 White—Buddina: Green—Code Enforcement: Canary—ADDlicant: Pink—Revonuo; Goldenrod—Assessor county CITY OF COSTA MESA - BUILDING PERMIT PERMIT NO: P 060352 PLAN CHECK NO: N CONSTRUCTION TYPE; IFR SP PERMIT TYPE: PLU JOB DESCRIPTION : REROUTE IHR CORRIDOR (BEHIND SP#1872) CLAIM VALUE; CALC-VALUE: PERM NO: P 06035 GOVT; N SUPP: N PURPOSE; ALT SQ FT: GROUP OCC: B-2 / COMMENTS: REROUTE CORRIDOR RE:#B60137 Z O N I N G S E T B A C K S R E Q U I R E M E N T S ------------ MAIN BUILDING ---------- --------- ACCESSORY BUILDING--------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT; FT IN PARKING REQ- PROV: PARCEL: 41050105 ZNE: AEF NO: PLANNING N TES> > �► . D E V E L O P M E N T S E R V I C E S R E Q U I R E M E N{TS ZONING APPROVED BY DATE: . BUILDING APPROVED BY ; DATE: APPLICATION *ISSUED BY; ** *DAT iE iE iE iM iM �k ik � -IC' !E if � �1E iE'lE * � iE !!� if 1E iF 1E * �E � * * �E'1! �'1E if it iE it it it * �E * 9E iF jF � it 4t iE * �E'Jf iE if iF 3E � �} AE iE it• iE * it iF 9E if it iE iE !E iE iE iE �E �lE �1E iE it ?E LEGALIZATION:N F E E S U M M A R Y STRUCTURAL SEGMENT:N BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT BASIN 35252 1 WATER CLOSET (TOILET) PLU SMIP/NON-RES PLAN HEATER AND/OR VENT PLU 1 ISSUE FEE DRAINS 20,00 1 BUILDING -DIV-> PERMIT ISSUE PLAN -CHECK TOTAL PAID DUE TOTALS ---- > 35.00 20.00 0.00 55.00 55,00 .00 REVENUE DIVISION TOTALS--> COLLECTED: 55.00 OVER/SHORT: .00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN -CHECK 55,00 �F*�E9E**iE**��*iF-1i*�***if�fF*�Eit�E*iF*IEiE****,7FiEi6*�EiE1EiM9f���dF1EiE*�t*�E�E�4**itlE�E**9F**��F�EiEitit�iEitit•iEit!! I N D I V I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I 0 N PLU 1 WASH BASIN PLU 1 WATER CLOSET (TOILET) PLU 1 WATER HEATER AND/OR VENT PLU 1 FLOOR DRAINS PLU 1 SEWER CAP / DEMOLITIONEACH END OF FEES UNIT COST TOTAL COST 7 00 7 00 7;00 7.00 7.00 7. Q0 7 , �aHa Ml4r xr 7 O DEC 1 51992 " ,1 CUJG OF COSTA MESA CONSTRUCTION AND PLANNING POi SPA APPROVALS Permit # bate Inspector APPROVALS Permit # Date Inspector 1. Temporary Electrical Service or Pole_, 52. Poo! & Equipment Location 2• Sgi1 Pipe-Undrgrnd, r�/� L � 53. Steel Reinforcement 3.`EJgctiiCofttit lIility l7ndrgrnd.: ' 54. Forms �-4• Electrical Cor;du4-Undrgrnd. �. 55. Electrical Bonding r �• 1,5.- S.e'f Ffeinforcement - 56. Rough Plumbing & Pressure Test 6:`i?tectaibaf LIFER Gd. Gid. 57. APPROVAL TO COVER GUNITE '7..Footings' �,it 58. Electrical Conduit•Undrgrnd. f 87' Foundation r 59. Gas Pipe, ❑ Undrgrnd., Test 9. Water Pipe-Undrgrnd. 60. Backwash Lines, P -Trap, ❑ Undrgrnd, 10. Structural Floor System 61, APPROVAL. TO DECK 11, Property Seikbr Lihe & House Connection 62. Backwash & Receptor -Final 12. Sewer Cap 63. Heater & Vent -Final 13. Roof Drains 64. Plumbing System - Final 14. Rough PlumtiiKig 65. Electrical -Final 15. Rough Electrical -Conduit 66. Solar System -Final 16. Rough Electric Wiring 67. Fencing & Access Approval J7, Rough V+ Eng Sign 68. APPROVED FOR PLASTERING 8. Rough Eiectrio]-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT, REQUIREMENT -APPROVA $ -Permit # } 20 "RoGgh Factody Fireplace 1 e rJ ' r 214-Du"ets, in)StructuFel ..., - 70. UndergrdLrhd Hydro 22, quctrs, Ventting i t=• ------------- r71. Product PipiPg ❑Gas ❑'Oil , r' 23 -Ga; Pip�pough •Test -+72, Underground FI ushr s 24!_'Ro8f Framing �,j• r t i. ••' ► : '� ° 73',Undergrnci'Stor'age7ank't]Gas ❑OiI r r r 25. Roof Sheathing ,`' ;, , �'. '74r;Overhead Hydro`'. 26'CT-Bar Ceiling (Structural) &'-Monocoat V_ = 75 -Dry Chem�,eal r- 27; Frame aid Flash' gc :� r, x , . 76. JDry Stancl�pipe i-28. Lafhing�Siding� 4� „ .t r 77'. FIXED Y TE 1P1`0AL T F�' 29. lrrsUatiq.n ' I L 7dFAIRE PREY, FINAL S ,} ,; 30. Drywall Nailingt _ HEALTH DEPT REQ liiREMEAiT `1. Plaster �tov�rt Co - _ .7 L . 79. FikAL' Ny5P5CTIQN $ , 32r!Electrical P;v er Mete? -Final :. • 80., -FOOD CERTiFIGA"TE ISSUED r t X33. Final El�ctri _ � 34rFiQ Huting& Air Conditioning; L7 t T L 35.7inal Gas Pipe -Test -36. Hood or ECanopy 37. -Final Factory Fireplace =38, Final PluTnbing 4 J L"+ - f:39. Water Service-Finail '-1 40. Gas Service -Final 41. Solar Domestic- Finat'> Backflow Preventer ` x , 43. Backflow Irrigation' -^ ' _ - •� v / `44. Landscage Irrigation SysterQ"- Sound Attenuation - F•- `46. Handicap, Regulatigjts - _ r 47.iFII4AL STRUCTURE & BUILDING `• `- 48.`FINAL PLANNING 49. -Electric Release to Edison Y t I . `50, -Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY No. Date PROJECT ADDRESS: 3 3 3 3' B R I S TTOL ST UNIT: Oklnik'S NAME: � , ,I SEGRE,STROM & SONS ADDRESS: •3315 FAIRVIEA RD C.M. 92626 ARCHIENGINEER: NADEL PARTNERSHIP, INC. REG.NO,: C-5674 ADDRESS: 3090 BRISTOL ST UNIT:_ C.M. CA 92626 PERMITTEE: BLAKE AIR COND . & SERV. (714)630-6412 ADDRESS: 1175 N. OSPREY CIRCLE ANAHEIM CA 92807 LECENSED CONTRACTOR DECLARATION: I hereby atfirm that I m licensed under provisions of Chapter 9 {commencing with Section 7000) of CIMS 3 �f the Bus' ess and Prolessions Cade. an y Iicen full farce and effect. c1TY Llc.: STATE LIC., 3 9 610 9 CLASS: C- 2 0 Signature 440 KERS' COMPENSATION DECLARATION: I hereby of m that I ave a cortilicate of consent to sult-insure ora certificate of Workers' Compensation �FC oo{ c??}}rt re copx t�jjereef {Section 3800, Lab. C) POLICY NO.: vw z 7 y g` v" EXP. TE: 0 7/0 1 / 9 4 1COMPANy: GOLDEN EAGLE rr ertilied py is h(Qereby furnished. L+ Certified copy s led wit y Building Division, Oa[e' Applicant: 4 MPTION FROM WORKERS' COMPENSATION DECLARATION: {This section need not be completed it the permit is for one hundred (SiO%or less). I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subleta to the Workers' Compensation Laws of California. Date: Signature: NOTICE: If, atter making this declaration. you should become subject to the Workers' Compensation provisions of the Labor Code. you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY: I herRby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Section 3097. Civ. C). LENDER: ADDRESS: OWNER BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractors' State License Law for the following reason (Section 7031.5 Business and Professional Code: Any city of county which requires a permit to construct, alter, improve, demolish, or repair any slructure. prior to its issuance, also requires the applicant for such permit to tile a signed statement that he/she is Siconsetl pursuant to the provisions of the Contractors' State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he/she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a dvil penally of not more than five hundred dollars (5500). 1. as owner o1 the property or my employees with wages as their sole compensation, will do the work, and the ❑ structure is nor intended or offered for sale (Section 7044, Business and Professional Code: The Contractors' State License Law does not apply to an owner of a property who builds or improves thereon• and who does Such work himselilherself or through his or her own emi provided that such improvements are not intended or offered for sate. 11, however the building or improvement is sold within one year of Completion, the owner will have the burden of proving he/she did not build or improve for the purpose o€ sale). I, as owner of the property, am exclusively contracting with licensed contractors 10 construct the project (Section 7044, Business Eland Prolessions Code: The Contractors' State License Law does not apply to an owner of property who bwlds or improves thereon and who contracts for such projects with a contractur(s) license pursuant to the Contractors State License Law). I am aware that proof of their Worker's Compensation insurance should be provided to me. I am exempt under Section: 8. d P. C. for this reason, CITY OF COSTA MESA -- BUILDING PERMIT PERMIT NO: M 067522 PLAN CHECK NO; i12 PERM NO: M 067522 GOVT: N SUPP: N CONSTRUCTION TYPE; I --FR PERMIT TYPE: MEC PURPOSE; ALT JOB DESCRIPTION UPGRAD,bNG OF BATHROOM TO HANDICAP SQ FT: CLAIM VALUE: CALC—VALUE': • GROUP OCC: B-2 / COMMENTS: RE-F:,B-67586; = t Ze 0. N J N G :R E Q U I R E M E N T S S E T B A C K S --------MAIN BUILDI'NG—--- ----- ---------- --•—— ACCESSORY BUILDING — —r— — FRNT: A FT= IN REAR; TT: IN FRNT: FT IN REAR; FT IN LEFT: FT IN RGHT: FT< IN LEFT.> FT IN RGHT: FT IN PARKING REQ: PROV: PARCEL,.i4-1,250107 ZNE: REF NO: PLANNING NOTES>; -'rh'JFiE##_9F•}[•9Fi(•�I-i4iEiFiE}F##########iE#iEi{-*.+FiFiF#iE9FiEit:it•#�iF##1FiF*iF+FiEiEit#lt•iEiF###iE#iEaE�(--1Fif•#*�:itiF#if•iF##### D E V E L O P M E N T S:E R V I C E S `R E Q U T R E M£ N T S ZONING APPROVED BY DATE: BUILDING APPROVED BY : ti DATE; 'APPLICATION ISSUED±BY; DATEfi �1* ; 1*4k• aE##�EiEiEiF#if##!F##![•#'rtiE'rL##iEiEjEiFiE'##eE#iE**#3EiGi[•-#F�(-#'IE�EiE'rc#�E##iEiF#####iF}E••}F#'rFiE####iE## ¢jE# iEiFif•#iF3F# LEGALIZAfiION;N F E E S U M M, --,A R Y STRUCTURAL SEGMENT:N BLDG PMT PLUMBING 'ELECTRIC. MECHANIC FIRE SMIP/RES GRADING PERMIT 24.50 PLAN 25% SMIP/NON-RES ISSUE FEE 15.00 BUILDING—DIV--> PERMIT ISSUE PLAN -CHECK TOTAL PAID DUE TOTALS-----> 24.50 15.00 0.00 39.50 39,50 ,00 REVENUE DIVISION TOTALS--> COLLECTED: - 39.50 OVER/SHORT: 00 BLDG PMT PLUMBTNG;ELECTRTC M-CHANIC FIRE SMIP/TOT GRADING PLAN—CHECK 3 9-. 0 r iE•*if•iEiE##iF##•}E•>'F#91-�iFMF�Eir•�1•�[•###if 9f it#iEif•##iF##iFiF�F�(•##a(•iE�#ih#�#�FlF•}k#####iE#aEiEiEiE###iF'lEi(•+f;F#3E•#iE*iEit•if I N D I V I D U A L _-F E E B R E A K D O W N 1 TYPE QTY Date: Owner I MEC I do hereby certify that I am aware of and understand the requirements of California,Health and Safety Code Sections 25505, 25533, and ildinI MEC 25534 and that l or any future bug occupant willlwill not (circle one) need io comply with said state codes and the requirements fora MEC permit for construction or modificalion from the Air OuaMy Management District. Residential construction applications are exempt from mese provisions. Date; Applicant' I hereby certify that I have read this application and slate that Jpe above information is correct. I agree to comply with all city and county ordinances and state laws relating to building Construct on and eby authoriz mauves of this city to enter upon the above•menlioned pry or inspection purposes. 9ar�: -�—L. { Signature License or Social Security 1641.46 While—Building; Green—Code Enlorcemem; Canary—Applicant: Pink—Revenue: Goldenrod—Assessor D E S C R I P T I O N. ''� UNIT COST TOTAL COST 1 REPAIR/ALT COOLING UNIT/SYS,W/CNTLS 9,00 9,00 1 REPAIR/ALT HEATING UNITYSYS W/CNTLS 9.00 9,00 1 VAV BOX6.50 '�oF 6,50 END FEES 01 00162017-00162017 TOT 39-90 DATE: 06/09/94 TIME.: 11:24 a A qPNSTRUCTION AND PLANNING 1 APPROVALS Permit # Hate Inspector POUt &SPA APPROVALS Permit # Date Inspector i 1. Temporary Electrical Serni ,e Q Pole 52, Pool & Equipment Location 2. 'Soil Pipe_Lindrynd; ' 53, Steel Reinforcement � 3. -:Electrical ,(Jtili1y_ Un0rgrnd.- 54. Forms 4.lectricai r,,{it Undrgrnd. 55, Electrical Bonding 5."Sleet Reinfcirc6.1h;t' }-, F r 56. Rough Plumbing & Pressure Test 6• Elutrical•UFERGrnd. 57, APPROVAL TO COVE R-GUNITE { 7. 'Fb1 Lings-. j 58. Electrical Conduit-Undrgrnd. S. _F6uhdation r- 59. Gas Pipe, 0 Undrgrnd., Test 9, Water Pipe•Undrgrnd. 60. Backwash Lines, P -Trap, CJ Undrgrnd. 10_ -Structural Floor System' 61. APPROVAL TO DECK 11, Property Sewer fine Hods'e Connection 62. Backwash & Receptor -Final 1,2, Sewer _Cap f 63. Heater & Vent -Final I 13. Aoof Drains 64. Plumbing System - Final I 14. Rough Plumbing 65. Electrical -Final 15. Rough Electrical -Conduit 66, Solar System -Final r 16. Rough E12ctric yhring 67. Fencing & Access Approval 17•. Rough Wiring Sign 68. APPROVED FOR PLASTERING i 18, Rough Electrical•T Bar Ceiling 69, POOL/SPA SYSTEMS FINAL 19- Rough Heating & Air Conditioning ll pp FIRE DEPT. REQUIREMENT APPROVALS' Permit # � 20. Rough Factory F:teplace 21. Ducts, in Structure 70. Underground Hydro c 22, Ducts, Ventilating 71, Product Piping © Gas I-] O;i i 23. Gas Pipe -Rough & Test 72. Underground Flush 24, Roof Framing 73. Undergrnd. Storage Tank L Gas C1 Oil 25. Roof Sheathing 74. Overhead Hydro 26. T -Bar Ceiling (Structural) & Monocoat 75. pry Chemical 27. Frame and Flashing 76. Dry Standpipe 28, Lathing & Siding 77. FIXER SYSTEM FINAL r 29. Insulation 78. FIRE PREY. FINAL 30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat 79. FINAL INSPECTION 32. Electrical Power Meter -Final 80. FOOD CERTIFICATE ISSUED 33, Final Electric Notes: 34. Final Heating & Air Conditioning 35. Final Gas Pipe=Test 36. Hood or Canopy 37. Final Factory Fireplacemel ji /6 _ �^►�_ 6` '" F` 38, Final Plumbing 39. Water Ser1;ce-Final 40. Gas Service -Final 41. Solar Domestic -Final 42, Backflow Preventer ! 43. Backflow Irrigation 44. Landscape Irrigation System 45. Sound Attenuation 46. Handicap Regulations 47, FINAL STRUCTURE & BUILDING ; 48, FINAL PLANNING 49. Electric Release to Edison 50. Gas Release to Southern California Gas Co 51: CERTIFICATE OF OCCUPANCY No. Date r PROJECT AODRE$I." 3 3 3 3 BRISTOL S T UNIT: OWN-rS NAME: C.J. SEGERSTROMS " ADDRESS: 3 315 FAIRVIEW C. M. 92627 546-0110 ARCHIENGINEER:. NADEL PARTNERSHIP REG.NO.: 000000 ADDRESS: 3090 BRISTOL ST 540-5000 UNIT: 200 C.M. CA 92626 PERMITTEE: GENESIS MECHANICAL (714)361-5750 ADDRESS: 944 CALLS AMANACER SAN CLE14ENTE CA 92673 LICENSED CONTRACTOR DECLARATION: I heresy affirm that I am licensed under provisions of Chapter 9 icommencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. CITY tic. -.05 1 458 STATE LIC,. 4 9 3 7 8 4LAss: C— 3 6 'EXP-. 09/92 ate: -3 O TJ Signature: _ - _ H_MdERS' COMPENSATION DECLARATION: I hereby affirm that I have a ce is of consent to sell -insure or a certificate of Workers' Compensation I sq a ce. o a certi led cppy thereof (Section 3800, Lab. di/01/95 C� . POLICY NO.: U U j 1 EXP, DATE: U 1/ 0 1/ 9 5 COMPANY: STATE rrS�1t ❑ Certified copy is hereby furnished. LJ Certified Copy!tiled with the city Building Division. ate: Q Applicant: O f= PTION FROM WOR6ERS' COMPENSATION DECLARATION: (This section need not h completed it the permit is for one hundred ($100} or less), I certify that in the performance of the work for which this permit is issued. I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California. Date: Signature: NOTICE: 11, after making this declaration, you should become subject to the Workers' Compensation provisions of the Labor Code. you must forthwith comply with Such provisions or this permit shall be deemed revoked. k' CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency tar the,peddrmance at the work for which this permit is issued (Section 3097, Civ. Q. ' LENDER: ADDRESS: CONVER STORAGE FACILITIES TO H,C. ACCESSIBILTY OWNER BUILDER DECLARATION: I herebyaffirm that I am exempt from the Contractors' State License Law for the following reason (Section 7031.5 Business and Professional (de: Any city of county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he/she is licensed pursuant to the provisions of the Contractors State License Law (Chapter 9 {commencing with Section 7000) of Division 3 at the Business and Professions Code) or that helshe is exempt therefrom and the basis for the atleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than sive hundred dollars ($500). I, as owner of the property or my employees with wages as their sole compensation, will do the work, and the ❑ structure is not intended or altered for sale {Section 7044, Business and Professional Code: The Contractors' State License Law does not apply to an owner of a property who builds or improves thereon, and who does such work himseltlherself or through his or her own employees, provided that such improvements are not intended or offered for safe. If, however the building or improvement is sold whin one year of completion, the owner will have the burden of proving he/she did not build or improve for the purpose of sale). I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Section 7044, Business ❑ and Processions Code: The Contractors' Stale License Law does not apply to an owner of properly who builds or improves thereon and who contracts for such projects with a cdniracloris) license pursuant to the Contractors' State License Law). i am aware that proof of their Worker's Compensation insurance should be provided to me. ❑ I am exempt under Section: B. 3 P, C. for this reason: Date: Owner: I do hereby certify that I am aware of and understand the requirements of California,Fiealth and Safety Code Sections 25505, 25533, and 25534 and that I or any future building occupant will1will not (circle one) need to comply with said state codes and the requirements for a permit ler construction or modification from the Air Duality Management District. Residentiai construction applications are exempt from these provisions. Dale: Applicant: I hereby certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction and hereby authorize representatives of this city to enter upon the above-mentioned pro erty for inspection purposesQ. Dat l Signature: river's License or Social Security f: 1641-46 White --Building: Pink—Revenue: Goldenrod—Assessor "~ CITY OF COSTA MESA — BUILDING PERI= PERM NO: P 06T9 PERMIT NO; P 067859 PLAN CHECK NO: N GOVT: N SUPP: N CONSTRUCTION TYPE: I—FR PERMIT TYPE: PLO PURPOSE: ALT JOB DESCRIPTION CONVERT 7505F STORAGE TO H.0 BATHROOM SQ FT;' CLAIM VALUE; CALL—VALUE: GROUP OCC: B-2 / COMMENTS; AT END OF CORRIDOR BETWEEN LADY FOOTLOCKER E GYMBOREE ####### x•ic•#it•#TFaE#�#�##iE�•##it?�••fEJtie######r####iF�*aE#�•#iF��•##�3t•->f##�#iE3t••x•-rFiF�#�##ac-g: ##it•iF#9t•##jF Z O N I N GS E R T E B Q A U C I K R S E M E N T S --- -- MAIN BUILDING ---------- --------- ACCESSORY BUILDING • •------- — FRNT; FT IN REAR: FT IN FRNT; FT IN REAR; FT IN LEFT; FT IN RGHT; FT IN LEFT; FT IN RGHT: FT IN PARKING REQ • PROV; PARCEL; 41250107 ZNE; REF NO: PLANNING NOTES> aE # # # # i(• # # iF # # 3h # �(• # # # # # # # # # # # ar # of # # it # i4• #'f +t• # * # >E # aE 3t aE �!• iE-iE jt• Nr iH i(�b it• �(- iE iE is iE iE �F• it•,iE• �F ie 1E iE iE 1F ii iF• iE •Mf• it ft• iF if• # 3F is D E V E L O P M E N T S E R V I C E S R E Q U I R E M E N T S ZONING APPROVED BY DATE; BUILDING APPROVED BY DATE: APPLICATION ISSUED BY.�1�� DATE• CM # # # # * k iF 3F aE # # # ac # aF # # iE i(• iF :� -fr: � �F se �(• it• it• �t iF # �(• # •►� 5E if 9r• �F x �!• dE• # ih # ' �E �t � iE fit• 9e it• iE iF iN ik •>F iF iF• •1F 3E jF k iF is 3F it vE f fe iE##if•##iF##.#aF#it•)F'1Fir•#�E##########ick'•##9E##ieaEa(•aEaE�(•at•####at•aE###�E•####iC••x•aPih-16#aN###ae#aEak#� at• LEGALIZATION : N F E E S U M M A R '-Y -_� STRUCTURAL . 'GMENT : N BLDG PMT PLUMBING ELECTRfC• MECHANIC I,FIRE_r SMIP/RES GRADING PERMIT 161.00 c 250 SMTP/NON—RES PLAN ISSUE FEE 20.00r " BUILDING—DIV—> PERMIT ISSUE PLAN—CitECK T67A11 PAID DUE TOTALS ---- > 161.00 20.00 0.00 181.00 181.00 •00 REVENUE DIVISION TOTALS--> COLLECTED: 181.0'0 OVER/SHORT: ,00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIR -E :SMI—.P/TOT- GRADING PLAN—CHECK 181.00 r #iE###iF###aP###aF#####iE#-IEaF#iF######-1(•#at 3tiEif-iE##iE#####aEir•###a[•###irie##.}E# iE�f-�(•iE•#•x-*� ###*# YriEi(•## I N D I V I D U A L F. 'E E B R' E'.A K D O�14 N TYPE QTY D E S C R I P T I O N- i UNI'' 60ST TOTAL COST PLO 6 WASH BASIN '`7.00 42,00 PLO 9 WATER CLOSET (TOILET)• 7.00 53.00 PLO 1 WATER HEATER AND/OR VENT ' X7.00 7.00 PLO 1 DRINKING FOUNTAINS ' ..7.•00 7.00 PLU 2 FLOOR DRAINS7. 0400 PLU 1 SINKS, FLOOR �.y , � 7; 00 17 , 00 PLU 3 URINALS, WALL r 7`,;0.0 21.00 END . OF FEES • ,A' , ovi s2x7-0016321.7 T0_ -V 181.00 `_� ti �ATErt 16/30/94 TI14E: 13:41 CONSTRUCTION AND PLANNING APPROVALS -Permit # Date Inspector P6,41F& SPA APPROVALS Permit :#- Date Inspector 1. Temporary Electrical Service dr Pole 52. Pool & Equipment Location Soil Pipe•Undrgrnd. Lid- i 53. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. 54. Forms 4. Electrical Conduit-Undrgrnd,"' 55. Electrical Bonding 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6. Electrical LIFER Grnd, 57. APPROVAL TO COVER•GUNITE 7. Footings 58, Electrical Conduit•Undrgrnd. 8. Foundation _-� 59. Gas Pipe, © Undrgrnd., Test 9. Water Pipe-Undrgrrtd, 7 60. Backwash Lines, P -Trap, 0 Undrgrnd, 10. Structural Floor System 61, APPROVAL TO DECK 11. Property Sewer Line & House Connection 62. Backwash & Receptor -Final 12. Sewer Cap 63. Heater & Vent -Final 13, Roof Drains 64. Plumbing System - Final i 14. Rough Plumbing ! ! 68. Electrical -Final 15. Rough Electrica(-Conduit 66. Solar System -Final 16. Rough Electric Wiring 67. Fencing & Access Approval 17. Rough Wiring Sign 68. APPROVED FOR PLASTERING 18, Rough Electrical -T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT, REQUIREMENT APPROVALS Permit # 20. Rough Factory Fireplace 21. Ducts, in Structure 70. Underground Hydro 22. Ducts, Vent -slating 71. Product Piping C3 Gas 0 Oil 23. Gas Pipe -Rough & Test 72. Underground Flush 24. Roof Framing 73. Undergrnd. Storage Tank ©Gas ©Oil 25. Roof Sheathing 74. Overhead Hydro 26, T•Bar Ceiling f5tructurall & Monocoat 75. Dry Chemical 27. Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding 77. FIXED SYSTEM FINAL 29. Ins0ation 78, FIRE PREY. FINAL 30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Piaster Brown Coat 79. FINAL INSPECTION 32. Electrical Power Meter -Final 80. FOOD CERTIFICATE ISSUED 33. Final Electric Notes: L�s U [C 34. Final Heating & Air Conditioning 35. Final Gas Pipe -Test 36. Hood or Canopy 37. Final Factory Fireplace Q� op44�L�`&,.eIF, dill 38. Final Plumbing 39. Water Service -Final 40. Gas Service -Final 41. Solar Domestic -Final -- LOQ 1)U7 42, Backflow Preventer .Q 43. Backflow Irrigation r 44. Landscape Irrigation System 45, Sound Attenuation 46. Handicap Regulations 47. FINAL STRUCTURE & BUILDING 48. FINAL PLANNING - 49. Electric Release to Edison , 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY No. Date " PROJECT ADDRESS: -T ` UNIT: OWNER'S NAME: 3333 BRISTOL ST 1�u ADDREss:3315 C.J. SEGERSTROM & SONS , 3 315 FAIRVIEW RD COSTA MESA CA 92626 ARCHIENGINEER: (714)546-0110 REG.NO.: ADDRESS: UNIT: PERMITTEE: GRAHAM BROTHERS (,714)546-1653 ADDRESS: 2952 CENTURY COSTA MESA CA 9262,6 LICENSED CONTRACTOR DECLARATION: I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code. and license is in full forte and effect. CITY LIC.:005963 STATE LIC. 2 4 8 6 4 CLAS- C 7 n r� Date: r'� �� Signature: _ ,V`�—J) WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure or a certificate of Workers' Compensation Insurance. or a certified copy thereat {Section M, Lab, Q. OpLICY No.: WC '1161030226012 EXP DATE: 0 8/ 0 1/93 IOMPANY:LIBERTY MUTUAL ,3 Certified copy is hereby furnished. Certified ZS Certified co thhcity uild-i ng Divisi Date: Apptic EXEMPTION FROM WORKERS' COMPENSATION DECLARATON: ebmneedDtbeBcompdifho pemis for ane undred (5100) or less). I cerlity that in the performance of the work for which this permit is issued. I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California. Date; Signature: NOTICE: It. after matting this declaration, you should became subject to the Workers' Compensation provisions of the Labor Code. you must forthwith comply with such provisions or this permit shaft be deemed revoked. CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Section 3097. Civ. C). ALL WORK IN THE CORRIDOR SYSTEMS. OWNER BUILDER DECLARATION: I hereby affirm that I am exempt IrOm the Contractors' State License Law for the following reason {Section 7031.5 Business and Professional Code: Any city o1 county which requires a permit to construct, alter, improve, demolish, or repair any structure. prior to its issuance. also requires the applicant for such permit to file a signed statement that he/she is licensed pursuant to the provisions of the Contractors' State License Law (Chapter 9 (commencing with SecWn 7000) of Division 3 of the Business and Professions Code) or that he/she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penal;y of not more than five hundred dollars (5500). I, as owner of the property or my employees with wages as their sole compensation, will do the work, and the ❑ structure is not intended or offered for sale (Section 7044, Business and Professional Code: The Contractors' State License Law does not apply to an owner of a property who builds or improves thereon, and who does such work himsellfhersell at through his or her own employees, provided that such improvements are not intended or offered for sale. l;, however the building or improvement is sold vnthin one Year of completion, the owner will have the burden of proving helshe did not build or improve for the purpose of sale). I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sectian 7044, Business © and Professions Cade: The Contractors' State License Law does not apply to an owner of property who bunds or improves thereon and who contracts for such projects with a corllraciops) license pursuant to the Contractors' State License Law). I am aware that prool of their Worker's Compensation insurance should be provided to me. ❑ I am exempt under Section: B. E P. C. for this reason; Date: Owner: I do hereby certify that I am aware of and understand the requirements of California Health and Safety Code Sections 25505. 25533, and 25534 and that I or any luture building occupani�willlwill not (circle one) need to comply with said state codes and the requirements for a permit for construclion or modification from the Air Duality Management District. Residential construction applications are exempt from these provisions. Dale: Applicant: I hereby certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and stale laws relating to building construction and authori a representatives Of Iles City to enter upon the above-mentioned properly for inspection purposes. Date.eA,! . 7-5 ' � � Signature Driver's License or Social Security 164 1 -46 While—Building; Green—Code Enforcement; Canary—Applicant Pink—Revenue; Goldenrod—Assessor CITY OF COSTA MESA — BUILDING PERMIT PERM NO: M 062763 PERMIT NO: M 062763 PLAN CHECK NO: N GOVT; N SUPP: N CONSTRUCTION TYPE; 1FRSP PERMIT TYPE; MEC PURPOSE; OTH JOB DESCRIPTION : INSTALL 3 VAV BOXES IN 2 CORR, LOCATIONS SQ FT; CLAIM VALUE; CALC—VALUE; GROUP OCC: B-2 / COMMENTS; 1 VAV NEAR THE "CRABTREE" STORE & 2 NEAR "ROBINSON'S—MAY" *#f irt1lif�ifif k�iF9f9EJTiEdF����****�������*****�*��*�-•�ta�iaiE�til•�Ex�F*�iE�k+�****�*�***���+�*��***�*� Z O N I N GS ERTEBQAUCIKRSE M E N T S MAIN BUILDING - --- FRNT; FT IN REAR: FT IN LEFT: FT IN RIGHT, FT IN — ACCESSORY BUILDING — — FRNT; FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN PARKING REQ• PROV: PARCEL; 41250102 ZNE: REF NO; PLANNING N TES> -1F1E-l1-*iEifiFiE*fit•iEiE'1EibitititlEitlEiEJE�3E*iE***iEit•�(•iE*�*3FitftJE�*!F*�?tt*�i��-!F*i6***it it***�-**�*�f-iEiEiEit•iE�ib�?rE** D E V E L O P M E N T S E R V I C E S R E Q U I R E M E N T S 'ZONING APPROVED BY DATE; BUILDING APPROVED BY DATE; APPLICATION ISSUED BY: ;, DATE; S! ******kit it** k -fit it if Itftft ft �**�r**•>Est**�r�r�r�*�*�•����*�-*�**�r��***�-ic-*��r�c-�c�-���ic-��* ��il-�-���r�;f�����-�•�����-�*���-�c*� LEGALIZATION:N F E E S U M M A R Y STRUCTURAL SEGMENT:N BLDG PMT PLUMBING ELECTRIC MECHANIC PERMIT 19.50 PLAN ' ISSUE FEE BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTALS ---- > 19.50 15,00 ,r 0,00 REVENUE DIVISION TOTALS--> COLLECTED; BLDG PMT PLUMBING ELECTRIC MECHANIC 34,50 15,00 FIRE SMTP/RES GRADING SMIP/NON—RES TOTAL PAID DUE 34.50 34,50 ,00 34,50 OVER/SHORT: ,00 FIRE SMIP/TOT GRADING PLAN—CHECK i(- �E iF IE * � * * iE it * it i4 IE it * * iE J! TE * iE i! T! it * JE JE lE JF �E iE i@ -lE it• it � it � if �t-it• iE i6 �! iE ik •>F * it � #E iE �F it• iE * * !t !4 iB * iE #! iE iE iF i!- �t * * it � iE � � AF !f I N D I V I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST MEC 3 VAV Box END OF FEES 6.50 19.50 01 00141756-001417',56 T O T 34.50 DATE: 06/25/93 TIME: 15:03 7/ CONSTRUCTION AND PLANNING - APPROVALS Permit # Date Inspector P\.&SPA APPROVALS Permit # Date Inspector .� • 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location 2, Soil Pipe-Undrgrnd, . _ 53. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. 54. Forms 4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6• Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE 7. Footings 58. Electrical Conduit•Undrgrnd. ' 8, Foundation ' 59, Gas Pipe, 0 Undrgrnd., Test 9. Water Pipe-Undrgrnd. 60. Backwash Lines, P•Trap, © Undrgrnd. l F 1e:-Structurai Floor System - �' 61. APPROVAL TO DECK 11. Property Sewer Line & House•Connection 1( 62. Backwash & Receptor -Final 12. Sewer Cap 63. Heater & Vent -Final A8. Roof Drains 64. Plumbing System - Final 14. Rough Plumbing 65, Electrical -Final 15. Rough Electrical -Conduit 66. Solar System -Final 16. Rough Electric Wiring 67. Fencing & Access Approval = 17. Rough Wiring Sign 68, APPROVED FOR PLASTERING 18. Rough Electrical -T Bar Ceiling 69, POOLISPA SYSTEMS FINAL 19. Rough ))eating &Air Conditioning FIFE DEPT. REQUIREMENT APPROVAL: _-, Permit # 20. Rough Factory Fireplace 21. Ducts, in Structure -70. Underground Hydra 22. Ducts, Ventilating . - X71, Product Piping 0 Gas I]Oil 23. -Gas Pipe -Rough & Test 72. Underground Flush 24. Roof Framing 73. Undergrnd. Storage Tank 0 Gas © Oil 25. Roof Sheathing 74. Overhead Hydro 26. T -Bar Ceiling (Structural) & Monocoat 75. Dry Chemical 27. Frame and Flashirjg - 76. Dry Standpipe 28. Lathing & Siding 77. FIXED SYSTEM FINAL 29. Insulation ; 78: FIRE PREV, FINAL 30, Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat € 79. FINAL INSPECTION 32. Electrical Power Meter -Final r - 80. FOOD CERTIFICATE ISSUED 33, Final Electric ` Nodes: 34, Final Heating & Air Conditioning 35. Final Gas Pipe -Test l € 7 36. Hood or Canopy t a 37. Final Factory Fireplace I 38. Final Plumbing € 39. Water Service -Final 40, Gas Service -Final 41. Solar Domestic -Final 42. Backflow Preventer 43. Backflow Irrigation 44. Landscape Irriqation System 45. Sound Attenuation 46. Handicap Regulations i € 47. FINAL STRUCTURE & BUILDING 48,• FINAL PLANNING 49, Electric Release to Edison 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY No. Date I PROJECT ADDRESS: 3333 BRISTOL ST UNIT: WLKWY OWNER'S NAME: C J SEGERSTROM ADDRESS: 3315 FAIRVIEW RD C.M. ARCHIENGINEER: STERLING & ASSOC REG.ND.: C 14 800 ADDRESS: 16 FO X GL E N UNIT: IRVINE CA 92714 PERMITTEE: ROBERTS ELECTRICAL (714)495-3541 ADDRESS: 12 SAND POINTE LAGUNA NIGUEL CA 92677 LICENSED CONTRACTOR DECLARATION: I hereby allirm that I am licensed under provisions of Chapter 9 (comment' with Section 7000) of Division 3 of the Business and Professions Cade, and my license i in toll torte and elle CITY LIC.: 021384 //�+ STATE LIC.: 3801 16 ss: C- i Dale: _�� 4fa _;!, l Signature: WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure or a certificate of Workers' Compensation Insurance, or a certified copy thereof {Section 3900, tab. C). POLICY NO.: EXP. DATE: "OMPANY: � Certified copy is hereby furnished. ❑ Certified copy is filed with the city Building Division. Date: Applicant: EXEMPTION FROM WORKERS' COMPENSATION DECLARATION: (This section need not completed if the rmit is for one (51 DO) or less). I tertily that in the performance of the work for which this permit is issued, not empl a so in any m so as to become Subject to the Workers' Com nsalion Laws of California. Date. — Signature: ✓ NOT& E: If. after mai this declaration, you should become subject to the Workers' Compensation provisions of the Labor Code. you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction tending agency for the performance of the work for which this permit is issued (Section 3097, Cry. C). LENDER: ADDRESS: OWNER BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractors' State License Law for the following reason (Section 7031.5 Business and Professional Code: Any City of county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he/she is licensed pursuant to the provisions of the Contractors' State License Law (Chapter 9 (commencing with Section 7000) o1 Division 3 of the Business and Professions Code) or that helshe is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (5500). I, as owner of the property or my employees with wages as their sole compensation, will do the work, and the ❑ structure is not intended or offered for sale (Section 7044, Business and Professional Code: The Contractors' State License Law does not apply 10 an owner of a property who builds or improves thereon, and who does such work himself/herself or through his or her own employees. provided that such improvements are not intended or offered for safe. If, however the building or improvement is sold within one year of completion, the owner will have the burden of proving helshe did not build or improve for the purpose of sale). h as owner of the property, am exclusively contracting with licensed contractors to construct the project (Section 7044, Business ❑ and Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon and who contracts for such projects with a contractors) license pursuant to the Contractors' Stale License Law). I am aware that prool of their Worker's Compensation insurance should be provided to me. ❑ I am exempt under Section: B. & P. C. for this reason: Date: Owner: I do hereby certify that I am aware of and understand the requirements of California Health and Safety Code Sections 25505, 25533, and 25534 and that I or any future building occupant willlwiN not {circle one) need to comply with said state codes and the requirements for a permit for conslruc6oa or modification from the Air Duality Management District. Residential construction applications are exempt from these provisions. Date: Applicant: I hereby certify that I have read this application and state that the above ordinances and slate laws relaling to building construction and hereby aulh property far inspection purposes. Date: Signature: Driver's License or Social Security N: is correct. I are io camply tvb�ll city and county 164146 White --Building; Green—Code Enforcement; Canary—Applicant; Pink—Revenue; Goldenrod—Assessor CITY OF COSTA MESA — BUILDING PERMIT PERMIT NO: E 064921 PLAN CHECK NO: N CONSTRUCTION TYPE: PERMIT TYPE: ELE JOB DESCRIPTION : MISC PDESTRIAN WALKWAY IMPROVEMENTS CLAIM VALUE: CALC—VALUE: PERM NO: E 064921 GOVT: N SUPP: N PURPOSE: ALT SQ FT: GROUP OCC: B-2 / COMMENTS: WALKWAY ENTRANCE NEXT TO ANN TAYLOR, REF:B-64902 Z O N I N G R E Q U I R E M E N T S S E T B A C K S --------------- MAIN BUILDING ---------- --------- ACCESSORY BUILDING--------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN PARKING RE • PROV: PARCEL: 41250105 ZNE: REF NO; PLANNING NOT£S> 3E if � * }F # iF if ir- �h �F �F # iE # �E 4E iE ir• iE iE ie it iE i� iE'1E iF � � iF iF iF iffE'if iE # aE'#'�E iF �E i[- }F iE ih ii iE if iF i(iF ii'1!• iF iF iF iF # iE �E 3f ifiE if if iF iF +4 i(�F iE iF iF i4'1F iF'aF D E V E L O P M E N T S E.,R -V I,C E S R E Q U I R E M E N T S ZONING APPROVED BY DATE - BUILDING APPROVED BY DATE: APPLICATION ISSUED BY: DATE: '3 ��aE#3FiF**iF*�iEiF9E�iFiFiE?t•9E���jF��iEiflfif�iFdFdE�f3FiE�Fii-�iF�ir.'Fir•ir•iF�-IFiFiFTf��}F,1caF�jF#**��iF;(•*�#aF�FiFirriF��if•)F� LEGALIZATION:N F E E .S U M M A R Y STRUCTURAL SEGMENT:N BLDG PMT PLUMBING ELECTRIC MECHANIC PERMIT 3.00 50% PLAN - ISSUE FEE 15.00 BUILDING -DIV-> PERMIT ISSUE PLAN -CHECK TOTALS ---- > 3,00 15.00 0,00 REVENUE DIVISION TOTALS--> COLLECTEd: BLDG PMT PLUMBING ELECTRIC MECHANIC 18.00 FIRE SMIP/RES GRADING SMIP/NON-RES TOTAL PAID DUE 18.00 18.00 .00 18.00 OVER/SHORT: .00 FIRE SMIP/TOT GRADING PLAN -CHECK �F it iF iF ie �k #'!f'}F iE 'rF'lf- * ik iF iE it �k it ik � �F iF �E �E 9F jf �1t it ik � �e i4 it iE � T{ iE � if � iE !F * * if iF ik iE Irt iE• � �E iP � ih * if iE iF � �t � if aF � if � iE iE iP # iF iE iF if• iE fE I N D I V I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST ELE 4 FIXTURES, LIGHTING 'y 1 ST 20 EA, ,75 3.00 ^ END OF FEES EXPIRED Incomplete If1SpreG#" 08% �� r' �` pQ�j, fel 00150753-00150758 T li 18.00 F DATE: 11/16/93 TIME: 10:31 1 - CONSTRUCTION AND PLANNING APPROVALS Permit # - Date Inspector POS s, SPA APPROVALS Permit # Date Inspector 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location i 2. Soil Pipe-Undrgrnd. 53, Steel Reinforcement 3, Electrical Conduit Utility-Undrgrnd. 54. Forms 4. Electrical Conduit -Undrgrnd. 55. Electrical Bonding 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6. Electrical UFIrR Grnd. 57, APPROVAL TO COVER-GUNI T E 7. Footings 58. Electrical Conduit•Undrgrnd, 8. Foundation 59, Gas Pipe, © Undrgrnd., Test 9. Water Pipe•Undrgrnd, 60, Backwash Lines, P -Trap, D Undrgrnd. ; 10. Structural Floor System 61. APPROVAL TO DECK 11. Property Sewer Line & House Connection 62. Backwash & Receptor -Final 12. Sewer Cap 63. Heater & Vent -Final - 13. Roof Drains 64, Plumbing System - Final 14. Rough Plumbing 0 65. Electrical -Final �• 15. Rough Electrical -Conduit' ,�: 66. Solar System -Final 16. Rough Electric Wiring 67. Fencing & Access Approval 17. Rough Wiring Sign 68. APPROVED FOR PLASTERING 1$. Rough ElectricalT Bar Ceiling 69. POO L(SPASYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit # 7" 20. Rough Factory Fireplace 21. Ducts, in Structure 70. Underground Hydro 22, Ducts, Ventilating 71. Product Piping D Gas 0 Oil 23, Gas Pipe -Rough & Test 72. Underground Flush - 24. Roof Framing 73, Undergrnd. Storage Tank D Gas :D Oil 25. Roof Sheathing 74. Overhead Hvdro , 26. T -Bar Ceiling (Structural) & Monocoat 75, Dry Chemical - 27. Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding 77, FIXED SYSTENA, FINAL 3. 29. Insulation 78, FIRE PREV. FINAL 30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat 79. FINAL INSPECTION 32. Electrical Power Meter -Final 33. Final Electric 34. Final Heating & Air Conditioning 35. Final Gas Pipe -Test 80. FOOD CERTIFICATE ISSUED Notes: " 3_ A20 �zn5 o R cZ cess 36. Hood or Canopy 37. Final Factory Fireplace 38. Final Plumbing 39. Water Service -Final 40, Gas Service -Final 41. Solar Domestic -Final 42. Backflow Preventer 43. Backflow Irrigation 44. Landscape Irriqation System 45, Sound Attenuation 46. Handicap Regulations 47, FINAL STRUCTURE & BUILDING 48. FINAL PLANNING 49- Electric Release to Edison r : 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY No. Date PROJECT ADDRESS: 3333 BRISTOL ST UNIT: WL KWY OWNER'S NAME: C J SEGERSTROM ADDRESS: 3 315 FAIRVIEW RD C.M. ARCHIENGINEER: STERLING & ASSOC REG.NG.: 014800 ADDRESS: 16 FOXGLEN UNIT: IRVINE CA 92714 PERMITTEE: C J SEGERSTROM (714)546-1010 ADDRESS: 3315 FAIRVIEW RD C.M. CA 92626 LICENSED CONTRACTOR DECLARATION: I hereby affirm that I am licensed undef provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. CITY LIC.: STATE LIC.: CLASS: Date: Signature: WORKERS' COMPENSATION DECLARATION: I hereby allirm that I have a certificate of consent to self -insure or a certificate of Workers' Compensation Insurance. or a certified copy thereof (Section 3800. Lab. C). POLICY NO.: EXP. DATE: ;OMPANY: I Certified copy is hereby furnished. ❑ Certified copy is filed with the city Building Division, Date: Applicant: EXEMPTION FROM WORKERS' COMPENSATION DECLARATION: (This section need not be completed if the permit is for one hundred ($100) or fess). I certify that in the performance o1 the work for which this permit is issued, I shali n7empi any pe on in any manner so as to become subject to the Workers C mpensation Laws of California. Date: Z&LSignature: NOTICE: if. after 6king this declaration, you should become subject to the Workers' Co ation provisions of the Labor Code. you must forthwith comply with such provisions or this permit shall be deemed r d. CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Section 3097, Civ, C), LENDER: ADDRESS: OWNER BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractors' State License Law for the following reason (Section 7031.5 Business and Professional Code: Any city of county which requires a permit to construct, alter, improve, demolish, or repair any structure. prior to its issuance, also requires the applicant for such permit to file a signed statement that he/she is licensed pursuant to the provisions o1 the Contractors' State License Law {Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he/she is exempt therefrom and the basis lar the alleged exemption. Any violation of Section 7031.5 by any applicant Sar a permit subjects the applicant to a civil penalty of not more than five hundred dollars (5500). as owner of the property or my employees with wages as their sole compensation, will do the work, and the ElsI, tructure is not intended or offered for sale (Section 7044, Business and Professional Code: The Contractors' State License Law does not apply to an owner of a property who builds or improves thereon, and who does such work himselftherself or through his or her own employees. provided that such improvements are not intended or offered for sale. If, however the building or improvement is sold within one year of completion, the owner will have the burden of proving he/she did not build or improve for the purpose of sale). �5 I. as owner of the property. am exclusiveiyy contracting with licensed contractors to construct the project {Section 7044, Business L] and Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon and who contracts for such proiecis with a comractor(s) license pursuant to the Contractors' State License Law), I am aware that proof of their Worker's Compensation insurance should be provided to me. ❑ I am exempt under Section: B. & P. C. tar thisreason: Date: 7r J y� 3 Owner: I do hereby certify that I am aware of and understand the requirements at California Health and Safety Code Sec 25505, 25533, and 25534 and that I or any future building occupant will/will not (circle ane) need to comply with said state codes and the requirements for a permit for construction or modification from the Air utility Management District. Residential construction applications are exempt from these provisions. Dare, Applicant: I hereby certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction and hereby authorize representatives of this city to enter upon the above-mentioned property for inspeclion purposes. Dale: /r / f—r Signature: Driver's License or Social Security a: 1641-46 Whne—Duntlmg: Green—Code Enlorcement; Canary—Applicant: Pink—Revenue: Goldenrod—Assessor hill 6- CITY OF COSTA MESA — BUILDING PERMIT PERM NO; E 06490: PERMIT NO: E 064903 PLAN CHECK NO: N GOVT: N SUPP: N CONSTRUCTION TYPE; PERMIT TYPE: ELE PURPOSE: ALT JOB DESCRIPTION MISC PEDESTRIAN WALKWAY IMPROV, #B64902 SQ FT: CLAIM VALUE: CALC--VALUE: GROUP OCC: B-2 / COMMENTS: IMPROVE WALKWAY BET. S. PARKING STRUCT & MALL, RELOCATE LIGHTS Z O N I N G R E Q U I R E M E N T S S E T B A C K S ------------ MAIN BUILDING ----------- ---------- ACCESSORY BUILDING-----_---- FRNT: FT IN REAR: FT IN FRNT; FT IN REAR: FT IN LEFT; FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN PARKING RE • PROV: PARCEL: 41250105 ZNE: AEF NO: PLANNING NOTES> > ik##iEiE#iEifiFiF'lE�t#dFit*#lF��iEiE+EiE�fF###if##iE#iE�9E3EiF#*it iii(•iF#iE*9FiE�kiF##3F###F##ii•iE#it•##•St•ofaFaFiE*;E3E#iaiF#* D E V E L O P M E N T S E R -V I C E S R E Q U I R E M E N T S ZONING APPROVED BY DATE: BUILDING APPROVED BY DATE: APPLICATION ISSUED) BY: DATE; t� er-###*#########)EiE#ie#**riF#dETF#4E*#•]F##iF##iFaF9FjF#***####jr•*ac*TE#*#�FiE###iF•IFit�t*9E •?FiFiF9F�K*#**it-#9E LEGALIZATION:N F E E S U M•M A R Y STRUCTURAL SEGMENT:N BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT 2,25 50% SMIP/NON—RES PLAN ISSUE FEE 15.0'0 BUILDING -DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE TOTALS ---- > 2.25 15,00 •0.00 17,25 17.25 .00 REVENUE DIVISION TOTALS--> COLLECTED: 17.25 OVER/SHORT: ,00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK 17.25 iFiFjF##9F#####�t##�FiF##*##*i(•#3FikiFfF#1F#�E#####iF•►EiFir-#iF#iE#9E##*}Fair-iPiEiE*#####iFiFiEiE#-?F*94iFaf####iE*if• I N D I V I D U A L F E E B R E A K D O W N TYPE �` QTY D E S C R I P T I O N UNIT COST TOTAL COST ELE' 3 FIXTURES, LIGHTING 1 ST 20 EA. .75 2.25 END OF FEES EXPIRED x ���ip,w$ Inswtions 01 00150624-00150584 i O IT 17.25 DATE: 11/115/73 TIME: 11:37 CONSTRUCTION AND PLANNING APPROVALS Permit # Date inspector PG. & SPA APPROVALS Permit # date Inspector 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. 54. Forms 4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6- Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE 7, Footings 58. Electrical Cortduit•Undrgrnd. 8, Foundation 59. Gas Pipe, 0 Undrgrnd., Test 9. Water Pipe-Undrgrnd. 60. Backwash Lines, P -Trap, © Undrgrnd. 10. Structural Floor System 61. APPROVAL TO DECK 11, Property Sewer Line & House Connection 62. Backwash & Receptor -Final 12, Sewer Cap 63. Heater & Vent -Final I 13, Roof Drains 64. Plumbing System - Final 14. Rough Plumbing 65. Electrical -Final 15. Rough Electrical -Conduit 66. Solar System -Final 16. Rough Electric Wiring 67, Fencing & Access Approval 17- Rough Wiring Sign 68. APPROVED FOR PLASTERING 18. Rough Electrical -T Bar Ceiling 69- POOLjSPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REOUIREMENT APPROVALS Permit 20- Rough Factory Fireplace 21. Ducts, in Structure 70, Underground Hydro 22. Ducts, Ventilating 71. Product Piping ©Gas ©Oil 23, Gas Pipe -Gough & Test 72. Underground Flush i 24, Roof Framing 73. Undergrnd. Storage Tanis G Gas 0 Oil 25. Roof Sheathing 74. Overhead Hydro 26. T -Bar Ceiling (Structural) & Monocoat 75. Dry Chemical 27. Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding 77, FIXED SYSTEM FINAL 29, insulation 78. FIRE PREY. FINAL 30, Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat 79,1 FINAL INSPECTION 32. Electrical Power Meter -Final gr -P . 112- In 80, IF00D CERTIFICATE ISSUED 33. Final Electric } 34. Final Heating & Air Conditi =1 35. Final Gas Pipe -Test }�jp�� Notes: 36. Hood or Canopy 37. Final Factory Fireplace r 3$. Final Plumbing 39. Water Service -Final 40, Gas Service -Final 41. Solar Domestic -Final 42. Backflow Preventer 43, Backflow Irrigation 44. Landscape Irrigation System 45. Sound Attenuation 46. Handicap Regulations 47. FINAL STRUCTURE & BUILDING 48. FINAL PL-ANNING 49. Electric Release to Edison 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY No. Date City of Costa Mesa Development Services Department Building Safety Division CERTIFICATE O F OCCUPANCY No. 003027 P. O. Box 1200 Costa Mesa, California The Building located at 3333 Bristol Street, Space 1509 has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group 1R1) Occupancy. Use of Building Rol' i1 Legal Description 41 ;0Qi—Q7 (See reverse side for Metes and Bounds) Building Permit No. A 1A410 Electrical Permit No. E35416,534441PIumbing Permit No. P 34450 Mechanical Permit No. M 34572 Number of apartments and/or guest rooms ISSUED TO: Building Official merge Edmiston C. J. Sdaerstrom S Sans 3315 Fairview toad by_`� Costa Masa, CA 92626 Date N ovdmber 14, 1989 This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 {e} U.B.C. CMF 1015-46 rev. 1/83 White - Owner; Canary - Numerical File; Pink - Bldg. Permit File City of Costa Mesa Development Services Department Building Safety Division CERTIFICATE OF OCCUPANCY No. 0 O 3 '"F>� r'J' .. P. O. Box 1200 Costa Mesa. California The Building located at 3n'4 Arict-r-0 street, saace 1509 has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group ccupancy. Use of Building_ Opp - Ail Legal Description Al )See reverse side for Metes and Bounds) Building Permit No. 8 25438 Electrical Permit No.E26235,E25524 Plumbing Permit No. P 25458 Mechanical Permit No. 53 25509 Number of apartments and/or guest rooms Fire Prevention Permit No. F 26276 ISSUED TO: Building Official William T. Howard 10..i Seaerstrom & Sons 3315 Fairview Road by Cngt a Masa, CA 92626 -- ` Date JU1Y 19,. 1986 This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. CMF 1015-46 rev. 1/83 White - Owner; Canary - Numerical File; Pink - Bldg. Permit File City of Costa Mesa TEMPORARY Development Services Department Building Safety DivisioninionCERTIFICATE OF OCCUPANCY No. DU0 74 P. O. Box 1200 Costa Mesa, California The Building located at AA011 Ari 4 i f -a 1 r;AQ has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group B2 Occupancy, Use of Building Lina Lee Legal Description 412-501-02 (See reverse side for Metes and Bounds) Building Permit No B25438 Electrical Permit No. E25529 Plumbing Permit No. P25458 Mechanical Permit No. M2c;5nco Number of apartments and/or guest rooms L I l ISSUED TO: Lina Lee .459 71. Rodeo Drive Building Official by Beverly Hills, CA Date Rds Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 lel U.B.C. CMF ID15-45 rev. 1/83 White -Owner; Canary - Numerical File; Pink - Bldg. Permit Fite (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.cBUILDING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 .Job Address: 3333 BRISTOL ST Status: ISSUED Suite: 1509 Applied: 10/1812005 Vicinity: Issued: 10/18/2005 Primary Occ: M Display/Sale Merchandise Type of Construction: I -FR Parcel Number: 41249102 Zoning: PDC Applicant: DENNIS TOMAS Address: 7159 VINELAND AVE Phone: 818-982-0316 ISSUED BY: NORTH HOLLYWOOD, CA _ Zip: 91605 Owner: SOUTH COAST PLAZA. Address 3315 FAIRVIEW AVE misc. Phone: COSTA MESA, CA Zip: 92626 Contractor: AMERICAN NEONICS INC Address: 7159 VINELAND AVE v Phone: 818-982-0316 NORTH HOLLYWOOD, CA Zip:.. 91605 License: 520181 Arch Eng: Address: Address: Phone: Phone: Zip: License: License: SCOPE OF PERMIT 9 318" X 70 318" NON -ILLUMINATED CHANNEL LETTERS FOR "TIFFANY AND COMPANY" IN SPACE 1509 FEE SUMMARY Plan Check: $45.01 _ _ ... _____. Calc Valuation: $2,000.00 Permit: $69.25 Claim Valuation: $2,000.00 SMIP Res: $0.00 SMTP Com:, $0.50 Other: $0.00 Inspection:' $0.00 Total: $114.76 PLANNING ZONING SETBACKS _& MAIN STRUCTURE Front • '0- 0 Rear '0- 0 Left 0-0 Right 0-0 ACCESSORY Front 0-0 Rear 0- 0 Left 0-0 Right 0-0 PARKING Existing:,.- ,. 0 Required: 0 Proposed: 0 11 NOTICE. The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work Is not commenced within 180 days, or If work Is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 1446.4$ (6=) 0 - LIF DECLARAMNS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. (ttav and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. "workers' compensation Insurance carrier and policy number a e: _timer 5+It r f° � JJ C� f�A'to a 1 11S . ' hirgection need not be. completed if th permit is valued at one hundred dollars ($f 00) or, less.J ❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any meaner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the labor Code, I shall forthwith Comply with these prove Ions. I'Applicant gnaaplicant Slur�e:Pr::! . Dar -.R ' '!ID- •• _ W : FAICORE 7 SO ECURE ORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EM , YER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED WOUSAND DOLLARE ($100,0001, IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: !erekry-aifrtrti f a—t4 am Ifcail"nsed nder provisio s of Chapter 9 (commencing with Section 7000) of DivisionCoe-,orc effeet-L•ie i :--tel-t� i b CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Coda: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sate. It, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or dead): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ i hereby certify that no excavation five (5) or more feel in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division o1 Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight o1 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ................................................................................................................................................................................................................................................................................................... 2 Does or wilt the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight o1 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ­---­­ ...........-•----•.......................................................................•---............................................---------------........................................................................................................1.............1,1111........................... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. .......-•........................................................_-------.........----................................................................................................................................-.........-.----................................................................................................................................................... 4 I! an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes [:J No .........................-..........................--•------------,.......................................................•----...,..,................................................................._..................•---.........•-----............................. 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes 0 No (If "yes', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or outer air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ...... ............ .......................... ................................................................................................................................................................ ........................... 111... B (It yes", attach certificate of compliance from the appropriate air pollution control officer), CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. nature egalOwner(s) Data A OruR[ A'orized Applicant -- or .CODE 0 INSPECTION TYPE DATE JNTtfJAL.�-.:�. CODE 1i ICPECTIQNTYPE G,5]!€ INTITIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention .202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign D 1 37- 222 Final Site 204 Final Demolition 250' Final Building/Occupancy V (714) 754.5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 BUILDING PERMIT Job Address: 3333 BRISTOL ST Permit: $237.25 Suite: 1509 SMIP Com: $2.94 Vicinity: $0.00 Inspection: $0.00 Parcel Number: 41249102 Zoning: PDC PDC Applicant: HONDA, STEVE Address: 308 S CROCKER ST Phone: 213-680-3500 LOS ANGELES, CA Zip: 90013 Owner: SOUTH COAST PLAZA Address 3315 FAIRVIEW AVE MISC. Phone: COSTA MESA, CA Zip: 92626 Contractor: THREE STAR SIGN CO Address: 308 S CROCKER ST Phone: 213-680-3500 LOS ANGELES, CA Zip: 90013 License:-. 400056 ' ISSUED BY: Status: ISSUED Applied: 04/16/2003 Issued: 04/16/2003 Arch Eng: Address: Address: Phone: Phone: Zip: License: License: SCOPE OF PERMIT INSTALL 2 CHANNEL LETTERS AND 2 FIBEROPTIC SIGNS AT STOREFRONT AND SIDE OF STORE FOR "TIFFANY AND CO". SPACE 1509 Plan Check: $154.21 Permit: $237.25 SMIP Res: $0.00 SMIP Com: $2.94 Other: $0.00 Inspection: $0.00 Total: $394.40 SETBACKS MAIN STRUCTURE Front 0-0 ACCESSORY Front 0-0 PARKING Existing: 0 NOTES: FEE SUMMARY Calc Valuation: $14,000.00 Claim Valuation: $14,000.00 PLANNING & ZONING Rear 0-0 Left 0-0 Right 0-0 Rear 0-0 Left 0-0 Right 0-0 Required: 0 Proposed: 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work Is not commenced within 180 days, or If work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 4&48 (6=) i o WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ l have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I Rave and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. �yMy wvo3 ors' compensation Insurance carrier and policy number are: 'Carrier: r 45 r•'i' 6 H/AK ) /✓ P i c fPo€fCy.Numtier:.,FfvFsv/Jc oi= uJC 3 7SZ 493x2 ' ,(this section need not be completed if the permit is valued atone hundred dollars ($100) or less.) f ❑ 1 Certify that in the performance of the work for which this permit is Issued, 1 shall not employ any person In any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provision Applfcant'Slgnature: = Date 1Lff-, 1 3 �WARNING.;,,EAILURE'TQ'SECURE- _KERS' COMP SATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER T4 CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED TP OISANt3 DOLLAR ($100,000} DITION TO COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR COOE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby -affirm -f -am -licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full e -_ `force and effect. Lic. # OC]S`� Class # �/ O Contractor's Sign 2 (Date CONSTRUCTION LENDI GENCY: ❑ I hereby affirm that there €a a construction lending agency for the performance of the work for which this permit is Issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the fallowing reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, after, improve, demolish, or repair any structure, prior to Its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than Frye hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. It, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ' ❑ f, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Dale: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more foot in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above• unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires. with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Daes or will the applicant or present or future building occupant need to file a registraf€G; form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .............................................. __.......__...............................................-................................................................................. --..................................................................................................... --........... 3 I� Yeor will th❑e applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department, ...................._....................................._...............................................................................................................................................-.-......--..............-_.................... ..._.................... ....................... _. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied w€th? ❑ Yes ❑ No .................................................................................................................................................................................................................................................................................................................................................................... 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this a plication a armit Ior such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ......... .... ...................... .................... ................................ _._............................................................................................................................................................................................... ­...................................................................... 6 Will any part of the facility to be constructed under this permit be within 1000 feat from the outer boundaries of a school? ❑ Yes ❑ No (If 'fres", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ............ W... ..................................-.......... ...... ......... ...... _........................... ._--_.............. ----.............................-----.....-----.............. .................................................. _.........--_—_.......... ---- ... -........ ...... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which Is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No .. ............... -... ....... ._........................... .... _ . — — ——_...............—......--............. _................. _............. ...........................--- ----........._..............._............._.....—.......... - 8 (If yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Data: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. S atu I galOwner(s) Date And! r Authorized Applicant ` Date CODE I INSPECffN TYPE 2AN INTMAL$ gr40E f INSPECTIDN TYPE 120 IM]AL$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 04 Final Demolition 250 Final BuildinglOccupancy r 5 � (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.WILDING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Suite: 1509 Vicinity: Status: ISSUED Applied: 02/13/2003 Issued: 02/1 312 00 3 Parcel Number: 41249102 Zoning: PDC PDC Applicant: VAN BOXTEL, SCOTT ISSUED BY; Address: 1485 BAYSHORE BL SUITE 152 Phone: (415) 330-5818 SAN FRANCISCO, CA Zip: 94124 Owner: SOUTH -COAST PLAZA Address 3315 FAIRVIEW AVE MISC. Phone: COSTA MESA, CA.- " Zip: 92626 Contractor: FISHER DEVELOPMENT INC Address: 1485 BAYSHORE BL SUITE 152 Phone: . (415) 330-5818 SAN FRANCISCO, CA Zip: 94124" License:, 271781 Arch Eng: Address: ' , Y Address: Phone: Phone: Zip: License: License: SCOPE OF PERMIT DEMOLISH INTERIOR FOR FUTURE TENANT iMPROVEMENT, "TIFFANY 8 COMPANY" SPACE 1509 REF.: B02-02035 Plan Check. • $287.46 Permit: $442.25 SMTP Res: $0.00 SMIP Com: $6.30 Other- $0.00 Inspection: $0.00 Total: $736.01 SETBACKS' MAIN STRUCTURE Front 0-0 ACCESSORY Front 0-0 PARKING Existing: 0 NOTES: FEE SUMMARY', Calc Valuation: $30,000.00 Claim Valuation: $30,000.00 PLANNING & ZONING Rear 0-0 Leff 0-0 Right 0-0 Rear 0-0 Left 0-0 Right 0-0 R_ eguir_ed:. 0 Proposed: 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 2446.46 (SM) .A r DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code• for the performance of the work for which this permit is issued. I have and will maintain w comps tion insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. My coo ' pons n Insu a ce r 'er and policy number are: f * * , p `� Carrier: Policy Number: W V �� Z� 3� J (This section need not be coTOIatad if -the permit is valued at on undr dollars ($100) or fess.) ❑ 1 certify that in the performance o1 the wo r which this ermit Is i ued, I shall not employ any person in any manner so as become subject to the workers' compensation laws a eg hou become ubject to the workers' compensation provisions of Sectio 3700 of a Labor Code, I shall forthwith comply with 1 -Applicant Signature: Date: WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERXPE IS UNLAWFUL AND SHALL SUaIECT AN EMPLOYER TO CRIMINAL P NALTIES kND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed andr 's' of C apt r 9 (corn enc g with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic. a Class N Contractor's Signatur Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lenders Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. It, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). • ❑ I, as owner o1 the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Cade: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: owner ID verified by drivers license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made In connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work lrom the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ............... ..........................................._............................__......................._......_...................._. .................._ ........_ _ _... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California HeaUh and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ...... .................................... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required 10 register acutely hazardous materials with the Fire Department. ................................................................................................................................................................................................................................. ............................... 4 11 an RMPP is presently required, has Section 25534 of the California Hea)ih and Safety Code been fully complied with? ❑ Yes ❑ No .................................................1--............................................................................................... .....----............................... ... ................................. -.............--------........................................................... 5 Does ar will the applicant or present or future building occupant require for the work which is the subject of this gpplication agermit for such construction or modification from the South Coast Air Quality Maragement District or from any other air pollution control district or agency? L l Yes L I No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). __...................................---__....................... _...................... _...................... ......................... _..........._................................ ............................................................ 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes No (if yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ......................................................-.................................................................................................................................................--......--............................................................................................... ............... - ••-....................... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required tot the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? [:]Yes ❑ No _�._..................... --...__....__... _-........._.._—._..............-........... ............._.__......... . _...�......... ...................-............................-. t3 (tt yes , attach certificate of comptiance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Data: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTR : I certify under penalty of perjury that I have road this application and state that the information given is correct. I agree to comply with all state laws and city ordinan s reletin building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agreeo occupy ZrIlow occupancy of any building authorized by this permit until final inspection. n t Ig a r eget Z too And/Or Authorized Appli Date CODE P. 1NSPE00NTYPE pdI INTMAL CQQE# INSPECTION TYPE jlbjf. 1NTMAL$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition �� I 0 250 Final Building/Occupancy 1 �: I I : � K: W (714) 754-5273 - Fax (714) 754-4856 - www.ci.costa-mesa.ctILDING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Suite: 1509 Vicinity: Status: ISSUED Applied: 07/28/2003 Issued: 08/04/2003 Parcel Number: 41249102 Zoning: PDC PDC Applicant: TOM LOWMAN ISSUED BY: Address: 1485 BAYSHORE BL SUITE 152 Phone: 714-424-0291 SAN FRANCISCO, CA Zip: 94124 Owner! SOUTH"COAST PLAZA, Address .3315 FAIRVIEW AVE MISC. Phone: COSTA MESA, CA Zip: 92626 Contractor: FISHER DEVELOPMENT INC Address: 1485 BAYSHORE BL SUITE 152 Phone: (415)330-5818 SAN FRANCISCO, CA Zip: 94124 License:- 271781 Arch : Eng: Address: Address: Phone: Phone: Zip: License: License: SCOPE OF PERMIT INSTALL 10 FT HIGH STOCK SHELVING FOR 'TIFFANY AND CO.' SPACE #.1509. REF.: B02-02035 FEE SUMMARY Plan Check: $81.41 Calc Valuation: $5,867.00 Permit: $125.25 Claim Valuation: $5,867.00 SMIP Res: $0.00 SMIP Com: $1.23 Other: $0.00 Inspection: $0.00 Total: $207.89 SETBACKS MAIN STRUCTURE Front 0-0 ACCESSORY Front 6-6 PARKING Existing: 0 Insit*3 PLANNING & ZONING Rear 0-0 Left 0-0 Right 0-0 Rear 0-0 Left 0-0 Right 0-0 Required: 0 Proposed: 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754.5626 !44&-46 (WOO) DECLARATIONS WORKERS' COMPENSATION DECLARATION: OIL - I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers',compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. My workers' comp�sation Insurance carrier and policy number are: Carder. �? drG �G F, r _c f f714 f �t Policy Number: « 7,73 (This section need not be completed if the pan -nit is valued at one hundred dollars ($130) or less.) ❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that If 1 should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these prove ons. z Applicant Signature:Date:�/G/ WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PE'NALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,0001, IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under pr visions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic. It IZ 7 % 7 e/ I - Class a Contractors Signature: -� `��yxli �� _ Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code), Lenders Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: ! hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031 .5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or Improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). - ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to Construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet In depth Into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ............ ................................................................................................. ................:.................................................................................................................................................................. •..................... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑Yes ❑ No (Section 25533 of the California Health and Safety Coda, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any ane time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ---._ ................. ........ ........... ... ..........................._ - -----.._............-•----................_—............ ................ ..--....... --.............. ---_-_._........ 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. _......................................_................................................. ........................_................_..................---.................................._._.._._......-............................. ......... ... .......... _........................ _............ 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No ............................ ................ ........................................................................ .................... ....................... .......................... _........................................................... .........................."I................................................... _........................... _.. 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application aPermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes 15 No (Section 65850.2 of the California Government Cade requires that the requested information be furnished on applications for non-residential building permits). ..................................................................................................................................................................................................................................... ...I........................................................................................ fi Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if 'yee, the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). _ ........................... ....__...........................__ ................. _................._._ ........._..-....................................._.......................-............. .. 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ...............................1-- ............. ...........---–.......................................__.......................... .�................................................ ................................................................................................... ................................... -..................................... 8 pt yes attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is Correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. ignature Of Legal Owner(s) azG3 Date And/Or Authorized Applicant Date CODE t. INSPECTION TYPE DATE INTITIA C9DE i INSPECTION TYPE INTILIAL$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 20B Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 722 Final Site 204 Final Demolition 250 Final BuildinglOocupancy Z Z (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Suite No 1509 Vicinity: SPACE 1509 (TIFFANY & CO) Parcel Number: 41249102 Applicant: SANDERS, BILL Address: 1140 RED GUM ST ANAHEIM, CA Owner: SOUTH COAST PLAZA Address: 3315 FAIRVIEW AVE MISC. COSTA MESA, CA Contractor: PEREZ, RICHARD Address: C5245409 MECHANICAL PERMIT Phone: (714)630-3200 Zip: 92806 Phone: Zip: 92626 .Phone: Zip: License: 102216 Status: ISSUED Applied: 03/12/2003 Issued: 03/12/2003 ISSUED BY: SCOPE OF PERMIT MECH PERMIT IN CONJUNCTION WITH 10,738 SF INTERIOR ALTERATION FOR "TIFFANY & CO.". ALTERATIONS TO INCLUDE: NEW WALLS, COUNTERS, RECONFIGURE FLOOR SPACE. REMODEL EXISTING,RESTROOMS. 1 REPAIR/ALT COOLING/HEAT, 14 VAV BOXES, 3 VENT FANSISINGLE DUCT. REF: B02-02035 FEE SUMMARY Quantity Repair 1 Alt Absorbtion Unit $0.00 Quantity ISSUE FEE $23.50 0 Inst FAU <100 k BTU $0.00 0 Inst FAU >100 k BTU $0.00 0 Repair/Alt Cooling/Heat $13.70 1 Inst / Rep. Recess Wall Htr $0.00 0 Refrig Sys <100 k BTU $0.00 0 Refrig Sys >100 k BTU $0.00 0 Gas Piping $0.00 0 Factory Fireplace $0.00 0 . Hood w/Mech Exhaust $0.00 0 VAV Box $149.10 14 Vent Fan / Single Duct $21.75 3 Appliance $0.00 0 Fire Dampers $0.00 0 Smoke Dampers $0.00 0 Inst or Relocate Appl Vent $0.00 0 Air Handlers < 10000cfm $0.00 0 Air Handlers > 10000cfm $0.00 0 Floor Furnace $0.00 0 Floor or Suspend Heater $0.00 0 FEE SUMMARY Quantity Repair 1 Alt Absorbtion Unit $0.00 0 Repair / Alt Refrigeration Unit $0.00 0 Ventillat)on System $0.00 0 Evaporative Cooler $0.00 0 Commercial Incinerator $0.00 0 Domestic Incinerator $0.00 0 Com ressors 1 Absorption Systems Up to 3 hp7 100k BTU $0.00 0 3 To 15 hp 1500 k BTU $0.00 0 15 To 30 hp 11,000 k BTU $0.00 0 30 To 50 hp 11,750 k BTU $0.00 0 Over 50 hp / Over 1,750 BTU $0.00 0 Boilers Up to 3 hp $0.00 0 3 To 15 hp $0.00 0 15 to 30 hp $0.00 0 30 to 50 hp $0.00 0 Over 50 hp $0.00 0 Other Mechanical Fee Investigation Fee $0.00 Plan Check Fee $0.00 Reinspection Fee $0.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2448-4$ (6100) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier. _>Ae % fr% L T_P,Je_ , Co Policy Number. _A Sd 0 3ly 3Q (This section need not be completed if the permit Is valued at one hundred dollars ($100) or fess.) ❑ I certify that in the performance of the work for which this permit is issued. I shall not employ any person In any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith Comply with thesre�rovislons. C� A Applicant Signature: IS t�, �•-- -dt _ Date: WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions o1 Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license Is in full force and effect. Lic. 1f Class p C Contractor's Signature:_S.gt CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). - ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ f am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, Le. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Data: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 WIII the applicant or present or future building occupant need to file and ceAify a Business Pian for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _........._._._..._.........................._....._.._.__..........-.._.� _......................_.__...._.—...............—...._.._....._-.._................------._..................... .._................_ ............. - ........_... 2 Does or will the applicant or present or future building occupant need to file a registration form Tor acutaly hazardous materials? ❑ Yes ❑ No (Section 25533 of the Califomia Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Dasa or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ......................................... _..................................................................................................................................................................... .,.,.,,.,................................................. ....................................................................... 4 if an RMPP Is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No ......................illt...............lic--............................................................................................u"ir--..........'h.e......................---h'I'...........................................................................---------•----............................................................................. 5 Qoes or will the applicant or present or future building occupant require for the wosic which is the subject of this a plication a erm'st for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes [� No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). _............................................................ - - ..._...---........................._......................._....................- ......................................._.............. 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). - ....-.................................-•--.----....-------.............._..--------•-------•................ ......................... .................... 7 It a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No — ................ __...... ---..._.__...................._—._._........-_._.............--.._............._............ _.__........_....._.............. ----- --_.._........._....._...................._._......... 8 (if yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Delo: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Masa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Sigtura Of Legal Owner(s) Date And/Or Authorized Applicant Date CODE f. INSPECTION TYPE 2,i¢ li111mal.ff CODS fir INSPECTION TYPE 2&U 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 PLUMBING PERMIT Job Address: 3333 BRISTOL ST Suite No 1509 Vicinity: SPACE 1509 (TIFFANY & CO) Parcel Nunmber: 41249102 Applicant: JOHNSON, DARRYL Address: 12262 GEORGIAN ST Status: ISSUED Applied: 03120!2003 Issued: 03/20/2003 Phone: (714)799-1907 GARDEN GROVE, CA Zip: 92814 Owner: SOUTH COAST PLAZA Address 3315 FAIRVIEW AVE MISC. Phone: COSTA MESA, CA Zip: 92626 Contractor: JOHNSON'S DISCOUNT PLUMBING Address: 12262 GEORGIAN ST Arch / Eng: Address: Phone: (714)799-1907 GARDEN GROVE, CA Zip: 92814 License: 724339 Phone: Zip: License: SCOPE OF PERMIT PLUMBING PERMIT IN CONJUNCTION WITH 10,738 SF INTERIOR ALTERATION FOR "TIFFANY 8 CO.". ALTERATIONS TO INCLUDE REMODEL EXISTING RESTROOMS. 1 DISHWASHER, 2 FLOOR DRAINS, 1 EXPANSION TANK, 1 SEWER CONNECT, 1 BAR SINK, 1 COMMERCIAL SINK, 1 KITCHEN SINK, 1 SERVICE/MOP SINK, 2 TRAP PRIMERS, 2 WASH BASINS, 2 WATER CLOSET, 1 WATER HEATERfVENT. REF: B02-02035 FEE SUMMARY AMT CITY ISSUE FEE $23.50 Landscape Irrigation Backflow irrigation $0.00 0 . Backflow Preventer $0.00 0 Bathtub $0.00 0 Clarifier System $0.00 0 Connect (Ice,Soda.etc) $0.00 0 Dental Units $0.00 0 Dishwasher $9.80 1 Drain, Floor $19.60 2 Drain, Rainwater $0.00 0 FEE SUMMARY AMT Laundry Tub 1 Washer $0.00 Landscape Irrigation $0.00 P -Trap $0.00 Pressure Regulator $0.00 Process Piping (per 10 ft) $0.00 Receptors $0.00 Septic Tank $0.00 Sewer Cap for Demo $0.00 Sewer Connect $24.65 Sewer Private Line $0.00 QTY AMT CITY 0 Sump Pump $0.00 0 0 Swimming Pool $0.00 0 0 Trap Primer $19.60 2 0 Urinal $0.00 0 0 Vacuum Brkr Bkflow(9-4) $0.00 0 0 Vacuum Brkr Bkflow(5+) $0.00 0 0 Wash Basin $19.60 2 0 Wash Basin Set $0.00 0 1 Waste and Vent System $0.00 0 0 Water Closet (Toilet) $19.60 2 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work Is not commenced within 180 days, or if work Is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result In the expiration of this permit. FOR INSPECTIONS CALL: (714) 754.5626 244646 (6/00) M WORKERS' COMPENSATION D15CLARATION: 1 hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. ❑ 1 have and will maintain workers' compensation Insurance, as required by section 3700 of the tabor Code, for the performance of the work for which this peril is issued. My workers' compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be Completed If the permit Is valued at one hundred dollars (S f 00) or less.) �f cartity that in ,he, work for which this permit Is Issued, I shall not employ any person in any manner so as to become subject to the workers' compensatlon laws of i orimia, and gree that If I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, f shall forthwith comply with these pr Ions. Applicant Signature: Date: &#,Orti Z (�J]T WARNING: FAILURE TO RE WORKERS' T10N COVERAGE IS UNLAWFUL AND SHALL SUEUECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES VP TO ONE HUNDRED THOUSAND DOLLARE (SI00,000), IN ADDITION TO THE DOST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is In full force and effect. Lic. a 'Clasel Com_ Contractor's Signature: Dater r to _ CONSTRUCTION LENDING AGENCY: ❑ i hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit to file a signed statement that he of she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Dlvlsion 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penplty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the ConlraCler3 License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner 1D verified by drivees license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, I.e. - property tax bill or dead): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth Inco which a person is required to descend, will be made In connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more then thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California AdminWrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Peril Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to fila and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the Califomia Health and Safety Code requires, with some exceptions, that a Business Plan be tiled with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure), —1 ................................................ _..................... -................. .._.._.............................................................................................................. ................................._...__...._...... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes 0 No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ....................................................1111..................................... .............. ............... .-.................................................................................................................... —... _................ -,.................. ._.................. . 3 Does or will theappplicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes 11No (Section 25534 of the Calitomie Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ........... ............................................. _...... .................. ............ _... _..... _._................... ----.................. -................... ...... .............. ................................ ...........,................. .......................................-.............._....._................. . ... 1111 4 If an RMPP is presently required. has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No .............................................................. 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a aril for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes �] No (Section 65850.2 of the California Goverment Code requires that the requested information be furnished on applications for non-residentlal building permits). ..1111...— ....................... ........._.._._........ -•----1111..-------------�................................................... ......--•------.. �.......... — 6 Will any part of the facifity to be constructed under this permit be within 1000 toot from the outer boundaries of a school? []Yes ❑ No (If 'yes', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 if a permit from the South Coast Air Quality Management District or other air pollution control distrid or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? []Yes ❑ No 8 (If 'yes", attach certificate of compliance from the appropriate air pollution control officer)• CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state taws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all sfato laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. ignasur egal tT�vner(s) Date d/Ot ad Applicant Data gQ,gE9. INSPECTION TYPE (M INTITIA CODE t INSPECTION TYPE h?AIE INTITIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 2D0 Final Re-Roof 210 Final Electrical 201 Final BlocklRetaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 BUILDING PERMIT Job Address: 3333 BRISTOL ST Suite: 1509 Vicinity: Parcel Number: 41249102 Zoning: PDC PDC Applicant: BOZARTH, PAUL Address: 18661 VALE AV Phone: 714-538-5777 SANTA ANA, CA Zip: 92705 Owner: SOUTH COAST PLAZA Address 3315 FAIRVIEW AVE Permit: misc. SMIP Res: COSTA MESA, CA ' Contractor: FISHER DEVELOPMENT INC Address: 1485 BAYSHORE BL Inspection: SUITE 152 SAN FRANCISCO, CA Zip: 94124 BOZARTH Phone: Zip: 92626 Phone: (415) 330-5818 License: - 271781 Arch . PAUL Address: 18661 VALE AV Phone: 714-538-5777 SANTA ANA CA Zip: 92705 License: C14800 Eng: Address: ISSUED BY: Status: ISSUED Applied: 12/17/2002 Issued: 0311112003 Phone: License: SCOPE OF PERMIT _ 10,738 SF INTERIOR ALTERATION FOR "TIFFANY & CO.". ALTERATIONS TO INCLUDE: NEW WALLS, COUNTERS, RECONFIGURE FLOOR SPACE. REMODEL EXISTING RESTROOMS. FEE SUMMARY Plan Check: $2,873.81 Permit: $4,421.25 SMIP Res: $0.00 SMIP Com: $157.50 Other: $0.00 Inspection: $0.00 Total: $7,452.56 Calc Valuation: $750,000.00 Claim Valuation: $200,000.00 PLANNING & ZONING SETBACKS MAIN STRUCTURE Front 0-0 Rear 0-0 Left 0-0 Right 0-0 ACCESSORY Front 0-0 Rear 0-0 Left 0-0 Right 0-0 PARKING Existing: 0 Required: 0 Proposed: 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, g 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work Is not commenced within 180 days, or if work is.suspendec r abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 !446.46 (6=) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following doclarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. i have and will maintain workers' compenseton Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit Is Issued. rkerslc pe sell In carrier and p llcy number are: i �► % y� `"� rrlor �i �U 'rl✓� action need not be completed if rhe permit is valued aroma hundred dollars ($ 100) or less.) ❑ I certify that in the performance of the work for which is pe It Is issued, I shall not employ any person In any manner so to become subject to the workers' c s of California, d agree that i1 i ould be ome subject to the workers' compensation provisions of Se on 300 of the Labor Code, I shall forthwith omply with the n plicant Signature Data: C v WAR E 70 SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMP PE TIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I her um that Ilc s oder provis' sof Chapter 9 (Dorn ncing with Section 7000) of Division and P o scions Coda, and my license Is in full roe d eHe Li ct mat CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Secllon 7000) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not Intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). - ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractors) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, Le. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth Into which a person Is required to descend, will be made In connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more then thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Data: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I WIII the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 2D0 cubic feet of compressed gas at standard temperature and pressure). .__.........................__._........_................................... ._..................... ............................ _................_........................................................ ........................... _................. ..__................. _...._................ 2 Does or wiu the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand,a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ......................................_................ .I'll ........ ................................. ................................... _.......................... _..... ..... ................................. _...................................................... .............. 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Sactlon 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RM PIP by businesses which are required to register acutely hazardous materials with the Fire Department. _...................................................................................................................................................................................�..........................................._............................................................................................................................................... 4 If an RMPP is presently required, hes Section 25534 of the California Health and Safety Code boon fully complied with? ❑ Yes C3 No _..._....................................—....................... ---.................. _............... ....__.................__................---.......................---------..................---....................................................... 5 Ooes or will the applicant or present or future building occupant require for the work which is the subject of this a plication a rmit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Ll Pe Yes I�] No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). .......... .................................................._.....................................................................w"it...............................................................................-e-s--o-i................................ ..........................*N.o.........,.,.,.,............................................... 6 Wt11 any part of the faculty to be Constructed under this permit be within 1040 feat from the outer boundaries of a school? ❑Yes ❑ Na (If yes-. the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). .................................................................._.........................................................................................................................................................................................................................................................................11.11......................... 7 If a permit from the South Coast Air Quality. Management District or other air pollution control district or agency is required for the work which Is the subject of this application, have all of the disclosures prescribed by Calitomla Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (If 'yes', attach ceAificate of wmplience from the appropriate air pollution control oNicer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building Construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. g tura Owners) Date w /0 �Aar Authoriza9pplIcant D CODE _I. INSPECTLQb JJP€ am INTMAL;! SQPJ I INSPECTION TYPE INTITIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final BlockfRetaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site r� 204 Final Demolition 250 Final Building/Occupancy z� 1 (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT Job Address: 3333 BRISTOL ST Suite No 1509 Vicinity: Parcel Nunmbev 41249102 Applicant: ROGER POPA Address: Phone: 562-802-3126 Zip: Owner; SOUTH COAST PLAZA Address 3315 FAIRVIEW AVE MISC. Phone: COSTA MESA, CA Zip: 92626 Contractor: TARGET ELECTRIC Address: 13040 TOM WHITE WAY #F .-Phone: (562)802-3126, NORWALK, CA Zip: 90650 License: 615651 ISSUED BY: Status: ISSUED Applied: 03/1412003 Issued: 03/14/2003 SCOPE OF PERMIT , INSTALL 500FIXTURES, 300OUTLETS, 50SWITCHES, 1-1000AMP SERVICE, 3-10HP MOTORS FOR "TIFFANY& CO" TI, RE:1302-02035. NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92.28, § 1, 1241.92) EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446-46 (6/00) FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 Temp Dist System 1 Lighting $0.00 0 Temp service test $0.00 Busway 1100 ft $0.00 0 Res. a/c package $0.00 Standing Section $0.00 0 New Res (1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0 New Res (3+units) $0.00 0 Transformers up to 1 kvalkw $0.00 0 Pool 1 Spa $0.00 0 ...up to 10 kvalkw $0.00 0 Lighting Fixts $372.40 500 .................up to 50 kva/kw $0.00 0 Recept Outlets $226.40 300 ....up to 100 kvalkw $0.00 0 Switches $43.90 50 ..................over 100 kvalkw $0.00 0 Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0 Res Appl 50.00 0 Low Volt Wiring System / Ckt $0.00 0 Service to 200a $0.00 0 Misc. Conduit $0.00 0 Service to 1000a $62.15 1 Misc. Conductor $0.00 0 Service over 1000a $0.00 0 Circus ( gen or ride) $0.00 0 Motors to 1hp $0.00 0 Circus (meth ride or lights) $0.00 0 Motors to 10hp $36.90 3 Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 0 Fireworks Stand . $0.00 0 Motors to 100hp $0.00 0 Other Electdcal Fee $0.00 Motors over 100hp $0.00 0 Communication drops $0.00 0 Investigation Fee $0.00 Sub panel to 200a $0.00 0 Plan Check Fee $0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92.28, § 1, 1241.92) EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446-46 (6/00) 14 M WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. ❑ 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit Is. issued. My wo ars' pe{t ad Insurancq carrier art icy number are: n Carrior: to ( l Q�/SCLLi,_ Ct L . / Policy Number. �r" �� 2� -Q (This section need no com�ad it the perm! is valued at one hundred dollars (�J or less.) ❑ I certify that In the performance of the work for which this permit Is Issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California. and agree tha ' I should become subject to the workgrs'compensation provisions of Section 3700 of the Labor Code, i shall forthwith comply with these provlsl 7 Applicant Signature: _ _ _ _ Date: 3 `� - Q 3 WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADOrnCN TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions a1 Chapter 9 (commencing with SectionJA00) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lie. # l Class # w Contractor's Signature:. _ �Z / Date: - CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lenders Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penaltyof perjurythat I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its Issuance, also requires Iha applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031,5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500)•): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for safe (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or Improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). - ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). © I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification o1 Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth Into which a person Is required to descend, will be made In connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, All 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be tiled with the Costa Mesa Fire Department by every business which has at any one lime during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic foot of compressed gas at standard temperature and pressure). .... ........... ........................................................ ........................................_............................................................................................................................................................. .................. .... .........._...................... _................. 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ ND (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time hes on hand a quantity of acutely hazardous maleriats equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _._............................................................................................................................................................... _..................... _........ ....... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costs Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. _ ................. _...---- --..._.—..............,.... ........................................................... _ 4 11 an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? [I Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application a ermil for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes No (Section 65850.2 of the California Government Cade requires that the requested information be furnished on applications for non-residential building permits). _........................._..�.........__....._.. _ - _.__......._......—..............._. — 6 Will any part of the facility to be constructed under this parmit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (I1 'res', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Cada). -y ...............Ii_............ ........ ..._ __.......—..........._....................... _...._.................... ... _ If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑Yes ❑ No ................ 11- 11.. ........................... 11.......11 ........... _ - -._.....__...................._..._.................................................................................................................................._._ _._.._............ ---........ 6 (If yes attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Caste Mese to enter upon the above-deschbad property for Inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. 141 / I ature LegalOwner(s) Data And/Or Authorized Applicant Date 009E f• INSPECTION TYPE 2M (lM ;20g 1 iNSP109N TYPE M INTITIA 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 206 Final Plumbing �^ 200 Final Re -Roof 210 Final Electrical����//��77��pp�� 201 Final BlocklRetaining Well 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 - Fax (714) 754-4856 - www.ci.costa-7fR1?9bPRE SSI ON PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Suite: 1509 Vicinity: Parcel Number: 41249102 Applicant: RETIC, VANESSA Address: 3221 SAN FERNANDO BLVD LOS ANGELES, CA owner: SOUTH COAST PLAZA Address 3315 FAIRVIEW AVE MISC. COSTA MESA, CA Contractor: JAM FIRE PROTECTION INC Address: 3221 SAN FERNANDO BLVD Zoning: PDC PDC Phone: 323-259-9700 Zip: 90065 Phone: Zip: 92626 Status: ISSUED Applied: 03121/2003 Issued: 04/11/2003 ISSUED BY: Phone: 323-259-9700 LOS ANGELES, CA Zip: 90065 License:' 791060 SCOPE OF PERMIT INSTALL NEW FIRE ALARM SYSTEM. CONNECT TO EXISTING FACP IN SOUTH COAST PLAZA. "TIFFANY & COMPANY" SPACE 1509 REF.: B02-02035 FEE SUMMARY Plan Check: $108.71 Permit: $167.25 Other: $0.00 Total: $275.96 Calc Valuation: $9,000.00 Claimed Valuation: $9,000.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days, or if work is suspended or abandoned for a period of 160 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446-46 (6100) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Cade, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: a%h .� Policy Number: 1 Cl is (This section need not be completed if the permit is valued at one hundred dollars ($100) or less.) ❑ I certify that in the part ange of the work for which this permit is issued. I shall not employ any person in any manner so as to become subject to the workers' compensation laws ofalif is nd agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith 00mpiywith these pr isohs. r, /! Appficant Signature: Date: �r / �� / � -s WARNING: FAILURE TO SE EIRKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRE INAL P ALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($1091',0001, IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: hereby affirm that I am li sed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic. # Class # 10 C_ Contractors Signature: r:et C Date: 4410/n _- CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Cade: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty 0f not more than five hundred dollars ($500).): ❑ 1, as owner of the properly, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended 0r offered for sale (Sec. 7044, Business and Professions Code: The Contractors license Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044• Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contracior(s) license pursuant to the Contractors License Laws.). ❑ l am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner iD verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit t0 do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I Will the applicant or present or luture building occupant need to file and certify a Business Plan for emergency response 10 release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Cotte requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ......---•---•-•...................................................I..............I'...---...;.....,................................... ...........:...................... ............. ........................... .... ................. ......................,.......�............................................................................... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials. ❑ Yes ❑ No (Section 25533 o1 the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feel of compressed gas at standard temperature and pressure). .. ........................... .... .......................... 1.•• ------....................... ............... ................... ......................................... --•--•-•---..................................... --......................... ............... ----............. ...................................................... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filling with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ............................................................................................................................................................................................................................................................ ................... .............................................................................. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No ................ ...11.11---........... .................... ........................................................................... ... .......................................... ... ...................................................................................................................................................................................... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of thisa plication arm'st for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? 5 Yes LJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ........................................................................................................................................................................ I........ ..................................................--.-------------•-•-------------•-•-•--...............--------............................................................... fi Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ............................................................................. ............. ....................... .�--•---............................................................................................ ................................................... _............................................. 1111............... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No .. .............. .............................................................................................................................................. .............................................................................................................................................. 8 (if yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. 1 agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this apptication and state that the information given is correct. I agree 10 comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes, i agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature f Legal Owner(s) Date 7 And/Or Authorized Applicant Date CODE F ASPECTION TYP j &N INTITIAL$ CODE INSPECTION TYPE PALE INTMAAL$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical � 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 2134 Final Demolition 250 Final Bui(dinglOccupancy (714) 754.5273 • Fax (714) 754-4856 * www.ci.costa-meMtu§UPRESSION PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 02035 Job Address: 3333 BRISTOL ST Suite: 1509 Vicinity: Parcel Number: 41249102 Applicant: HUI, LEON Address: 17992 COWAN IRVINE, CA Owner: SOUTH COAST PLAZA Address 3315 FAIRVIEtiW AVE misc. COSTA MESA,,CA, Zoning: PDC PDC Phone: 9494740555 Zip: 92614 Phone: Zip: 92626 Contractor: THE GREATER ALARM CO INC Address: 17992 COWAN Status: ISSUED Applied: 1 011 412 003 Issued: 10/29/2003 ISSUED BY: Phone: 9494740555 IRVINE, CA Zip: 92$14 License: 469046 SCOPE OF PERMIT INSTALL FIRE ALARM COMMUNICATING PANEL FOR "TIFFANY & CO" SUITE 1509. REF.: B02- Plan Check: $25.19 Permit: $38.75 Other: $0.00 Total: $63.94 FEE SUMMARY Calc Valuation: $1,000.00 Claimed Valuation: $1,Ooo.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21.92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446.46 {6!001 WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided tot by section 3700 of the Labor Code, for the performance of the work for which [his permit is issued. ❑ 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Cade, for the performance of the work for which this permit is issued. My work pe - n In nCe carrier nd policy number are: Carrier: % Policy Number: (This section need not be complateld if the permit is valued at one hundred dollars ($160) or less.) ❑ I certify that in the performance 9JWbe work for which this permit is Issued. I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Ca]If i , an agrf2 th 1 If I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provision - Applicant Signature: _ , r _, Date: 0 WARNING: FAILURE TO SECURE WORKERS' COMPENSATION OOVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,1100), IN ADDMON TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 37DB OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed er pro si ns of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license Is In full force and effect. Lic. a D Class a en ei Contractors Signature; Data: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a Construction lending agency for the performance of the work for which this permit Is Issued. (Sec. 3097, Civil Code). Lenders Name: Lenders Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to Its Issuance, also requires the applicant for such permll to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he of she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. 11, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). - ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner !D verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or dead): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet In depth Into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, An 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-bullder, I will not employ anyone to do work which would require a permit from the Division of industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 WIII the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Cade requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _ ................... _. _--------------------------- ................................................. _....... _._..._—._..._..._...... _.—_....- 2 Doas or wi11 the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes Q No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater then a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). Y­_­ _........... --- _.. _ ._..... _.._.......... _........................ ....... -- Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes El No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department, 4 If an RMPP 19 presently required, has Section 25534 of the California Health and Safety Code boon fully complied with ]•Yes ❑ Np _ ....._............................---...................—......................................................................................................................_....._............__.................._.—............_..-- 5 Does or will the applicant ar present or future bullding occupant require for the work which Is the subject of this application a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes No (Section 65850.2 of the California Government Code requires that the requested information be furnished On applications for non-residential building permits). ............................................................... _...--................. be wi.................. fWe_---------....--.o-u-I'............................................................................ ......................................--.......... ....... ........................._...—............__......._.....---- 8 WIII any part of the facility to be constructed under this permit be within 1000 feat from the outer boundaries of a school? ❑ Yes ©No (if yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). .... ........... .......................... __.................................. _... _..... _...................... •----�._--................... __—................. ................................................ ................ .........................._.......................-_.................... - .............. .............. 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (tf yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the abova-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. I ( U gnalure f Legal Owner(s) n Date diOr Authorized Applicant D CODE ". INSPECTION T1PE 2M INMALS CODE 4 INSPECTION TYPE prig, ifl,YII3d1� 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Root 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention J22 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754.5273 • Fax (714) 754-4856 • www.ci.costa- FIRE SUPRESSION PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Status: ISSUED Suite: 1509 Applied: 02126112003 Vicinity: SPACE 1509 (TIFFANCY & CO) Issued: 03/26/2003 Parcel Number: 41249102 Zoning: PDC PDC ISSUED BY: Applicant: LOONEY, SHEILA Address: 5200 E HUNTER AV Phone: (714)993-2822 ANAHEIM, CA Zip: 92807 Owner: SOUTH COAST PLAZA Address 3315 FAIRVIEW AVE MISC. Phone: COSTA MESA, CA Zip: 92626 Contractor: ALERT FIRE PROTECTION INC Address: 5200 E HUNTER AV Phone: (714)993-2822 ANAHEIM, CA Zip: 92807 License:' 316324 SCOPE OF PERMIT REWORK 142 EXISTING SPRINKLER HEADS AND CHANGE ALL EXISTING SPRINKLER HEADS TO CONCEALED HEADS IN CONJUNCTION 10,738 SF INTERIOR ALTERATION TO RECONFIGURE FLOOR SPACE & REMODEL EXISTING RESTROOMS FOR "TIFFANY & CO." IN SPACE 1509. REF: B02-02035 FEE SUMMARY Plan Check: $172.41 Caic Valuation: $16,000.00 Permit: $265.25 Claimed Valuation: $16,000.00 Other: $0.00 Total: $437.66 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work Is not commenced within 1 B0 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 0 DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' coMI2 ation Ins rance carrier and policy number are: Carrier: Policy Number: /� V % / (G (This section need not be Completed if the Aermit is valued at one hundred dollars (51 6)) or less.) ❑ 1 certify that in the performance of the work for which this permit is issued. I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Califom's , d ag a that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Coda, I shall forthwith comply with these provisions. T 26 U3 Applicant Signature: Date; WARNING' FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE NLAWFUL AND SHALL SUBJECT AN EMPLOYER 70 CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensedunder provisio of Chapter9 ommencing with Secti 7000) of Division 3 of the Bus'sness d Professions Code, and my license is in full farce and effect. 1- # 3 L Class O 'S Contractor's Signature: Date: :Y-2,(17 —C/ CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lenders Name: Lender's Address: Signature: Data: OWNER-BUtLDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build Or improve for purpose of sale.). - ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Tille 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ................. ....-re,..................................,iI'd-.'n'*g* ............... n,t-.....-ad, --- .Iio,.........gi'st.r'a'...-'r,i............'o,r....................................................... �--....................................- N . .............. ............................... ... 2 Does or will the applicant or present or future building occupant need to file a retion form for acutely hazardous materials? ❑Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of $00 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .............. ...................................................... ............................ ........................................ .............................. ........................................................................ -------............. ........................... .......................................................................... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Seclion 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire [)apartment of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ....................................................................................................................................................................................................................................................................... ............................................................................................ 4 If an RMPP is presently requited, has Section 25534 of the California Health and Safety Code been fully complied with? []Yes ❑ No ................................................................. ........................................................................................................... -------...----........................................ ...................................................................................„....................................... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of thIs. application aggermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes LJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ......................................................................................................................................................._-------................................................................................................................................................-• 8 Will any part of the facility lobe constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of tate California Health and Safety Code). ......................... ................................................................................................................................................................................................................................................................... ..................... 7 It a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ............ ..............._........................................................................... -......................... -------............................................. .............................................................................................................................. ............. 8 (lf yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certity that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Sig ure Of Le al Owners / Date AndlOr A h dzod Applic Date CODE M. INSAECTIONTYPE (&U UJLIALS CODE�E INSPECTIONTYPE PATE lam$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy PIAM SIGN PERMIT .lob Address: 3333 BRISTOL ST Status: ISSUED Suite: 1509 Applied: 0411612003 Vicinity: Issued: 04/16/2003 Parcel Nunmber: 41249102 Zoning: PDC PDC r ISSUED BY: Applicant: HONDA, STEVE Address: Phone: 213-680-3500 Zip: Owner: 'SOUTH COAST PLAZA Address 3315 FAIRVIEW AVE M15C. Phone: COSTA MESA, CA Zip: 92626 Contractor: THREE STAR SIGN CO Address: 308 S CROCKER ST Phone: 213-680-3500 LOS ANGELES, CA Zip: 90013 License: 400058 Arch / Eng Address: Phone: Zip: License: SCOPE OF PERMIT ONE ILLUMINATED CHANNEL LETTER SIGN TO REPLACE EXISTING ON'THE WEST ELEVATION AND FOUR INTERIOR "TIFFANY & CO," SIGNS. SPACE 1509 FEE SUMMARY Plan Check: $61.41 Calc Valuation: $6,000.00 $0.00 Permit: $125.25 SMIP Com: $1.26 Other: $0.00 $0.00 Inspection: $0.00 $0.00 $0.00 Total: $207.92 PLANNING & ZONING NOTES: Claimed Valuation: $6,000.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work Is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 44646 (6=) DECLARATiONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: J$ i have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. -;0,,, 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit Is Issued. y My workers' compensation Insurance carrier and policy number are: carder: SUM77or✓TG Hn. rt N F E` .=„1 rrvS.,,;,,CC) Py a7'.-imb—r _ pj�tyOC OX !</_ C 752 `)�30 (7>tiis:,s doii need not be completed if the permitis valued at one hundred dollars ($ t o0) or lass.) ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that 111 should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisions •Appltcant'Sfgnature:- Dat = U-•iFEJLURE,TO SECUREERS' COMFIEV6ATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO'CRIMFNAL PENAL IES AND CIVIL FINES UP TO ONE ?HUNDRED THOUSAND DOLEARE J$100,000) ;21MONTO THE 0057 OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hareb affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 01 -the BosTness and Professions Code, and my license Is in full Ci ss p' Confractor s S[gnature:4 1Y.4 lo S'. e��::.:-moi:."_ a CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior t0 its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ' ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ N0 Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, tatsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title B, Califomia Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the Califomia Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .......................................................... .................................................................... .............................................. ...................... .............. ....... ..................... --.....__...................................... ........................... . ................... 2 Doas or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑Yes Q N0 (Section 25533 of the Califomla Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal 10 or greater than a weight of $00 pounds, or a volume of 55 gallons, or 200 cubic feet o1 compressed gas at standard temperature and pressure). _..---......._....................................................................................._................_.................._�...................._ ............... __..................__................. ...................................... ..... —...................... ........,......... _.................. 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No Section 25534 of the Califomia Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ................................-r-o..........'y r'..'qu. l`r.e......._...........................................'li-e...........................aa*l.........._............'r*y......................... f'u"............."'p-l'ie, d......................................................_................................................................ 4 I1 an RMPP is presently required, has Section 25534 of the California Health and Safety Code boas fully Complied with? ❑Yes ❑ No ----illt--...._..................................-------....lu"ra"'b-'u--.....__.... c'c'................_...'u-ir.....................................---..........th _-.....................-__ ........--.ti .............................._....._.....__..................—...............--- 5 Does or will the applicant or present or future building occupant require far the work which is the subject of this a plication a ffrmlt for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes No (Section 65850.2 of the Califomia Government Code requires that the requested Information be furnished on applications for non-residential building permits). ........._..- ................. ..•--............................ _.__................................................... _........................................ __...................... _._................................... ..............................................—.................. 6 Will any part of the facility to be Constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if "}res", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ..r _ .... ._ ...............---._................ - - -- — __ _........................._................_............_............-—.—. —......-----.............._......................................_.....—._.............—._.................................. 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency Is required for the work which is the subject of this application, have all of the disclosures prescribed by Califomia Health and Safety Code Section 42303 been made? ❑ Yes ❑ No - ......................._.... —• ---... ..................._—_............................---............—...............---......._....__................_..--........................................................................................._.—_.................. —._........... 8 (If "yes', attach corlificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: i certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection, Signature Of e I Owner(s) Date -1-/6--D rAndtOr-A offz— _d;4ppGeaapE� `LDate—y CODEr. 1j�� )MALS CODE A INSPECTION TYPE Q&9 jNTMAj S 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 206 Final Plumbing 200 Final Re -Roof T 210 Final Electrical 201 Final Block/Retaining Wali i' 212 Final Fire Prevention 202 Final Factory Fire Place gg _ 220 Final Planning Approval 203 Final Sign O 222 Final Site 204 Final Demolition 250 Final Building/Occupancy rN =1 10 ADDRESS OF BUILDING: 3333 BRISTOL ST OWNER'5NAME1f00N:C J SEGERSTROM ADDREss 3315 FAIRVIEW RD COSTA MESA, CA 92626 APPL. MAILING ADDRESS: IARCHITECT OR ENGINEER: ARCH. OR ENG.'S ADDRESS: UNIT: 1509 FLOOD: AO -38 LIC. NO.: DNR. ca+TRAcTOR'sNAME:WATSON CONSTRUCTION (714)662-7933 0OKMACTOxs1tAILING 1260 LOGAN AV ADDRESS:COSTA MESA CA +x -No.: 546538 92626 uMT. B-1 LICENSED CONTRACTORS DECLARATION: I hereby affirm under penalty of perjury thel I am licensed under provisions d Chapter 9 (commencing with Section 7000♦ of Division 3 of the Business and Professions Code, end my license is in hull foroe and efled, CITY LIC. NO -0 4 7 413��aar 6Lic. CLAss: B UC. NO.: 5 4 6 5 3 8 XP . 0 3/ 9 7 Pate: Jr; '79L _Q1 Contractor 11 A q%WNER BUILDER DECLARATION: I hereby affirm under penally of perjury that 1 am xempl from the Conlrectors License Law for the 'owing reason (Section 7031.5 Business and Professions Code: Any city or county which requires a panne to construct, after, improve. nolish, or repair any structure. prior to its issuance. also requires the appficant for such permit to file a signed statement that he or she licensed pursuant to the provisiorns of the Contractors License Law [Chapter 9 (commencing with Section 7000) of Division 3 of the Business and professions Code] or that he or she is exempt therefrom and the basis for the alleged exemption. Arty violation of Sedion 7031.5 by any appikant for a permit subjects the applicant to a d d penalty of not more than five hundred dollars (S5o0]). I, as owner of the property or my employees with wages as their sole compensation, win do the wodl. and the structure is not imanded or offered for sale (Section 7044. Business and Profession Cede: The Contractors License Law does not apply to an bwrw of property who builds or improves thereon, and who does such work himself ar herself or through his or her own employees, provided that such improvements are not intended or offered for safe. II, however. the buffing or improvement is sold within one year of completion, the owner -builder will have the burden of proving he or she did not bund or improve for the purpose of sale), 1. as owner of the property. am exck*, ly contracting with licensed eoneaddora to construct the project (Section 704x, Business and Professions Code: The Conlradors License Law does not apply to an owner of property who buillds or improves thereon and who contracts for such projects with a contrador(s) licensed pursuant to the Contractors License Law). Q I am exarnpl under Section: B. d P.C.. for this reason: Dale: Owner: I do hereby certify that I am aware of and understand the requirements of Cal[omis Health and Safety Code Sections 2&505. 25533. and 25534, and that I or any future building occupant will / will not (tittle one) need to comply with said state codes and the requirements for a permit lot construction or modifieationhom the AirMMY anegemenl District. Residemieloonstrudion applications are exempt from these provisions. Data: Applicant: WORKER'S COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the fdbwing declarations: I have and will maintain a certificate of oomenl to self -insure lot workers' compensation, as provided for by Section 3700 of the Labor Code, for the performance of the wok for which this perms is issued. I have and will maintain workers' oompeneatibn insurance. as required by Section 3700 of the Labor Coda, for the performance of the work for which this permit is issued. My workers compensation insurance carrier and policy number are: Carrier: Poky Number: (This eedion need not be compfefed it the perms is br one hundred dogare jS1001 or feta.) © 1 certify that in the performance of the work for which this permit is issued. I anal not employ arty person in any manner so as to become subject to the workers' compensation laws of California. and agree that d I should became ubject to the workers' Com nation provisions of Section 3700 of the Labor Coda, I ehffi onhwith comply with tho rovision , Dais: -7.� - Ct Co Applicant: Warning: F*Hufv to secure workers' compensadon eoveraya Is unlam*d, and 811 subject an arnployW to criminal panaldes and clvll Anes up to ore hundred thousand dollars IS100,0001 In ddldon to the cost of con*NVWfbn, damages as provfdad for In Secdon 3706 of the Labor Code, lrtfowl, and attorney's fees. CONSTRUCTION LENDING AGENCY: I hereby affirm under penalty of perjury that them is a construction landing agency for the performance of the work for which this perms is issued (Section 3097, Civ. C). LE"DEADDRE1 _EPAIR WALLS & REFLECTED LENDER'SADDRE CEILING I certity that I have read this application and state that the above information is correct. I agree to comply with all edy and county ordinances and slate laws totaling to building construction and hereby authorize representatives of this dry to enter upon the above-mentioned property for inspection purposes. WAYNE WATSON PVIE t oma 5_2a_940 -- ^ p Q � I. �_7" d. ` — 40 Signature of Owner3Agenl1ApperanVContrac3or (6151.46.WP) Whee-Building 8 Safety; Gras Rle; Canary-Appficanl; Pink -Revenue: Goldenrod --Assessor CITY OF COSTA MESA — BUILDING PERMIT PERM NO: B 077891 PERMIT NO: B 077891 PLAN CHECK NO: 02113-96 L GOVT: N SUPP: N CONSTRUCTION TYPE: PERMIT TYPE: STR PURPOSE: ALT JOB DESCRIPTION REPAIR WATER DAMAGED WALLS, ALT RESTROOM SQ FT: 35,000 CLAIM VALUE: 35,000.00 CALC—VALUE: 35,000.00 GROUP OCC: B / COMMENTS: "TIFFANY" STORE TI ENLARGE CONFERENCE RM CREATE CASH CONT AREA Z O N I N G R E Q U I R E M E N T S S E T B A C K S ------------ MAIN BUILDING ----------- ---------- ACCESSORY BUILDING--------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN PARKING REQ: PROV: PARCEL: 41249102 ZNE: CiS REF NO: PLANNING NOTES> INTERIOR ALTERATION FOR A RESTROOM. iE iE iE iE iE � 9E if- iE iE iE iF 3E'E -1E'E -1E iE * � iF iE * 1E dE i(• iE iE iE iE iE iE iE iE iE iE iE iE iE• iE dE iE i6 � � dE * jE �E jF iE 9E iE'E' aE iE iE * � � iF iF iE iE iE iE iE i[• iE iE it• iE dE iE iE lk * 'IE �E D E V E L O P M E N T S E R V I C E S R E Q U I R E M E N TfS. ZONING APPROVED BY DATE: h� BUILDING APPROVED BY DATE: APPLICATION ISSUED BY: DATE: LEGALIZATION:N F E E S U M M A R Y STRUCTURAL--:SEGMENT:Y BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT 439.75 SMIP/NON—RES PLAN 285.84 7.35 ISSUE FEE BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE TOTALS ---- > 447,10 0.00 285.84 732.94 732.94 .00 REVENUE DIVISION TOTALS--> COLLECTED: 732,94 OVER/SHORT: .00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK 439.75 7.35 285.84 iE iE iE iE iE iE iE iE 9E iE 9E )E )E -1E iE'dE !E � dE iE ulE ulE iE * iE fP iE dE !E iE iE jF iE � iE �t � iE * �E * 3F * 3F �E �E iE � #�'1F �E iE iE iE '1E iE iE * �f 'IE �E �[• i6 iE iE iE iE iE iE iE iE * � 9E iF * � I N D I V I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST SFC 35000 T.I. STORE END OBY F FEESE/$1 1.00 35,000.00 -'�5-.-- CONSTRUCTION AND PLANNING APPROVALS Permit # Date Inspector PO 'SPA APPROVALS Permit # Date inspector 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location ' 2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement 3; Electrical Conduit Utifity-Undrgrod. 54. Forms •4. Electrical Conduit-Undrgrnd. - 55. Electrical Bonding 5. -,Steel Reinforcement- 56. Rough Plumbing & Pressure Test i 6: Electrical UFER.-Of'rid, 57. APPROVAL TO COVER-GUNITE 7 T.Footings 58. Electrical Conduit-Undrgrnd. 8. Foundation 59. Gas Pipe, ❑ Undrgrnd., Test 9. Water Pipe-Undrt3rnd. 60. Backwash Lines, P -Trap, © Undrgrnd. 10. Structural Floor System 61, APPROVAL TO DECK 11, Property Sewer Line & House Connection sat, Backwash &Receptor -Final ' 12. Sewer Cap 63. Heater & Vent -Final 13. Roof Drains _ 64. Plumbing System - Final 14. Rough Plumbing 65. Electrical -Final 15. Rough Electrical -Conduit +. 66. Solar System -Final + 16. Rough Electric Wiring' 67. Fencing & Access Approval f 17. Rough Wiring Sign 68. APPROVED FOR PLASTE=RING 18. Rough Electrical -T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19, Rough Heating & Air Conditioning R r • FIRE DEPT, REQUIREMENT APPROVALS Permit # TM 20. Rough Factory Fireplace 'r s 21. Ducts, in Structure r 70. Underground Hydro 22. Ducts, Ventilating - 71. Product Piping a Gas coil - 23. Gas P--spe-Rougb & Test ,- r - - 72. Underground Flush 24. Roof Framing rr .73,' Vndergrnd. Storage Tank ❑ Gas ©Oil 25. Roof Sheathing " " ; 74. Overhead Hydro 26. T -Bar Ceiling (Structural) & Mono -coat + - 75--. Dry Chemical 27. Prame and Flashing _ 76. Dry Standpipe 28. Lathing & Siding - 77. FIXED SYSTEM FINAL 29. Insulation - 78, FIRE PREY. FINAL 30, Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Plaster Brown, Coat r 4� 79. FINAL INSPECTION 32. Electrical Power Meter Final 80. FOOD CERTIFICATE ISSUED 33. Final,Electricw y rr _ Nates 34. Fina( Heating & Air-donditioning 35. Final Gas Pipe -Test ' 36. Hood of Canopy 37. Psnal •Factory Fireplace - c ; ; 38. Fina0lumbing 39. Water Service -Final: Y ; 40. Gas Service -Final 41, Solar Domestic -Final, 42. Backflow Preventer 43. Backflow Irrigation y '! 44. Landscape Irrigation,System ; - - 45. Sound Attenuation 46, Handicap Regulations 47, FINAL STRUCTURE & BUILDING 48. FINAL PLANNING 49. Electric Release to Edison 50. Gas Release to Southern California Gas Co ' 51. CERTIFICATE OF OCCUPANCY No Date _ ADOREss alt Bu1Lma; 3333 BRISTOL ' S T UNIT: 1509 ONF[ER'SNwEIFIQNOWN:C J SEGERSTROM FLOOD: AO -38 4 ADDREss:3315 FAIRVIEW RD COSTA MESA, CA 92626 AM. "LING ADDRESS: Gv o ? Y ARCHITECT OR ENGINEER: LIC, NO.: ARCH. OR ENG.'S ADDRESS: UNIT: IMTRACTOLTS NAPE: J E D S PLUMBING (714)283-1586 CONTRACTOR'SYULING 387 SMOKERIDGE TERRACE IDREss:ANAHEIM CA uc.ND., 547467 92807 Dan. LICENSED CONTRACTORS DECLARATION: I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (oommencing with Section 7900) of Division 3 of the Business and Profasslons Cade, and m license is in full farce and effect. CRl'uc.No,064588 Lic,ouss:C 36 L.IC.NO.:54747 EXP: 03/97 Date: ,�l �i/i G Contractor: w OWNER BUILDER DECLARATION: I hereby affirm under penalty of perjury that I p from the CoMractom License Law for the following resson (Section 7031.5 Business and Professions Code: Arry city or mu ragtlrao a permit to construct, otter, Improve, demolish, or repair any structure, prior to ds issuance, also requires the applirani for such pormh to fib a slgned statement that he or she is Iioensed pursuant to the provisions of the Contractors Liceme Law (Chapter 9 (oommencing with Sedion 70001 of Division 3 d the Business and Professions Code] or that he or she is exempt therefiom and the basis for the alkgad exemption. Any violation of Section 7931.5 by any applicant for a pemna subjects the applicant to a dvi penalty of not more than five hundred dollen [s509)). (3 I, as owner of the property or my employees with wages as Ther note compensation, will do the work, and the structure is nor intended or offered for onto (Section 7041, Business and Professions Code: The Conlredors License Law does not apply to an owner of property who builds or improves Iheraon, and who does such work fimsefl or herself or through he or her own ampbyeas, prwidod that such improvements are not kasrded or offered for sale. ff. however. the building or improvement is sold within one year of oompbrion, the ! owner4wilder will have rho burden of proving he or she did not build or improve for the purpose of sale)! © I, as owner of the property, am exclusively oonlrading with licensed e0mtradon to construct the project (Section 7044, Business and Professions Code: The Coruredors License Law does not appy to an owner of properly who builds or,improves thereon and who contracts for such projects with a owractor(s) licensed pursuant to the Contractors License Law). e-4 C]I am exempt under Section: &. d P.C.. for this reason: Date: Owner: I do hereby certify that I am aware of and understand the raWrements of California ile fth and Safety Code Sections 25505, 25533, and 25534. and that 1 or any future buildN occupant will! will not (circle one) need to comply with said stela codas and the requirements for a ps" fotconsiructanor modification homrhsAi�ityy anagamem District, Residential construction applications we attempt from these provisions. Dasa: Applicant: WORKER'S COMPENSATION DECLARATION: I hereby affirm under penally at per]uay one of the following dsctsrutbm: i I have and wig maintain a cen£icate d consent to seffminsurs for worker' try Cada. for the performance d the work for which this compensation, as provided for Section 3700 d the Labor ptarmic is issued. I have and will maintain workers' Compensation insurance. as required by Section 3700 of the Labor Cada. for the performance of the work for which this permit is issued. My workars�ffpprp�gn irrffmffrier and policy number ere: EXPIRES Policy Number. Cartier: LHS i 9 18 CY l7 0 O 01/01/97 (nds aectim need nor be compWad d the permk is for one hundred dollars 1S1001 or few.) I *only that in the performance of the work for which this permit is issued, I that not employ any person in any manner so ss to become sub]ect to the workers' compensation laws of California, and agree that N I should become subjed to the workers' compenss0ion provis ww of Section 3700 of the Labor Code. I shall f hue' ompfy with thea provisions. C Date: "Zic-_ __ Appliram: [l� .... 1Nanrinp: Failure to secure worlrers' corWansadon covsrapo Is unlawful, and elraf srb/ect an employer to cAmfnal por aflfes and cfvff rine, up to one hundred thousand dollars (SIMO9W1 In addiffon to the cost of compensation, damages as provided fir In Sacdon 3706 of the Labor Code, fntarast, and attorney's fees. CONSTRUCTION LENDING AGENCY: I hereby affirm under penalty of perjury that then is a oonsiruction landing agency for the performance of the work for which the permd Is issued (Section 3097, Civ. C). LENDER'SNAME:REPAIR WALLS & REFLECTED LENDER'S ADDRESS E I L I N G I comity that 1 have read this application and sten that the above information is correct. I agree to campy with all * and ocunty ordinainoes and supe laws relating to budding construction and hereby authorize napresenlativea of this city to enter upon the ahove­mersioned property rorimpadionpurposes.DAVID GRIMM Print Nape Date: 5OwnerlAgenttApplicantlCoruractor (5/51180P) Whee-Building & Safety; Green -File: Canary-Appkcam; Pink -Revenue; Goldenrod -Assessor CITY OF COSTA MESA -- BUILDING PERMIT PERM NO: P 0779911 PERMIT NO: P 077991 PLAN CHECK NO: N GOVT: N�SUPP: N CONSTRUCTION TYPE: PERMIT TYPE: PLU PURPOSE: ALT JOB DESCRIPTION : REPAIR WATER DAMAGED WALLS, ALT RESTROOM SQ FT: CLAIM VALUE: CALC—VALUE: GROUP OCC: B / COMMENTS: "TIFFANY" STR TI, ENLARGE CONF. RM, CREATE CASH CNT AREA, #877891 Z O N I N G R E Q U I R E M E N T S S E T B A C K S ------------- MAIN BUILDING ---------- --------- ACCESSORY BUILDING--------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN -LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN PARKING REQ: PROV: PARCEL: 41249102 ZNE: REF NO: PLANNING NOTES> > �!) iE iE !E !E �E 'IE NE � NE NE �E'Ik � �E 1E lE iE iF iE �E iE l(- iE iE iE -)E 1f• �E i(- iE iF * jF �F iE iE iE iE iE 9E 1E * NF iE * iE NE• �E NE NE Nt iE iE iE * � * iE �E * iE * * #E �E NE iE � � * iE iE � 3E 1E -)f iE � iE D E V E L O P M E N T S E R V I C E S ,�/R E Q U I R E M E N T S ZONING APPROVED BY !71 DATE: BUILDING APPROVED BY DATE: APPLICATION ISSUED BY: ' DATE: (O ca, NE ifr * � � it• iE iE # � * NE NE NE �E 9E * iE iE iE iE iE iE * iE iE * �E iE �E iE iE 9E iE LEGALIZATION:N F E E S U M M A R Y STRUCTURAL SEGMENT:N BLDG PMT PLUMBING ELECTRIC MECHANIC PERMIT 8.75 25% PLAN ISSUE FEE 22.00 BUILDING -DIV-> PERMIT ISSUE PLANiCHECK TOTALS ---- > 8.75 22.00 '0.00 r REVENUE DIVISION TOTALS--> COLLECTED: BLDG PMT PLUMBING ELECTRIC MECHANIC 30.75 FIRE SMIP/RES GRADING SMIP/NON-RES TOTAL PAID DUE 30.75 30,75 .00 30.75 OVER/SHORT: ,00 FIRE SMIP/TOT GRADING PLAN—CHECK iE 3E iE �IE iE � iE iE iE iE -IF 9E iE iE i(� iE iE iE � � � it 9E iE i(• iE• iE � NE if• if � !E �lE � �lE dE �fE �lE !E NF �E iE �E i'E iE * �E # iF 3(- )E iE iF * iE ?•E iE iF dE � iE iE iE �1E iE 9E iE iF � jF * *)(- * * )E �E iE I N D I V I D U A LTL F E E B R E A K D O W N TYPE QTY D E S C R I P T T O,N UNIT COST TOTAL COST PLU 1 WASH BASIN .- 8,75 8.75 END,OF FEES i of ��. Ail r CONSTRUCTION AND PLANNING APPROVALS Permit # Date Inspector POOL & SPA APPROVALS Permit # Date Inspector 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. 54. Forms ' 4. Electrical Conduit-Undrgrnd, 55. Electrical Bonding 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6. Electrical UFER Grnd. 57, APPROVAL TO COVER-GUNITE 7. Footings 58. Electrical Conduit-Undrgrnd. 8. Foundation 59, Gas Pipe, CI Undrgrnd., Test 9. Water Pipe-Undrgrnd, r 60. Backwash Lines, P -Trap, 0 Undrgrnd. 10. Structural Floor System 61. APPROVAL TO DECK 11. Property Sewer Line & House Connection 62, Backwash & Receptor -Final 12. Sewer Cap 63. Heater & Vent -Final 13. Roof Drains 34. Rdugh Plumbing �, _ u 64. Plumbing System - Final 65, Electrical -Final 15- Rough £lectrica[-Conduit 66• Solar System -Final 16. Rough Electric Wiring 67. Fencing & Access Approval 17. Rough Wiring Sign 68. APPROVED FOR PLASTERING 18. Rough Electrical -T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning 1 FIRE DEPT. REOUIREMENT APPROVALS Permit # 20. Rough Factory Fireplace 21. Ducts, in Structure 70. Underground Hydro 22. Ducts, Ventilating 71. Product Piping G Gas C Oil 23. Gas Pipe -Rough & Test 4: 72. Underground Flush 24. Roof Framing 73. Undergrnd. Storage Tank O Gas ©Oit 25. Roof Sheathing 74. Overhead Hydro 26. T -Bar Ceiling (Structural) & Monocoat 75. Dry Chemical 27. Frame and Flashing 76. Dry Standpipe ' 28. Lathing 8( Siding 77. FIXED SYSTEM FINAL 29. Insulation 78, FIRE PREV. FINAL '- 30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat 79, FINAL INSPECTION 32. Electrical Power Meter -Final 80: FOOD CERTIFICATE ISSUED Notes: !' - 33. Final Electric 34. Final Heating & Air Conditioning 35. Final Gas Pipe=Test 36. Hood or Canopy 37. Final Factory Fire6lace - 38. Final Plumbing 6 'ML I 39. Water Service -Final 40. Gas Service -Final 41. Solar Domestic -Final a 42. Backfiowe Preventer 43. Backflow Irrigation 44. Landscape Irrigation System 45, Sound Attenuation 46. Handicap Regulations 47, FINAL STRUCTURE & BUILDING 48. FINAL PLANNING ' 49. Electric Release to Edison A ' 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY NoDate 1 ADDl1'fSs OF BUILDING: 3333 BRISTOL ST mmwswaEIFmom; C J SEGERSTROM ADDRESS: 3315 FAIRVIEW RD COSTA MESA, CA 92626 APPL. "UNG ADDRESS! i ARCHITECT OR ENGINEER: E ARCN.OR ENVS. ADDRESS; UNT: 1509 FLOOD: AO -38 LIC, NO.: UNIT: coNTRAcTOR'SNAw_. SMALLCOMB WIRING INCORPOR ( 714 ) 556-8591 CONTRACTOR'S MAILING 136 E GAR R Y ABDRESs SANTA ANA CA l mo. 145961 92707 UNIT: U LICENSED CONTRACTORS DECLARATION: f hereby affirm under pen that I am I under provisions of Chapter 9 (commencing wth Section 7000► at Division 3 of the Bu mass and P s Code, and my ss is in full lone and edea. CITY LIC, No, 01 10 0 5 LIC. cuss: C u NO.: 1459 EXP ; 08/96 Date: r)WNER BUILDER DECLARATION; I hereby affirm under penalty d perjury t I am exempt from the Contractors License Law for the 'owing reason (Section 7091,5 Business and Proleasiom Cade; Arty city a which requires a permit to construct. after, improve, mofish. or repair any structure, prior to its 'ssosrlos, also requires the applicant for such perm l to fib a signed statement that he or she s licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000] of Division 3 d the Business and Professions Code] of that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permil subjects the applicant to a kiwi penalty of not more than We hundred dollars [S500]). ❑ I, as owner of the property or my employees with wages as their sole compensation, will do the wale and the structure is not intended or offered for sale (Section 7044. Business and Professions Code; The Contractors License Law does not apply to an owner d property who builds or improves Thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. lf. however, the budding or improvement is sold within one year of completion, the ownerhulder will have the burden of proving he or she did not build or improve for the purpose of sale). ❑ I. as owner of the property, an, ncknivefy cors—tit; with kensed contractors so ocnatruct she prclact (Section 7041, Business and Professions Code: The Contractors License Law does nil apply to an owner of Property who &;Ids or improves thereon and who contracts for such projects oath a oovractar(s) licensed pun rani to the Gantraciors License Law}, ❑ I am exempt under Section: B. 8 P.C.. for this noon: Data: Owner. I do hereby candy that I am aware of end understand the requiremads of CaRomfe F eeRh and Safety Code Section 25505, 25533, and 25534. and that I or eery future brx7dig occupant will h will not (mcb on) need to comply with said state coda and this requirements lar e pant for oantnlcticne a rnodiSratLon hon the Aranapanev District. Resides ad construction applfcetiom are exempt From dose Provisions. Dale: Apphcmel WORKER'S COMPENSATION DECLARATION: I hereby affirm oda penalty of perpay ons d the following declensions: ❑ I neve and will maintain a nndieas of consent to sediatse lor waken' compensation. as Provided for by Section 3700 of the Labor Code, for the pedormarce d cies work for which this permit is issued. [fj I neve and oil maintain workers' ootnpatsation insurance. as.equired by Section 3700 d the Labor Code, for the perammce d the 7� work for which Mo pant isrued. My workars'len Imkaance cmisr and posey number are: Carrier: CMASUALTY EXPIRES Percy Number 10/01/96 (This section need not be completed 1 the perms is Iso arm hundred doles [$fool or Mn. ❑ I caddy that In Oro performance d the work for which thi n �hdl nor �Vzy person In try manner so as to become subjed to the workers' compensation that Aawme subject to the workers' compenaetion provililns d nark 3700 or ! 1 p x`4W_ Warning: Failure to secure wartirere' conpsnesdon coveralls is unhawhd, and shall sublect on employer to crimfnsl penalties and civil 0nas up to one hundred thousand ddhra {$104000), In sddldon to da cost of compensation, damn" as provided for In Seedon 9706 at dta Latror Cods, hnreeaaL and aftomare foss. CONSTRUCTION LENDING AGENCY: I hereby affirm under perwy of perjury that there is a c"suction ending agency for she performance of the work fa which this permit is issued {Section 3097, Civ. C). LENDER'S NAME: REPAIR WALLS L REFLECTED LENDER'S ADDRESS: CEILING I certify that I have read this appliMion and state that the above indonmion is correct. I agree to comfy with aft city and county ordinanoes and state laws relating so building construction and hereby authorize rspreseretatrrm of this city to over upon the above-mentioned property for inspeaicn purposes. Neva % Date: G ? 9 (515146.WP) White -Building d Safety; Gnssr-F"; Canary- kppirart; PwA4%vemse; Goldenrod --Assessor CITY OF COSTA MESA - BUILDING PERMIT PERM NO: E 078047 PERMIT NO: E 078047 PLAN CHECK NO: N GOVT: N SUPP: N CONSTRUCTION TYPE: PERMIT TYPE: ELE PURPOSE: OTH JOB DESCRIPTION : REPAIR WATER DAMAGED WALLS, ALT RESTROOM SQ FT: CLAIM VALUE: CALC-VALUE: GROUP OCC: B / COMMENTS: "TIFFANY" STORE TI/ RE: B77891 Z O N I N G R E Q U I R E M E N T S S E T B A C K S ------------- MAIN BUILDING ---------- --------- ACCESSORY BUILDING--------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN PARKING REQ: PROV: PARCEL: 412491.02 ZNE: REF NO: PLANNING NOTES> • r iE iE iE iE'rt iE iE iE iE iF iE iE iE iE iE 9t �IE'1[• If 9E iE iE iE iE 1E iE i@ iE * iF # jF � !E'iF * iE ?K: iE �E �E � �E iF � i[• it �IF jE f4 iE iE # iE iE # i[• ih iE� iE � * !E 9E �E'f � ib # iF iE iE �E iF iE iE iE'IE �E D E V E L O P M E N T S E.R V I C E S R E Q U I R E M E N T S ZONING APPROVED BY DATE: BUILDING APPROVED BY �1�. DATE; el��� �v APPLICATION ISSUED BY: DATE; �1qa dE iE LEGALIZATION;N F E E S U M M IVR Y STRUCTURAL SEGMENT:N BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT 8,00 50$ SMIP/NON-RES PLAN L ISSUE FEE 22.00 BUILDING -DIV-> PERMIT ISSUE PLAN -CHECK TOTAL PAID DUE TOTALS ---- > 8.00 22,00 0.00 30.00 30.00 .00 REVENUE DIVISION TOTALS--> COLLECTED: 30,00 OVER/SHORT: .00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN -CHECK 30.00 lE IE �'IE aE iE if� iE iE dE IE Mf �E � IE �E iE 3E IE 1E !E �E * 3E iE � � !E 9E iE * iE �E !F !( II- iE MfIE 1E 1F � aE iE iE lE iG!(9E iE'IF � iF iE �E �E •lE •1E'}� �E ♦'E iE iE iE'}E !E ik'k dE iL- �E iE � � iE iE iE iE I N D I V I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST ELE 6 FIXTURES, LIGHTING 1 ST 20 EA. 1.00 6.00 ELE 2 RECEPT/OUTLET 1 ST 20 EA. 1.00 2.00 END OF FEES CONSTRUCTION AND PLANNING APPROVALS Permit # Date Inspector PG & SPP APPROVALS Permit # Date inspector 1. Temporary Electrical Service or Pdte 52. Pool & Equipment Location `` 2. Soil Pipe-Undrgrnd. -- 53. Steel Reinforcement 3. Electrical Conduit Utility•Undrgcnd. 54. Forms 4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding 5. Stee4 Reinforcement 56. Rough P4umbing & Pressure Test � 6. Electrical LIFER Grnd. 57. APPROVAL TO COVER-GUNITE 7. Footings 58. Electrical Conduit -Undrg'rrnd. 8. Foundation , 59. Gas Pipe, 0 Undrgrnd., -fest ' ` 9. Water Pipe-Undrgrnd. - 60. Backwash Lines, P-Tfap, Q Undrgrnd. 10. Structural Floor System 61. APPROVAL TO DECK 11. Property Sewer Line & House C6'il6ection 62. Backwash & Receptoir•Fin ! l 12. Sewer Cap 63. Heater & Vent -Fina! 13. Roof Drains 64. Plumbing System - Final 14, Rough Plumbing 65. Electrical -Final 15. Rough Electrical -Conduit 66. Solar System -Final 16. Rough Electric Wiring 67. Fencing & Access Approval 17. Rough Wiring Sign 68. APPROVED FOR PLASTERING 18, Rough Electrical -T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19, Rough Heating & Air Conditioning FIRE DEPT, REQUIREMENT APPROVALS Permit # 20. Rough Factory Fireplace 21. Ducts, in Structure 70. -Underground Hydro 22. Ducts. Ventilating 71, Product Piping 0 Gas 0 Oil 23. Gas Pipe -Rough & Test 72. Underground Flush 24, Roof Framing 73. Undergrnd. Storage Tank 0 Gas 0 Oil 25. Roof Sheathing 74, Overhead Hydro 26. T•Bar Ceiling {Structural} & Monocoat 75, (Dry Chemical 27. Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding 77. FIXED SYSTEM FINAL 29. Insulation 78. FIRE PREV. FINAL 30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat 79, FINAL INSPECTION 32. Electrical Power Meter -Final 80, FOOD CERTIFICATE ISSUED Notes:? 33. Final Electric 17 f�--���¢ 34. Final Heating & Air Conditioning 35. Final Gas Pipe -Test 36. Hood or Canopy 37. Final Factory Fireplace a - 38. Final Plumbing - 39. Water Service -Final 40. Gas Service -Final 41. Solar Domestic -Final 42. Backflow Preventer 43. Backflow Irrigation 44. Landscape Irrigation System 45, Sound Attenuation 46. Handicap Regulations 47. FINAL STRUCTURE & BUILDING 48: FINAL PLANNING 49. Electric Release to Edison , 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY No Date IiS Swum 3333 BRISTOL ST IFmn; C J SEGERSTROM & SONS ADDREss. 3 315 FAIRVIEW RD COSTA MESA, IWLM ADDRESS; ARCHITECT OR ENDDIEER: RCH, OR END: S ADDRESS: CONTRACTOR's NAME THREE STAR SIGN CO I N C CONTRACTOR'S UAILM 308 S C ROCKER ST UNIT: 1.11 F_ [509 UC. NO.: UNIT: (213)680-3500 amm LOS ANGELES CA =40. 400058 90013 Ute, LICENSED CONTRACTORS DECLARATION: I hereby affirm under p@nsty d perjury that I am I4:eraed under provobrn d Chapter a (commencing wllh Section 7000) of Division 3 of the Business and Profession Code. and my kwwb Is in full foros and effect. CITY LIC. NO.: era. a ms: C-10 uc. NO.: 400058 Date: contractor OWNER SUI DER DEC RATION: I hereby affirm under psnesy of grju E em asempl from t Contredon► Lkoenss Law for the 'awing 'sewn (Section 7071.5 Business and Profe*= Cods: Army a oouray @triol'squires 'etms to construct, after, improve, lolish, or repair any structure, prior fo its issuance, also requires IN ham for such permit to file a signed statement that he or she ricensed pursuant la the provisions of the Contractor@ License Ls [Chapter 9 (commencing with Section 7000) of Division 3 of ft Business and Professions Code) or that he or she to wwmpt therefrom and the basis for the alleged exemption. Any vbletbn of Section 7031.5 by any applicant lore permit subjects the applicant to a ciwl penalty of not more than rive hundred dollars ji500)). C] I, as owner of the property or my employees with wages as their sok compensation, win do the work, and the structure is stat Intended or offered for axle (Section 7044, Business and Professiorts Code: The Contractors License Law does nor applytoan owner of property who builds or inprovea thereon, and who does such wok himsed or herself or through he or her own employees, provided that such improvements are not intended or offered for sale, d, however, the building or improvemem is said within one year of completion, the owner builder will have the burden of proving he or she did not build or improve for the purpose of sale). 0 1. as owner of the property, am exclusively contracting with licensed contractors to construct the project (Section 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon and who contracts lar much projects with a cordrador(s) licensed Pursuant to the Contractors License Law). Q I am exempt under Section: B. & P.C., for this reason: Dads: Owner: I do hereby certify that I am aware of and undewland the requirements of Ullomia Health ane Safety Code Sedions 25505.25533. and 25534, and that I or any future building occupanl will / will not (circle one) need to comply with said state codes and the requirements for apermB for construction or modification from the Air ua�M-a-nagemenl Distdd.ResWwtialconstnxtionappicaliomamexemplfromlkee provisions. Date: Applicant: WORKER'S COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following dertermions: I have and will mainlain a certificate of consent to sedwrraure for waiters' compensation, as provided for by Section 3700 of the Labor Coda, for the performance of the work for which This permhl is issued. 1 have and will maintain workers' compermation insurance. as required by $action 3700 of the Labor Code. for the peAormanca of the rs work for which this permit is issued. My workers' g{p it i�nier and policy number aro: EXPIRES Carrier: 1 Lei j Poky Number: 04/01/96 (This section need std be compfetod if the perms is for one hundred dollars [$1001 of less.[ I certify tlat in the performance of the work for which this permit is Wsued. I shall nal employ any parson in any manner w as to become subject to the works i compensation laws of California, and agree that ! I should become subject to the waken' compensation prwisiors of Section 3700 d the Labor Code, I chap Igthwr[ orgy WWI thw ' Is Date: Applicant: Warning: Failure to s urs wo*wo' co npensadon =waregga is un , and sMll sub tan wriployer to crimfnal penalties and ra civil Dnup to one hundred thouserd dollars ($1ag000X In n to tyre cost of nlpansatloq damps ss provided for in Section 3706 o1 Ma tabor Cods, Interest, and attorney's CONSTRUCTION LENDING AGENCY: I hereby affirm under penalty of perjury that there is a construction larding agency for the performance of the work for which this perms is issued (Section 3097. civ" C)" LENDER'S NAME: LENDER'S ADDRESS: I certify that I have read this application and state that the above information is correct. I agree to campy with all city and county ordinances and state laws rotating to building construction end hereby authorize representatives of this city to @mer upon the above-mentioned Property f0f inspection purposes. STEVE HONDA Date: 3 h7 At, (5151-46.WP) While -Building d Salely: Green -File: Canary -Applicant: Pink -Pe nue; Goldenrod -Assessor CITY OF COSTA MESA -- SIGN PERMIT PERM NO: SB 076944 PERMIT NO: SB 076944 PLAN CHECK NO: 01141-96 L GOVT: N SUPP: N CONSTRUCTION TYPE: I—FR PERMIT TYPE: STR SIG PURPOSE: OTH JOB DESCRIPTION 19.3 SQ FT NON—ILLUMINATED WALL SIGN SQ FT: CLAIM VALUE: 4,000.00 CALC—VALUE: 4,000.00 GROUP OCC: M ! COMMENTS: "TIFFANY & CO." WALL SIGN OUTSIDE MALL S I G N I N F O R M A T I O N DISTRICT: 1 TYPE: WALL ILLUMINATION: NON CATEGORY: NEW DIMENSIONS: 14FT 06IN X 1FT 04IN AREA: 19,30SQFT LETTER HT: 16 IN STREET FRONTAGE 1: 2000.00 STREET 1: BRISTOL STREET FRONTAGE 2: 0.00 STREET 2: PARCEL: 41249102 ZONE: C1—S LOCATION > FRONT: X REAR: BUSINESS NAME: TIFFANY & CO > LEFT: RIGHT: O T H E R T 0 T A L S G R O U N D S I G N THIS ACTIVITY 19.305 FT OVERALL HEIGHT: OFT OIN THIS SITE 0:01S FT GROUND CLEARANCE: OFT OIN ITEMS OF INFO 1 PLANTER AREA: O.00SQFT ITEMS FOR ACTIVITY: 1 BLDG SET BACK: 20FT COPY VERBIAGE : TIFFANY & CO PLANNING NOTES: PLACING STEEL LETTERS OVER EXISTING ECTH �E )E � iE'k ib ib jb ib ib ib �b 3E * iF iE'lE'lE ib jb �(- ib ib ib �E db iE iE iE iE ?f ib 9E ib iF iF iE ib iE ib ib �b ib ib 9E 3E * 9E -16 16 Ib ib iE ib * 16 iE iE �F if * iE * if � ib iE ib ib iE ab dE 96 �b X16 i("YE � 3F D E V E L O P M E N T S E R V I C E S R E Q U I R E M E N T S ZONING APPROVED BY_K-cl- - DATE:9� BUILDING APPROVED BY : DATE: -027-94, APPLICATION ISSUED BY: DATE: {Fib ib ib iE �E iE ib ib iE iE ib ib ib "hE iE iE 96 �b iE iE ib ib iE # * iE iE * ib � � fE iE LEGALIZATION:N F E E S U M M A R Y STRUCTURAL SEGMENT:Y BLDG PMT PLUMBING ELECTRIC MECHANIC SIGN SMIP/RES GRADING PERMIT 63.00 SMIP/NON-RES PLAN 40.95 .84 ISSUE FEE BUILDING -DIV-> PERMIT ISSUE PLAN -CHECK TOTAL PAID DUE TOTALS ---- > 63.84 0.00 40.95 104.79 104.79 .00 REVENUE DIVISION TOTALS--> COLLECTED: 104.79 OVER/SHORT: .00 BLDG PMT PLUMBING ELECTRIC MECHANIC SIGN SMIP/TOT GRADING PLAN -CHECK 63.00 .84 40.95 36 iE � iE ib �b ib iE ib ib iE ii iE ib iE iE jE ie * ib iE ib ib 36 iE Bb lib �b ib db �b dF iE ib iE ib ib ib iE iE iE ib iF ib ib iE ib ib ib ib ib ib * ib �b * iE ib �k dE ib iE ib iE 9E * >f'f * ib iF �b iF iE 9E jc iE air � I N D I V I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST NO FEES WERE SELECTED FQE MIT Y� fit: Qf1�J, .,1-' : r'_- - ` DATE "iE= CTION AND PLANNING SCO OVALS Permit # Date Inspector POC SPA APPROVALS Pefmit # Date inspector • P1. Temporary Electrical Service or Pole 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd, 53. Steel Reinforcement 3. Electrical Conduit Utility•Undrgrnd. 54. Forms 4.' Electrical Conduit-Undrgrnd. 55. Electrical Bonding 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6- Electrical LIFER Grad. 57. APPROVAL TO COVER-GUNITE :X. Footings 58. Electrical Conduit- Undrgrnd. A. Foundation 59. Gas Pipe, ❑ Undrgrnd., Test 9. Water Pipe-Undrgrnd. 60. Backwash Lines, P-Trap, 0 Undrgrnd, 10. Strut ural Floor System 61, APPROVAL TO DECK 11. Property Sewer Line & House Connection 62. Backwash & Receptor-Final 12, Sewer Cap 63. Heater & Vent-Final 13. Roof Drains 64, Plumbing System - Final 14. Rough Plumbing. 65. Electrical-Final 15. Rough Electrical-Conduit 66. Solar System-Final 16. Rough Electric Wiring 67. Fencing & Access Approval Rough Wiring Sign E�• 68. APPROVED FOR PLASTERING 1-8. Rough Electrical-T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit # 20. Rough Factory Fireplace 21. Ducts, in Structure 70. Underground Hydra 22. Ducts, Ventilating ' 71. Product Piping ❑ Gas ❑ Oil 23. Gas Pipe-Rough & Test 72. Underground Flush 24, Roof Framing 73, Undergrrid. Storage Tank 0 Gas ❑ Oii 25. Roof Sheathing 74, Overhead Hydro 26. T-Bar Ceiling (Structural) & Monocoat 75. Dry Chemical 27. Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding 77. FIXED SYSTEM FINAL 29. insulation _78, FIRE PREY. FINAL 30. Drywall Nailing HEALTH,DEPT..REOUIREMENT 31. Plaster Brown Coat 79. FINAL INSPECTION 32, Electrical Power Meter-Final 80. FOOD CERTIFICATE ISSUED 33. Final Electric Notes, 34. Final Heating & Air Conditioning 35. Final Gas Pipe-Test _ 36. Hood or Canopy 37. Final Factory Fireplace 38. Final Plumbing 39, Water Service-Final r 40, Gas Service-Final r 41. Solar DornestiG-Finai ' 42. Backflow Preventer 43. Backflow Irrigation 44. Landscape Irrigation System 45, Sound Attenuation 46. Handicap Regulations 47. FINAL STRUCTURE & BUILDING 48, FINAL PLANNING 49, Electric Release to Edison 50. Gas Release to Southern California Gas Co ' 51. CERTIFICATE OF OCCUPANCY No Date PM ADDRESS OF BUILDING: 3333 BRISTOL S T OWNER'S NAME IF KW": C J SEGERSTROM & SONS wDRm. 3315 FAIRVIEW RD COSTA MESA, APPL. RAILING ADDRESS: ARCHrrECT OR ENMEER: ARCH. OR END: S ADDRESS: cpNrRAcrORSNA�E THREE STAR ' SIGN CO INC carrRAcrORs MAitJNG 308 S C RO C K E R ST UNIT: 1 t) U 9 FLOOD: AO -38 LIC. NO.: UNT: (213)680-3500 ,wDREss, LOS ANGELES CA „-NO.: 400058 90013 UNIT: LICENSED CONTRACTORS DECLARATION: I hereby affirm under penalty of perjury the I am licensed under provisions of Chager 9 (oommencing with Section 7000) of Division 3 of the Business and Professions Code ata is in full force and afled. CITY LOC. NO.: LIC. CLASS: C--10 LIC. No, 4 d �1 �� EXP Data: 3 2Contractor OWNER 13111ILDIER D LARATION: I hereby affirm under penalty of Ihat I am exempt f the Contractors License Law for the li llowing reason (Section 7031.5 Business and Professions Code: y or county which res a permit to oonstrucl, after, improve, molsh, or repair any structure, prior to its issuance, also requi a applicant for such permit to file a signed statement that he or she ioensed pursuant to the provisions d the Contractors Igoe Law (Chapter 9 (oommancirq with Section 7000) d Divsien 3 d the ..rsiness and Professions Code) or that he or she is exempt theretmm and the basis fa the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of nit more than five hundred dollars IS5001). ❑ 1, as owner d the property or my employees with wages as their ode compensation, will do the work, and the structure is nd intended or offered for sale (Section 7044. Business and Professions Code: The Contractors License Lew does not applyto an i>wmrof property who builds or improves thereon. and who does such work !messed or herser or through his or her own employees, provided that such improvements are not intended or offered for sale, lf. however. the building or impriwismorit is sold within one year of oompktion, the owner -builder will have the burden of proving he or she did not build or improve for the purpose at sale). ❑ 1. as owner of the property. am exclusively coniractng with licensed oontrectoa to construct the project (Section 7044. Business and Professions Code: The Contractors License Law does not apply To an owner of properly who builds or irr r ov thereon and who contracts for such projects with a owdractor(s) licensed pursuant to the Contractors License Lew). ❑ 1 am exempt under Section: B. h P.C., for this reason: Date: Owner: I do hereby *wufy that I am aware at and understand the regdroments of Callomis Haahh and Safety Coda Sodom 25505, 25533. and 25534, and that I or any heure building oompam will / win nam (tints one) need to comply with said state codes and the requirements for apermit f000mtructionormodification fromlheAir y araigament District. Residential construction applicallons are exampt from those provisions. Dale: Applicant: WORKER'S COMPENSATION DECLARATION: I hereby affirm under penalty of perjury ons of the ldlowing dedamliom: ❑ I have and will maintain a ceniRcale of consent to self -insure for workers' compensation, as provided for by Section 3700 of the Labor Code, for the performance d the work for which this permit is issued. 1 have and wAl maintainworkers' compensation insurance, as required by Section 3700 of the Labor Code. for the pe[ormenoe of the work for which this permit s issued. My workers' 2gpfii ft insrVpJisr and policy number are: Carder: EXPIRES Policy Number: — 04/01/96 n This section need mol be completed Y the perms is for one hundred ddlere jSrOO] of Imj ❑ 1 certiy that in this performance of the work for which this pemnt is issued, I shalt to employ any person in any manner so as to become subject to the work&W compensation laws of California, and agree that d I should became subject to the workers' compensation provisions of Section 3700 of The Labor Code. I shell fo ' h oonpy with those p tenons. Date: 2-7 Applicant: Waminy: Fadlun fo ueurr workera'rompsnaatlon rovanye la !u!, and shall emaDh an @mpl*ysr to crfrnfrAd p*wfflos and civil 17r)" ys to ore hundred thousand dollars ($104OW), don ro nn coal o/ mprnaarkn, damayss as provided for m Section 3706 of the labor Code, Into sat, and sttorrray m lass. CONSTRUCTION LENDING AGENCY: I hereby affirm undo penally of perjury that [hens is a cominhction lending agency for the performance of the Mark for which this permit is issued (Section 3097, Civ. C). LENDER'S NAME: LENDER'S ADDRESS: I cenifythet I have read this application and state that the above information is oDmed. I agree to comply with all city and oounty ordinances and state laws rolafing to building cangruction and hereby authorize representatives of this city to enter upon the above•memioned property for inspection purposes' STEVE HONDA Dale: 4 % {5151 sB.WK Whits -Building d Safety; Greet -File; Canary-Appicard: Pink -Revenue; Goldenrod -Assessor CITY OF COSTA MESA — BUILDING PERMIT PERM NO: B 07694 PERMIT NO: B 076945 PLAN CHECK NO: 01143-96 L GOVT: N SUPP: N CONSTRUCTION TYPE: I—FR PERMIT TYPE: STR PURPOSE: OTH JOB DESCRIPTION : 9 SQ FT NON—ILLUMINATED WALL SIGNS SQ FT: 3,200 CLAIM VALUE: 3,200,00 CALC—VALUE: 3,200.00 GROUP OCC: M / COMMENTS: "TIFFANY & CO." WALL SIGN INSIDE MALL REF SB -76944 Z 0 N I N G R E Q U I R E M E N T S S E T B A C K S ------------ - MAIN BUILDING ----------- --------- ACCESSORY BUILDING --------- FRNT:FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RIGHT: FT IN LEFT: FT IN RIGHT: FT IN PARKING REQ: PROV: PARCEL:.41249102 ZNE: REF NO: PLANNING NOTES> 40.95 .67 ISSUE FEE �E tE �E tE � dE iF �E 1>E AE iF � * 1E 9E 1E * iE )E 1E 1E iE iE iE dE iE iE dE'lE >tiE * * iE iE iE iE iE iE iE iE'lE >tiE �E iE iE iE iE iE �E iE iE iE iE iE iE iE 1E �E iE * iE iE iE iE iF iE * iE � -lE,9F lE -)t * iE 3E iE iE iE D E V E L O P M E N T R V I C E S R E Q U I R E M E N T_ S IS 63.67 0.00 40.95 104.62 104,62 ZONING APPROVED BY 'V REVENUE DIVISION TOTALS--> COLLECTED: DATE: BUILDING APPROVED BY : .00 BLDG PMT DATE: MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK 63.00 APPLICATION ISSUED BY: .67 DATE: )E -lE iE iE �E fiE iE iE iF �E'lE i>E i'E iE i>E -IE �E dE -)E iE -)E IE 1E �E iE 9E �E >tiE � )f )E iE E iF iE 3E LEGALIZATION:N F E E S U M M A R Y STRUCTURAL SEGMENT:Y BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT 63.00 UNIT COST TOTAL COST SFC 3200 SMIP/NON—RES PLAN 40.95 .67 ISSUE FEE BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE TOTALS-----> 63.67 0.00 40.95 104.62 104,62 .00 REVENUE DIVISION TOTALS--> COLLECTED: 104,62 OVER/SHORT: .00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK 63.00 .67 40.95 I N D I V I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST SFC 3200 ALTER BY VALUE COMMERCIAL NOZONE 1.00 3,200.00 END OF FEES 0 i 002037 -,-00203286 Ic T aryl.., DATE: 03/27/95 Trf E: ten. CONSTRUCTION AND PLANNING APPROVALS Permit # Date Inspector POO SPA APPROVALS Permit # Date inspector 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location ' 2. Soil Pipe-Undrgrnd. 53, Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. 54. Forms .4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6. Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE 7. Footings 58. Electrical Conduit-Undrgrnd. 8. Foundation 59. Gas Pipe, ❑ Undrgrnd., Test 9. Water Pipe-Undrgrnd. 60, Backwash Lines, P -Trap, ❑ Undrgrnd. 10. Structural Floor System r 61. APPROVAL TO DECK 11, Property Sewer Line & House Conriection 62. Backwash & Receptor -Final 12. Sewer Cap 63. Heater & Vent -Final 13. Roof Drains 64. Plumbing System - Final 14. Rough Plumbing 65. Electrical -Final 15. Rough Electrical -Conduit 66. Solar System -Final 16. Rough Electric Wiring 67. Fencing & Access Approval 17. Rough Wiring Sign 68. APPROVED FOR PLASTERING 18, Rough Electrical•T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit # 20. Rough Factory Fireplace 21. Ducts, in Structure 70. Underground Hydro 22. Ducts, Ventitating 71. Product Piping f_7 Gas 00il 23. Gas Pipe -Rough & Test 72, Underground Flush 24. Roof Framing 73. Undergrnd. Storage Tank C) Gas ❑ Oil 25, Roof Sheathing 74. Overhead Hydro 26. T -Sar Ceiling (Structural) & Monocoat 75. Dry Chemical 27. Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding 77. FIXED SYSTEM FINAL 29. Insulation 78. FIRE PREV. FINAL 30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31, Plaster Brown Coat 79. FINAL INSPECTION 32. Electrical Power Meter -Final 80. FOOD CERTIFICATE ISSUED 33. Final Electric. Notes: 34. Final Heating & Air Conditioning 35. Final Gas Pipe -Test 36. Hood or Canopy 37. Final Factory Fireplace 38. Final Plumbing 39. Water Service -Final 40, Gas Service -Final i 41. Solar Domestic -Final 42. Backflow Preventer 43. Backflow Irrigation 44. Landscape Irrigation System 45, Sound Attenuation 46. Handicap Regulations 47. FINAL STRUCTURE & SUI UDING 48. FINAL PLANNING 49. Electric Release to Edison 50. Gas Release to Southern California Gas Co 51.. CERTIFICATE OF OCCUPANCY No. Date --AI ADDRESS OFBUILDINa: 3333 BRISTOL ST' UNIT: 1509 OWNERS NAME IF MM; C J SEGERSTROM ADDREss: 3 315 F I AR V I EW RD C.M., CA 92626 APDL. HAILING ADDRESS: ARCRTrECTORENm+EER: BERMAN & BERTOLINI Data_ C2674 ARDN. OR m's AGGRESS: 16250 VENTURA B L UHT: 316 ENCINO CA 91436 CONTRACTarsKmE. WATSON CONSTRUCTION (714)662-7933 CONTRACTORS mmuNG 1260 L OGAN AV ADDRsss: COSTA MESA CA Liamo, 546538 92626 UHT. B-1 LICENSED CONTRACTORS DECLARATION: I hereby affirm urder penaly of perjury dud I am I'ceMed under provisions of Chapter 9 (dommend+g wah Section 7000) of Division 3 of the Business and Professions Code. and my IiceMe is In full force and puect. CITY LIC. No.: 0 47 41 3 LIC, CLASS: B UC. N 546538 X P: 3/ 9 6 t Date: I�i _�,4 Contractor: OWNER BUILDER DECLARATION: I hereby affirm under penalty d perjury that I am ampt from the Contractors License Lawlor the following reason (Ssdion 7031.5 Business and Professions Code; Any ody or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law {Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code] or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031,5 by any applicant for a permit subjects the applicant to a civil penalty of nit more than live hundred dollars [5500[). ❑ I, as owner of the property or my employees with wages as their sole compensation, will do the work, and the structure is not intended I or offered for sale ($action 7041, Business and Professions Code; The Contractors License Law does nol apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such immovernerus are nit intended or offered for sale. If. however. the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving he or she did not build or improve for the purpose or sale). [] I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Section 7044. Businrss and ProlessioM Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon and who contracts for such projects with a contactor(&) licensed pursuant to the Contractors License Law). ❑ f am exempt under Section: B. 6 P.C., for this reason: Date: Owner-. I do hereby certity that I am aware of and urderswd The requirements of Cal#omis Health and Safety Code Sections 25505, 25533, and 25534, and that I or airy future building comment will / will not (circle one) need to comply with amid state codes and the requirements for a P" for construction or modification from the Air anagernam Oistrid. Residera®I owkstr ion appfoations ars exempt from these prdvisk m. Date: Applicant: WORKER'S COMPENSATION DECLARATION; l hereby affirm urder penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of oonsanl to seltminsure for worked compensation, as provided for by Section 3700 d the Leber Coda, for the performance of the work for which this permit is issued. ❑ I have and will maintain worked compensation insurance, as required by Sedion 3700 of the Labor Code. for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy number are: carrier: GOLDEN EAGLE EXPIRES Policy Number: NWC 1 04/01/96 (This section need nor he complared d the perm# is for one hundred dd lars f310o) or less) ❑ I certify that in the pedormance of the work la which this permit Is issued, I shall not employ any person i manner so as to become subject to the wokers' compensation laws df Calif ,and agree thal f I shou+ become s b �d to the woduers' coym7Cpel tion p isicru of Section 3700 of the Labor Code, I forthwith oompy with time; ' Ions. Dare: "1 Applicant: WsminD: Failure to secure wonPen' eomoenmatron coverago la unlawful, and ILI sublocf an errwlayw to drrmfnal penin" and civil ones up to one hundred thouasad dalfarm (610400oj In addMDn to the coat of emrpensaflorb damages as provided for 1n Section 3706 of the Labor Cods, lnfw"4 and attornWa fess. CONSTRUCTION LENDING AGENCY: I hereby affirm oder penalty of perjury that there is a coristrudion lending agency for the performance of the work for which the permit is issued (Section 3097, Civ. C). LENDER'S NAME: LENDER'S ADDRESS: I certify that i have read this application and state that the above information is sorted, I agree to comply with all city stud county ordirwhces and state laws relalig to building construction and hereby authorize representatives of This city to enter upon the above•rtlemioned property for inspection purposes. WAY N E WIffSON Prim Dale: ,sta- Signature of OwnerlAgentlApplicant;Conlrador (515146.WP) White -Building A Safety; Green -File; Canary -Applicant: Pink -Revenue; Goldenrod -Assessor CITY OF COSTA MESA - BUILDING PERMIT PERMIT NO: B 074283 PLAN CHECK NO: 03523--95 S PERM NO: B 074281 GOVT: N SUPP: N CONSTRUCTION TYPE: I FR PERMIT TYPE: STR PURPOSE: ALT JOB DESCRIPTION DISPLAY WINDOW ALT, MINOR INSIDE ALT SQ FT: 11,000 CLAIM VALUE: 10,000.00 CALC-VALUE: 10,000.00 GROUP OCC: B-2 / COMMENTS: "TIFFANY & CO" WALL COVERING & DISPLAY ALT Z O N I N G R E Q U I R E M E N T S S E T B A C K S ------------ MAIN BUILDING ------------ ---------- ACCESSORY BUILDING----------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN PARKING REQ: PROV: PARCEL: 41250105 ZNE: CI -S REF NO: PLANNING NOTES> INTERIOR ALTERATION TO TIFFANY & CO TO OPEN UP A SHOW..- > WINDOW TO THE INTERIOR OF THE MALL. D E V E L O P M E N T S E R V I C E S R E Q U I R E M E N ]��_S I ZONING APPROVED BY UWJ DATE: '(- lI [�[% BUILDING APPROVED BY : DATE: APPLICATION ISSUED BY: DATE: j2 l L LEGALIZATION:N F E E S U M M A R Y STRUCTURAL SEGMENT:Y BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMTP/RES GRADING PERMIT 117.00 SM I P./ NON -RES PLAN 76.05 2.10 ISSUE FEE BUILDING -DIV-> PERMIT ISSUE PLAN -CHECK TOTAL PAID DUE TOTALS ---- > 119.10 0.00 76.05 195.15 195.15 .00 REVENUE DIVISION TOTALS--> COLLECTED: 119.10 OVER/SHORT: .00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN -CHECK 117,00 2.10 't t iE -)E iE )(iE• # dE # iE r1E # iE iE # iE # �E # # ')E # dE dE iE 3E # IE 3F TIE # # # # # # iE iE iE # 4E % # iE iE IE 3(- -)E -IE iE �E i( -'rt iE iE iE # iF iE iE iE iE iE iE iE iE iE 3F �E aE # � # dE iE dE # � # dE I N D I V I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST SFC 100010 T.I. STORE BY VALUE/$1 1.00 10,000.00 END OF FEES fit 00490631-00190612 TOT }19.T n;TE: 09/21/95 TINE= tit:5;3 •3 4 - CONSTRUCTION AND PLANNING APPROVALS Permit # Date Inspector Pob, & SPA APPROVALS Permit # Date Inspector 1, Temporary E Iectrical Service or Pole 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd. 53_ Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. 54. Forms 4. Electrical Conduit-Undrgrnd, 55. Electrical Bonding I 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test i 6. Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE i 7, Footings 58. Electrical Conduit-Undrgrnd. 8. Foundation 59. Gas Pipe, ❑ Undrgrnd., Test 9. Water Pipe-Undrgrnd. 60, Backwash Lines, P-Trap,`G' Uodrgrnd. 10. Structural Floor SystemI 61. APPROVAL TO DECK 11. Property Sevver Line & House Conr;ection •a 62, Backwash & Receptor -Final 12. Sewer Cap 63. Heater & Vent -Final 13, Roof Drains t 64. Plumbing System - Final 14. Rough Plumbing 65. Etectrical-Final 15. Rough Electrical -Conduit I 66. Solar System -Final 16. Rough Electric Wiring 67. Fencing & Access Approval 17. Rough Wiring Sign 68. APPROVED FOR PLASTERING 18, Rough Electrical -T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit 20, Rough Factory Fireplace 21. Ducts, in Structure 70. Underground Hydra 22. Ducts, Ventilating 71, Product Piping CI Gas ❑ Oil 23. Gas Pipe -Rough & Test 72. Underground Flush 24, Roof. Framirsg 73., Undergrnd. Storage Tank C Gas © Oil 25. Roof Sheathing 74. Overhead Hydro 26, T -liar Ceiling (Structural) & Monocoat 75. Dry Chemical i 27. Frame and Flashing 76, Dry Standpipe 28. Lathing & Siding 77, FIXED SYSTEM FINAL 29. Insulations 78. FIRE PREV. FINAL 30, Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat 79. FINAL INSPECTION 32. Electrical Power Meter -Final 80. FOOD CERTIFICATE ISSUED 33- Final Electric Notes: 34. Final Heating & Air Conditioning 35. Final Gas Pipe -Test 36. Hood or Canopy 37, Final Factory Fireplace I 38. Final Plumbing U 39. Water Service-Finai 40. Gas Service -Final 41, Solar Domestic -Final i 42. Backflow Preventer 43. Backflow Irrigation 44. Landscape Irrigation System 45.• Sound Attenuation 46. Handicap Regulations 47. FINAL STRUCTURE & BUILDING 48. FINAL PLANNING 49. Electric Release to Edison j; , 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY NO•. ,,, .__., Date ADDRESS OF sUIILDwa 3333 BRISTOL ST OnEwsNAME IFIWOWN: C J SEGERSTROM ADDRESS: 3315 FAIRVIEW RD COSTA MESA, CA 92626 APPL. MAILING ADOREM UNIT: 1509 ARCHITECT GRFJfmm: BERMAN & BERTOLINI uc.fro.: C2674 ARcK OR ENa's ADDREss: 16027 VENTURA BL UNIT: 102 ENCINO CA 91436 CONTRACTolrsNium WATSON CONSTRUCTION (714)662-7933 CONTRACTOR'sMAILING 1260 LOGAN AV ADDRESS; COSTA MESA CA uc,No.: 546538 92626 UNIT: B-1 LICENSED CONTRACTORS DECLARATION: I hemby affirm under penaiy of perjury that I am Goat under provisions of Chapter 9 (oommenciV with Section 7000) of Division 3 of the Business and Profession Code, and my licerma is in full force and effed. LIC. No.: 0 4 7 413 Lic. cLAss: B uc. o.: 546538 P: 03/96 We �� ��ff� �G � Contrador: ER BUILDER DECLARATION: I hereby affirm under penalty of perjury that t 4 exempt from the Contractors License Law for the stewing reason (Section 7031.6 Busies and Professioru Code: Any ciy or ow my which requiros a permit to construct, altar, improve, demolish. or repair arty smecturs. prior to as ewmnoe, also requires the epplimd for such per it to % a signed statemerq thm he or she is wormed pursuant to the provimn of the Contractors License Law [Chapter 9 {cc nmencrq with Section 7000) of Division 3 of the Business and Protessiom Code) or that he or she m exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicert for a perm) subjects the applicant to a civil panafty of not more than rove hurdred dollars JMD, ❑ 1. as owner of the property or my employees with wages as their We oompemation. will do the work, and the structure is not intended or offered for sale (Section 70u. Businessand Pmtassions Code: The Confradors Lioentse Lawdoes not appyloan owner of property who' ids or improves thereon, and who does such work fimsed or hem" or through his or her own arr ioyaes, provided that such imMo vemhrts are not intended or offered for sale. f, however, the building or inprovernw is sold within one year of completion, the ownerbtdider trill hays the burden of proving he or she did not build or improve for the purpwa of tele). ❑ I, as owner of the properly, am exdusivey oontrectkg with Iioensed contractors to nwnsuutt the project (Section 70U. Business and Professions CD&: The Contractors License Law does not apply to an owner of property who builds or irsprwes thereon and who contracts for such projects with a oontrador(s) licensed Pursuant to the Contractors Lioerme Law). 1 am exempt under Section: B. A P.C., for this reason: Date: Owner: I do hereby caaiy that I am aware of and understand the requirements of California lieafth and Safety Code Sections 25505, 25333, and 25534, and that I or any future buildrq omrpent win I will not (circle one) need to campy with raid Hale codes and the roqudnemenm for a Permit for mr to ction or modfimtion from theAi a y anagement Oislrk Residential mutrudion appicnipm are exempt from throe PrGvWDns. Data: Applicant: WORKER'S COMPENSATION DECLARATION: i hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a eerldicate at owsard to sadminsure for workers' aamprwation, as Provided for by Section 3700 of the Labor Code, for the performance of the work fa wfich this permit in issued have and will maintain workers' compernmion kquronce, as Mquired by Section 37M of IM Labor Code, for the pectorrma oe d the Tor which dnia partstC is" workers'&n ion insurance carrier and policy number are: carve: GLD EN EAGLE EXPIRES Policy Number: NHCjUZUJd 04/01/96 (This sadiron need not be comPrasd 1 urs prrml n for ane hundred donees 15=1 or Im ) ❑ t cartfy that in the perlom me of the work for which this perha is 4eued. I shell nal employ cry person in wry manner so as to becarha srrl>jea !a the workers' campenserion laws of CalfomAie, end pros that f 1 stradd become bjed to the wonloars' ompermation provisioro d Section 3700 of the Labor Code. I uR10 forthwtlh mmpy wih dhase ns. Date � Applicant: Warning, );&Burn in :stuns workers' conwww1lon coraraps L rmtatvhnl, shill sWpfcl an army+ora• to crkrsrnnrl perurltlu Rid civil ffnu tp to one hundred thousand dollars ($10Q0001 In addition to the cwt of con*w=tbrt damp m as provided for In Section 7706 of the Labor Carr, Interest and uromryr• tau. CONSTRUCTION LENDING AGENCY: I hereby affirm under penalty of Perjury that there is a construction k dig agency, for the performance of the work for which the pend is 'issued (Section 3097. Civ. C). LENDER'S NAME: LENOMS ADDRESS: I cerinfy that I haw read this application and state that the above irdormalion is cared. I agree to comply with all nay and county ordirwoss and state laws relating to lxMing oonsanrriat and hereby authorize repssenlatives of this city to sme upon the above•meaioned property forrmpeam' purposes. WAYNE WATSON _ r/ Print Name �� `i _ \ JL1 C Yui _ Data: Sionature di OwnelAoonuADDicantlContrador (5151-48 WP) While-WidiIf s Safety, Gat Rle; Canary-Apgicent; Pink-Revw ue: Goldenrod-Assssao CITY OF COSTA MESA — BUILDING PERMIT PERMIT NO: B 074897 PLAN CHECK NO: 04148-95 A CONSTRUCTION TYPE: I FR PERMIT TYPE: STA JOB DESCRIPTION : MINOR ALTERATION PERM NO: B 074897 GOVT: N SUPP: N PURPOSE: ALT SQ FT: 12,000 CLAIM VALUE: 12,000.00 CALC—VALUE: 12,000.00 GROUP OCC: B-2 / COMMENTS: STORAGE ROOMS MINOR ALT & NEW LOUNGE "TIFFANY & COt1 STORE Z O N I N G R E Q U I R E M E N T S S E T B A C K S ------------ MAIN BUILDING ----------- --------- ACCESSORY BUILDING--------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN PARKING REQ• PROV: PARCEL: 00000000 ZNE: CIS REF NO: PLANNING N TES> TENANT IMPROVMENTS FOR A RETAIL STORE (TIFFANY & CO)..,,- > 1E 1E iE''!E !E * * ill• ill iF'IE � ill � ill ill !E ill ill ill ill ill ill * �E * � * * 1E dE * * * * !E it #E * ill * ill * #F � ill ill ill � it• ill iE'!E * * �E 9E AE ill * ill !F ill * * lE #f'Ff 'IE 'IE' � � �F ill � * ill fE ill D E V E L O P M E N T S E R V I C E S R E Q U I R E M E ZONING APPROVED BY (%L;o DATE: BUILDING APPROVED BY : DATE; ZJz_ APPLICATION ISSUED BY: DATE: LEGALIZATION:N F E£ S U M M A R Y STRUCTURALnSEGMENT:Y BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT 135.00 NO PLAN 21,94 SMIP2.52—RES ISSUE FEE BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE TOTALS ---- > 137.52 0.00 21.94 159.46 159.46 .00 REVENUE DIVISION TOTALS--> COLLECTED: 137.52 OVER/SHORT:00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK 135.00 2.52 ��iF�EfE�illilliFi#**dE*3ElE'!F'lFiFiE�EiE1E'lE*�*#E���illiF****dEill1E1E�iE'lFiFillilliPiF*�iFillilllEi<•jiilEillillillillillillillillillill�E�E*�F*��E���� I N D I V I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST SFC 12000 T.I. STORE BY VALUE/$1 END OF FEES 1.00 12,000.00 ^lir • '�'. -4Ti_ Ir R 17 r� L`r:;T:i iC IJ.'a f1F1!': u' =ice: CONSTRUCTION AND PLANNING POt-,- & SPA APPROVALS Permit # Date Inspector APPROVALS Permit #'- Date inspector 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement 3. 8ectrical-Corrduii Utility•Undrgrnd. 54. Forms a ' E�ectrica oiYdy1! Undrgrnd. 55. Electrical Bonding �4, ,5r Steel Reinforcement _ 56. Rough Plumbing & Pressure Test ' 6 "Electrical [}FEF Gr 57. APPROVAL TO COVER•GUNITE .'.1 �G, J r 7J Footings �. -' .- 5B. Electrical Conctu [=Undrgrnd. �-S .•F-,aundation -•:< - 59• Gas Pipe, © UriBl�lrnd., Te;t 9..Water Pipe-Undrgmd. -. 60. Backwash Lines, RTrap, d Undrgrnd• 10. Structural Flooi System 61. APPROVAL TO DECK :1 -].'Property Sewer Line.& House Connection 62. Backwash & Receptor -f=inal 12. Sewer 63, Heater & Vent -Final 13, Roof dfains 64. Plumbing System • Final _ 14. Rough !Plumbing 65. Electricat-Final 15. Rough Electrical -Conduit 66. Solar System -Final 16. Rough Electricwiring 67- Fencing & Access Approval ' 17. Rough Wiring Sign 68. APPROVED FUR PLASTERING 181 Rough Electrical -,l- Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 7'9. Rough heating & Air Conditioning - FIREDEPT. REOUIREMEgT _ APPROVAl.5 Permit # 20. Rough FactoW f=ireplacext. , 21. Ducts, in Structure: • '�' t' 70. ~llndergi }{ydro _ �t 9; ' 22..Ducts, Ventii in "' k : r 71. Produc[; 1ping Gas Oil 23. Gas Pipe -Rough 72. Undergrpurtd F.tu'sit- r 24. -Roof Fr min r d 9 � rr :J �- " o ` r'• _ � .. 73. UndergrRd. StoFa*ge.7".anl<, ©Gas ©)i1 25. Roof Sheathing ,E+ e: t t' 74. Overhead Hydro _y 26. T-Brr'Ceiling (Structural) & Kkad--toat4 cc 7 lJr 27. :Frame arld Flashing' n• ,r '� ;' >, ;x7 t 76. Dry StarR3pipe ' 28. LatKLLhg $& Siding �1 - * '� .� ; 77� FIXED S,$TL��I IAt .` 29, Insulation 78 FIRE PREY. FINIAL a 30. Drywall Mailing DEP, i�EQUIR'EMENT �,FALTl1 31. Plaster Brown Coat , �• ,- rr + 79. FINAL I:NSPECTtON32. 4--4 E=lectrical Power Me{�rFal t' i 8f3:,FOOD CERTIPLCATE I��UEO ti33. Einat,ElectrirtiN ; w Notes: ~j 34• .Fina]Heating_& Ail Conditioning L: �` s: � � �" ' _ - .. F �• 35. Final Gas Pipe•Teit T 36. Hood or Canopy Y - _ ' , "' �• '-' °s 37, Ejnal Factory Fireglace 38. Fina'1'Plumbing 7 M{ 39. Water Service•Fina`>t; 1 t ... 40. Gas Service-Fin81 41. Solar Domestid-Firia�To y 42. Backflow Preventer 43, Backflow Irrigation 44, Landscape Irrigation System - '+ " •' t *V w 45. Sound Attenuation, 46. Handicap Regulations 47, FINAL STRUCTUq & BUILDING 48, FINAL PLANNING} 49, Electric Release to Edison _ y i• J r: • 1 �,:� 50. Gas Rieleese to Southern Caiifbrnia Gas Co * Y 11 4l 51. CERTIFICATE OF OCCUPANCY - No., Date _� ADDRESS OF BUtLDWG; 3333 BRISTOL ST OWNER'SNAMEIFKNOWN: C J SEGERSTROM ADORES$: 3315 FIARVIEW RD C.M., CA 92626 ►PPL. NAILING ADORES$: UNIT. 1509 ARCHITECT ORENr.TNEER: BERMAN & 13ERTOLINI uo.NG.: C2674 ARCH. OR ENG.'S ADOBES$: 16250 VENT URA BL UNIT: 316 ENCINO CA 91436 CONIR►cTOR'sNAff& WATSON CONSTRUCTION (714)662-7933 CONTRACTOWSMMN0 1260 LOGAN AV ADDRESS: COSTA MESA CA ur.NG.: 546538 92626 uw: B-1 LICENSED CONTRACTORS DECLARATION: I hereby affirm under penalty of perjury that 1 am licensed under provisions at Chapter 9 (commencing with Section 70001 of Division 3 of the Busirim end Professions Cade, and my license is in full farce and effect QC. NO.: 047413 LNC. CLASS: B Lic. .: 546538 C) Contrador: BUILDER DECLARATION: I hereby affirm under penalty of perjurythatI exemptfromtheContmdmsLicenseLawfmthereason(Section 7031.5 Business and Professions Godo: Any city or county which requires a Permit to construct. eller. improve, h, m repair any structure, prior Wes issuance, also requires the applkant for such permit to file a signed statementthat he or she purarmnLL to the provisions d the Contractors Lioenaa Lew [Chapter 9 (commenting with Section TOW) d Diveion 3 d the and Prdessimrs Code] m that he or she is exempt therehomi and the basis fm the alleged exemption. Arry violation d Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than We hundred dollars [5500]}. ❑ I, as owner d the properly or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Section 7044, Business and Professions Code: The Contractors License taw does not applyto an owner of property who !wilds or improves thereon. and who does such work himself or herself or through his or her own employees. provided that such inpro✓emants we not intended or offered fm sale. If, however, the building or ioprovemerd is sold within one year of completion, the ownerrbudder will have the burden of proving he or she did not build or improve fm the purpose of sale). ❑ I, as owner of the Property, am exdusivety contracting with licensed Contractors to Construct the pro ad (Section 7044. Business and Professions Code: The Contractors License Lew, does not appy to an owner of property who builds or improves thereon and who contracts for such projects with a contrador(s) licensed pursuant to the Contractors License Law]. ❑ I am exempt under Section: B. d P.C., for this reason: Date: Owner: I do hereby certify that 1 am aware of and understand the requirements of California Health and Safety Cade Sections 25505, 25533, end 2553x, and that I or any future building oocuponl will ! will not (circle one) need to compy with said state codes and the requirements for a permit for construction or modification from the Ai Quahly 9enagement District. Residential construction applications are exempt from these provisions. Date: Applicant: ER'S COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following dedaraticins: I have and will maintain a certificate d consent to sell -insure for workero' compensation, as provided for by Section 3700 of the Labor Coda, for the performance of the work for which this permit is issued. ❑ I have and will maintain wakens' compensation insurance. as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. My worker' compensation insurance carrier and Pdiq number are: Carrier: GOLDEN EAGLE EXPIRES Policy Number. MW 10') 0 _ _ 04/01/96 (This section need not be completed d the pwmk is nor once hundred dol" [51001 or leas.) I certify that in the pedormance d the work for which this pem+il is issued. 1 shag nal employ arrY pereon i en)r manner so as to became subject to the workers' compensation laws d California, and agree drat d I should become 'ed to the workers' ] compensa ion provisions d Sadiron 3703 11111, 1 stud orthwGh Campy with thus roJsioro. ate: Appiirart:LL ami Q: Fa Nun to secure wor*ars' corrpensstlon coveraya is unlawful, and U subfsct an employer to cAninal pondNas and c 1 a rep to one hundred thousand dollars ($1'04000), In addition to Me coat of compensation, damage; as provided for In S on 3706 of the labor Code, lnfenist, and Af frW'A tees. CONSTRUCTION LENDING AGENCY: I herby drum under penalty of perjury that there is a construction lendag agency for the performance of the work fm which this perm l is issued (Section 3097, Civ, C). LENDER'S NAME: LENDER'S ADDRESS: I certify that I have read this application and state that the above information is coned. I agree to comply with all city and county ordinances and state laws relating to buildirnp construe ion and hereby authorize representatives of this city to enter upon the abawrmentimled property fm inspection purposes. WAYNE WATSON (5151-d6.WP) White-Su11ding 6 Safety: Date: 0 Pink -Revenue: Goldenrod -Assessor CITY OF COSTA MESA — BUILDING PERMIT PERM NO: B 074405 PERMIT NO: B 074405 PLAN CHECK NO: 03861--95 L GOVT: N SUPP: N CONSTRUCTION TYPE: I FR PERMIT TYPE: STR PURPOSE: ALT JOB DESCRIPTION ; ENGRAVING ROOM MINOR ALTERATION SQ FT: 8,000 CLAIM VALUE: 8,000.00 CALL—VALUE: 8,000.00 GROUP OCC: B-2 / COMMENTS: "TIFFANY & CO" ENGRAVING ROOM ALT Z O N I N G R E Q U I R E M E N T S S E T B A C K S -----' — MAIN BUILDING------------------� ACCESSORY BUILDING --------- FRNT FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN PARKING REO • PROV: PARCEL: 41250105 ZNE: CI—S REF NO: PLANNING NTES> INTERIOR ALTERATION FOR TIFFANY & CO -- NO ADDITIONAL.-� > SQUARE FOOTAGE ADDED — NEW INTERIOR WALLS ONLY ;. iE •)f iE aE• iE aE aE * # iE aE of iE # alt of of aE iE of aE � aE dE a1- of aE iE � aF � of of aE of a4 aE aE i6 ib # aE aE iF iE aE # of aE i4 if at• of ae aE ae aF of ae # of aE iE if• iE * aE ae'lE'a4 � aE aF ae a4 aE � aE aE D E V E L O P M E N T S E R V I C E S R E Q U I R E M E NV -'S jlllo ZONING APPROVED BY1_ ,� DATE: Lza BUILDING APPROVED BY : DATE: _ O APPLICATION ISSUED BY: ('.6�-� DATE: /� aE ae ae !f iE of of !{- # aF of iy: aE i?- a� ie � ae •}F � at• aE aE � aF of at ae a4 aE aE of air• ati aF aF LEGALIZATION:N F E E S U M M A R Y STRUCTURAL SEGME T:Y BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT 99.00 SMIP/NON—RES PLAN 64.35 1.68 ISSUE FEE BUILDING—DIV--> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE TOTALS ---- > 100.68 0.00 64.35 165.03 165.03 .00 REVENUE DIVISION TOTALS--> COLLECTED: 165.03 OVER/SHORT: ,00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK 99.00 1.68 64.35 ��*�•�**�*aEaEiEiEiEaEiEaEaE�*�����-��aE���������aE��+�*�*+�aE-►F-rE�*�**���**•re�aFaF***�*��aE���;����c•-�� I N D I V I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST SFC 8000 T.I. STORE BY VALUE/$1 1.00 8,000.00 END OF FEES D � SEP 0 21995 CITY OF COSTA MESA G- CONSTRUCTION AND PLANN1111G - APPROVALS Permit # _ Date Inspector POt,_ Sc SPA `` \ �� _ J APPROVi4LS Permit # Date Inspector 1�. Temporary Electrical Service or Pole 52, Pool & Equipment Location 2. Soil Pipe-Undrgrnd. 53, Steel Reinforcement 3. Electrical Conduit Utility-Undrgrjd. 54, Forms 4. Electrical Conduit-Undrgrnd. 1 55. Electrical Bonding - 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6, Electrical LIFER Grnd. 57. APPROVAL TO COVER-GUNITE 7, Footings 58. Electrical Conduit-Undrgrnd. � 8. Foundation 59. Gas Pipe, 0 Undrgrnd., Test 1 9. Water Pipe-Undrgrnd. .' 60. Backwash Lines, P•Trap, 0 Undrgrnd. 10. Structural Floor System 61. APPROVAL TO DECK 11. Property Sewer Line & House Connection 62. Backwash & Receptor -Final 12. Sewer Cap 63. Heater & Vent -Final 13. Roof Drains 64. Plumbing System • Final 14. Rough Plumbing _a 65. Electrical -Final ; 15. Rough Electrical -Conduit 66, Solar System -Final 16. Rough Electric Wiring 1 67. Fencing & Access Approval ` 17. Rough Wiring Sign 1 68, APPROVED FOR PLASTERING 18, Rough Electrical,T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit # 20. Rough Factory'Fireplace 21. Ducts, in Structure 70, Underground Hydra 22. Ducts, Ventilating 71. Product Piping 0 Gas 0 Oil 23, Gas Pipe -Rough & Test 72, Underground Flush 24. Roof Framing 73. Undergrnd. Storage Tank 0 Gas ❑ Oil 25. Roof Sheathing 74. Overhead Hydro 26. T -Bar Ceiling (Structural) & Monocoat 75. Dry Chemical 27, Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding 77. FIXED SYSTEM FINAL 29. Insulation 78. FIRE PRE;V. FINAL 30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Plaster BroWn Coat 79, FINAL INSPECTION 32. Electrical Power Meter -Final 80. FOOD CERTIFICATE ISSUED 33. Final Electric Notes. 34. Final Heating & Air Conditioning 35. Final Gas Pipe -Test 36. Hood or Canopy V - 37. Final Factory Fireplace 38. Final Plumbing 39. Water Service -Final 40. Gas Service -Final + 41, Solar Domestic -Final t 42. Backflow Preventer , 43. Backflow Irrigation 44. Landscape Irrigation System 1 45. Sound Attenuation i 46. Handicap Regulations 47. FINAL STRUCTURE & BUILDING 1 -- - - 48. FINAL PLANNING • 49. Electric Release to Edison 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY No. Date �'� l 0 91 ADDRZVyDF BUILDING: 3333 BRISTOL ST UNIT: 1509 MiNEWS NAME IF OIM: C J SEGERSTROM 3315 FAIRVIEW RD COSTA MESA, CA 92626 APPL. MAIUNG ADDRESS: ARCNITECTOft OMEER: HERMAN & BERTOLINI uc.NG:. C2674 ARCK OR M'S ADDREss: 16027 VENTURA B L UNIT, 102 ENCINO CA 91436 CGNTRACTows NAME J E D S PLUMBING (714)283-1586 CONTRACTOR'SMMUM 387 SMOKERIDGE TERRACE AODREss: ANAHEIM CA ur-ND.: 547467 92807 UNIT: LICENSED CONTRACTORS DECLARATION: I hereby affirm under penally of parimy that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Prdassirns Cods, and my license is in lull force and sffed. CITY "' ND.: 4 6 4 5 8 8 LIC. CLASS: C 3 6 LIC, NO-: 547467 EXP : 03/96 Date' 9_T Contractor. t % ��• OWNER BUILDER DECLARATION: I hereby affrm order penally of perjury 1 exampl from the Contractors License Law for the Vowing mason (Section 7031.5 Business and Professions Code: Any city a county which requires a Permit to construct, aper. improve, imolish, of tepair any structure, prior to its issuance, abo requires the applicant for such permit to file a signed statement that he or she 9 licensed pursuant to the Provisions of the Contractors License Law [Chapter 9 (commencing with Section 7000) d Division 3 of the Business and Professions Code] o that he or she is exempt therefrom and the basis for the alleged examplron: Any violation of Section 7037.5 by any applicant for a Permit subjects the applicant to a civil penahy of not more than five hundred dogan (5500])• pI, as owner of the or my employees with as their sole compensation, or offered For sale ( n 7044. Business and Professions Code: The Con'License Law does r" apply to an borrow of property who builds or improves, thereon, and who does such work himself or hersel or through he or her own employees, provided that such improvemards are not intended or offered for safe. I. however. the building or inprwerment is sold within one year of completion, the owner -builder will have the burden of proving he or she did not build or improve for the purpose of Bale)- p 1, as owner of the property, am exclusively oontrectig with licensed contractors to construct the project (Section 7644, Business and Prdassias Coda: The Contractors License Law does not appy to an owner of property who builds or impooves thereon and who contracts for such projects with a ccntredorjs) licensed pursuant to the Contractors License Lal p I am exempt under Section: B. E P.C., For this reason: t Date: Owner. I do hereby certify that 1 am aware of understand li and uerstand the requirements of California nahh arid Safety Code Sections 33 25505, 255, and 25534, and that I or any hours building occupant will l will not (circle one) need to comply with said pale codes and the requirements for a permit for oonstructionor modification fromthe AkZiw iy anagement District. Reaidehuief construction appfaatiorsare exempt from these provisions. Date: Applicant: WORKER'S COMPENSATION DECLARATION: I hereby alfrm Under penalty o1perjury one of the following dedsraliors: © I have and wig maintain a cartdicata d consent to evil -insure for workeni compensation, as provided for by Section 3700 of the Labor Code, for the pedormance of the wok for which this permit is issued. I have and will maintain workers' co npeneation insurance. as required by Section 3700 of the Labor Code, for the performanos d the worts for which this permit Is issued. My workers' compensation insurance carrier and policy number are: Carrier. _STATS' FUMT7 EXPIRES Policy Number 229` 9-5 U bI T T 1 n n G 3 01/01/96 {This aeedan need incl be mmolstd I the permit is for arra hundred ddfars (Stool or Am) 1 csrily that in the perforoxer" d the work for which this permit is issued, I shall not employ arty person in any manner so as to become subject 10 do workers' compar"lon kora of California. and agree that I I should became subject to the workers' compensation proviso" of Sadicn 3700 of the Lebo Coda, I shag I h ply with those prwislars. Daixov « Applicant: za.,_ Warning: Failure to secure wonYars' conponaaffon eoversps Is urohne , and tl ib/aet an smployar to crfrrdnal penald" and civil fines up to one hundred thousand dollars (SIOADWo In sddidon to ft cost of corrparlsatlot; damages as provided for In Section 9706 of the Labor Code, lntarsaf, and altornay'a fans. CONSTRUCTION LENDING AGENCY: t hereby of m under penahy of perjury that there is a conslnrdion lending agency for the performance of the work for which the permit is 'issued (Section 3097. Civ. C). LENDER'S NAME: LENDER'S ADDRESS: I certify that I have read this application and stale that the above information is correct. I apnea to oompty with dl city and camty ordinarro" and state laws foliating to building construction and hereby authorize representatives of this rsry to enter upon the ebove•mentioned property For inspection purposes. DAVID GRIMM Data: (5151-46.WP) Whir"uildig d Safety; Goren- File: Canary-Appficarm; Pink-Rsvenus; Gokknrod-Assesso CITY OF COSTA MESA - BUILDING PERMIT PERM NO: P 075074 PERMIT NO: P 075074 PLAN CHECK NO: N GOVT: N SUPP: N ,CONSTRUCTION TYPE: I FR PERMIT TYPE: PLU PURPOSE: ALT JOB DESCRIPTION MINOR ALTERATION SQ FT: CLAIM VALUE: CALC-VALUE: GROUP OCC: B-2 / COMMENTS: STORAGE ROOMS MINOR ALT & NEW LOUNGE "TIFFANY & CO", RE:#B74897 Z O N I N G R E Q U I R E M E N T S S E T B A C K S -------------- MAIN BUILDING ---------- --------- ACCESSORY BUILDING --------•-- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN PARKING REQ: PROV: PARCEL: 00000000 ZNE: REF NO: PLANNING NOTES> 'IE iE �E iE 3E 9E 9E �F iE iE iE dE iE iF iE � iF 7E �E ?'E �E �E �E �E iE 1E * 1E �E �E � � * �F iE �E �E iE �E 1E 3E *'lE iE iE iF �F iF �E �E �E * �E 9E iE �E iE � iF �E iE iF iE �E �E iE �F 3F iE iF iE dE 9E iE �E 9F iE it- iE D E V E L O P M E N T S E R V I C E S r R E Q U I R E M E N T S i1✓ ZONING APPROVED BY DATE: BUILDING APPROVED BY DATE: APPLICATION ISSUED BY:DATE: �� r LEGALIZATION:N F E E S U M M A R Y STRUCTURAL SEGMENT:N BLDG PMT PLUMBING ELECTRIC -MECHANIC FIRE SMIP/RES GRADING PERMIT 14.00 PLAN 25% ✓ fr f. SMTP/NON—RES ISSUE FEE 20.00 (i- r. BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK, TOTAL PAID DUE TOTALS-----> 14.00 20.00 0.00 34.00 34.00 .00 REVENUE DIVISION TOTALS--> COLLECTED: 34.00 OVER/SHORT: 00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK 34.00 iE iF'1E fE iE iE iE iE � �E iE �E � iE ori iE iE iE iE iE * iE iE iE iF iE iE * iE 1E � IE �E !(i(-'1F'iE iE i�E iE it iE iELiE iE iE iE iF iEiE iE �E iE iE iE iE �E iF iE if iE 9E iE iE iE iE -l(- iF dE iE iF tiE iE * 3f i� iE iE if - I N D I V I D U A L') F E Er B R E A K D O W N TYPE QTY D E S C R I P T T 0�,-N1 UNIT COST TOTAL COST PLU 1 DISHWASHER '/nh 7.00 7.00 PLU 1 SINK, KITCHEN 7.00 7.00 END OF";FEES if E'rV = �ONSTftUCTION AND PLANNING 7 APPROVALS Permit # Date Inspector PQ dr SPA APPROVALS Permit # Date Inspector `', Temporary Electrical Service or Pole 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd. 53, Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. 54. Forms i = 4. Electrical Conduit-.t_Inlrgrnd. 6 55. Electrical Bonding ' r 5.. Steel Reinforcement. 56. Rough Plumbing & Pressure Test 6.' Electrical UFER'Grnd. 57, APPROVAL TO COVER•GUNITE T. Footings 58. Electrical Conduit-Undrgrnd. Foundation_ - 59. Gas Pipe, 0 Unk;lrgrnd., Test 9. Water Pipe-Undrgrnd. `. 60. Backwash Lines, P•Trap, © Undrgrnd. 10. Structural Floor System 61. APPROVAL TO DECK 11. Property Sewer Line & House Conrlection 62. Backwash & Receptor -Final ' 12. -Sewer Cap - 63. Heater & Vent -Final 13, Roof Drains 64. Plumbing System - Final 14. Rough Plumbi6(y 15, Rough Electricat-Conduit //� 65, Electrical -Final 66. Solar System -final 16, Rough Electric Wiring 67. Fencing & Access Approval 17, Rough Wiring Sign 6B. APPROVEDFdR'PLASTERING 18. Rough Electrical•T Bar Ceiling 69, POO LISPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning _. FIRE DEPT. REQUIRFEMEN,T , APPROVALS- • ' Pe,'mit # 20. Rough Factory fireIaca _ Y 21, Ducts, in Structure- _ 70. ,1Jnder4r6jnd Hydra ' 22. Ducts, Ventita3ing-71. Produt> Piping Cl -Gas © Oil 23. Gas Pipe -Rough & Test 72. Underground FLi3sh 24. Roof Framing - 73. Undergrnd. Storage Tank-© Gas 0 Oil 25, Roof Sheathing ' 74. Overhead Hydro. 26. T•Bar_Ceiling (Structural) & Monocoat - 75. Dry Chemical 27. Frameand Flashing 76. Dry Standpipe 28. Lathing & Siding 77, FIXED SYSTE.M:FINAL - 29. Insulation = x, 78: FIRE PREV. FIVAL 30. Drywall Nailing - .HEALTH DEPT. REQ61REMENT 31. Plaster Brown Coat - r ' 79, FINAL INSPECTION - 32, Electrical Power Meter -Final ,. ' ' 80., FOOD CERTIFICATE ISSUED _.33. Final Electric � � � I � Notes: !�l �! - jt-!_LZ�_ r• - - 34. Final Heating & Air Conditioning 35, Final Gas Pipe -Test _ 36. Hood or Canopy -. 37. Final Factory Fireplace # ,38. Final -Plumbing -39. Water"Service. Fi nal =- , -1.40. Gas Service -Final a - - 41. Solar Domes€ic•Fin-al 42. Backflow Preventer r t t 43. Backflow Irrigation t 44. Landscape Irrigation System 45. Sound Attenuation, 46, Handicap Regulations w ' 47, FINAL STRUCTURE & BUi WING '- 48. FINAL PLANNING f. 49, Electric Release to Edison _ 50. Gas Release to Southern California Gas Co 51, CERTIFICATE OF OCCUPANCY No Date W ADDRUS of BULDING: 3333 BRISTOL ST UMT: 1509 OWNERSNOEIF*MN; C J SEGERSTROM IDDRESS: 3315 FAIRVIEW RD COSTA MESA, CA 92626 APPL. htAIUNO ADDRESS: ARCHRECTOREAGNEER: GERMAN & BERTOLINI ul-"O.: C2674 ARCH. Olt EWS ADDRESS: 16027 VENTURA BL UNIT.. 102 ENCINO CA 91436 COMRACTORsNmmz SMALLCOMB WIRING INCORPOR (714)556-8591 CONTRACTORSMA)LING 136 E GARRY ADDRESS: n;SMTTA/\AA4,A c'M LIC. NO.: 1114)9"5,(11 92707 uw. U LICENSED CONTRACTORS DECLARATION: I hereby affirm under penaly of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000[ of Division 3 d the Business and Professions Code, and my ncense is in fun force and effect. Cmc LIC. No.: 011005 LIC, CUSS: C 10 uc• NO. 14 5 9 1 EXP: 08/96 Date: 11 Contractor f,( U) n . �. nWNER BUILDER DECLARATION: I hereby affirm under penally of perjury that I am exempt from the Contractors License Law for the bwing reason ($action 7031.5 Business and Professions Code: Any city or county which requires a parmh to conalntct, after, improve, nolish, or repair any stnxxuro, prior to is issuance, also requires the applicant (or such permit to file a signed statement that he or she licensed pursuant to the provisions of the Contractors License Law [Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Core) or thea he or she is exempt therefrom and the basis for the a5aged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a dA penalty of not more than five hundred dollars [S5001)' , . ❑ I, as owner of the properly or my employees with wages as (heir 0010 Compensation, win do the work. and the structure is nor intended or offered for sale ($action 7044, Business and Professions Code: The Cordraaora Lioense Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or trough his or her own empicyaes, provided that such improvements we not intended or offered for sale, n, however. the building or improvement is sold within one yew of oomplation, the owner -builder win have the burden al proving he or she did nal budd or improve for the purpose of sale). 0 I, as owner of the property. am exclusively contracting with licensed contractors to oanstruol the projed (Section 7044. Bisiness and Professions Codw The Contractors License Law does not apply to an owner of property who builds or improves thereon and who contracts for such projects with a contractor(s) licensed pumuart to the Contradore License Law). ' ry I am exempt under Section: B. A P.C., for this reason- f Dale: Owner. I do hereby certity That I am aware of and understand the requirements of California Flealth and Safety Code Sections 25505, 25533, and 23534, and that I or any tenure building comment will f will not (circle one) need to comply with said state codes and the requirements for e permit for owhstnretion or modification from the AOMMyVanitgwriem District. Residential eonsuudion applications are examp0n:im these provisions. Date: Applicant: WORKER'S COMPENSATION DECLARATION: I hereby 4" under penalty of perjury one of the following dedaraliono: ❑ 1 have and will maintain a canificale of consent to sendnsurs for worker' compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this paint is issued. I have and will maintain workers' mmpemwion insurance, as required by Section 3700 of the Labor Code, Ior the performance of the work for which this permit is issued. My workers' compensation insurance carrier arc poky number are: Carrier: CA CASUALTY EXPIRES Policy Number. W r A 4 n n n l l i n 10/01/96 (TMs section need nor be complered if the permir a for ane hundred dodws ($f 00) or ups.) I coney that in the performance of the work for which this permit is issued, I" not empby any person in any manner so m to become subject to the workers' compensation laws of California, and agree that 9 I should become wbisa to the workers' compeneafion provision( of Section 3700 of the Labor Code. I sh7rhwhh py wQkh tFhcae pmixnorhs. Dale: ' f `— 7 s Applicant: •if1f1 Warning: Fatfure to secure woAnrs' compensetlon coverage Is unletvRrl, and shall subject an employer to criminal penalties and civil Muria ep to one hundred Thousand dollars (SIMOOOJ, In addltlon to Me cost of cornperwtbr; dann"is of provided for In Section 5706 of the Labor Cods; fntereal, and attomay's fees. CONSTRUCTION LENDING AGENCY: 1 hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work for which this permit is issued (Sedion 3097. Civ. C), LENDER'S NAME: LENDER'S ADDRESS: I certify that I have read this application and state Ihat the above Information is coned. I agree to comply with an city and county ordinances and state laws relating to building construction and hereby authorize representatives of this cry to enter upon the above-mentioned property for inspection purposes. KEVIN SCHELIN Print Name Dab: gnat re C err/AgenYAppioaw/Contrador (515146.WP) Whi s"uildhg d Safely; Oreari­Rle: Canary-Appicanl: Pink-Revanue: Goldenrod-, somor CITY OF COSTA MESA - BUILDING PERMIT PERMIT NO: E 075094 PLAN CHECK NO: N CONSTRUCTION TYPE: I FR PERMIT TYPE: ELE JOB DESCRIPTION : MINOR ALTERATION CLAIM VALUE: CALC-VALUE : PtIPERM NO: E 075094 GOVT: N SUPP: N PURPOSE: ALT SQ FT: GROUP OCC: B-2 / COMMENTS: STORAGE ROOMS MINOR ALT & NEW LOUNGE "TIFFANY & CO", RE:#B74897 x�t:���e�����a�����;��i►:�a���s���������s�s�;��+e+E�e��e�s�����������e����;-ne����������►�c�tN��**�-►E�* Z O N I N G R E Q U I R E M E N T S S E T B A C K S ------------ MAIN BUILDING ---------- ---------- ACCESSORY BUILDING--------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN PARKING REQ: PROV: PARCEL: 00000000 ZNE: REF NO: PLANNING NOTES> > iF �E 9F �E iE iE iE iE iE iE iE 3E iE 1E IE iE iE iE iE iE � iE �E iE TE � iE i6 9E iF * iF iE �E ,hE �E � lE �E dE 1E �E iE �E jE �E iE �E �E iE �F iE �E iE iE IE �E �E iE iE iE $E * �E iE iE iE dE � 9E IE �E � lE � iE iE iE �E D E V E L O P M E N T S E R V I C E S R E Q U I R E M E N T S ZONING APPROVED BY - DATE: BUILDING APPROVED BY : DATE: (� APPLICATION ISSUED BY: DATE: iE 1E )E dE iF if iE iE iF iE iE iE ♦E * 3E iE jE• iE � iE iE iF iE iE dF �E �E')E')E'IE iE -TF iE IE LEGALIZATION:N F E E,! S U M M A R Y STRUCTURAL SEGMENT:N BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT 6.00 50R SMTP/NON-RES PLAN ISSUE FEE 15.00 BUILDING -DIV-> PERMIT ISSUE PLAN -CHECK TOTAL PAID DUE TOTALS-----> 6.00 15.00 0.00 21.00 21.00 .00 REVENUE DIVISION TOTALS--> COLLECTED: 21,00 OVER/SHORT: .00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN -CHECK 21.00 Il- �h �E �E � � -1E ib � * fE iF * �E i?F �F iF � jE'f iE iE iF �l- �E i(- �E iE �E �E iE dE �E !E iE �F * iE'!E iE iE iE iE ill• iE iE iE � !E iF !E• iE iE iE � ->F iF iE aE iE * * iE iE � iE * iF iE iE iE � +t -IF dE iE it iE iE I N D I V I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST ELE 1 FIXTURES LIGHTING 1 ST 20 EA. ELE 6 RECEPT/06TLET 1 ST 20 EA. ELE 1 RECEPT/SWITCH 1 ST 20 EA. END OF FEES 01 00j 94079-G51?4079 TOT . f . Go DATE! 111031515 TTM; 14:31 75 .75 75 4.50 .75 .75 01 00j 94079-G51?4079 TOT . f . Go DATE! 111031515 TTM; 14:31 CONSTRUCTION AND PLANNING i- APPROVALS Permit # Date Inspector . PC L SPA APPROVALS Permit # Date Inspector Temporary Electrical Service or Pole 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. 54. Forms 4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding 5. Steel Reinforcement 56, Rough Plumbing & Pressure Test 6. Electrical UPER Grnd. 57. APPROVAL TO COVER-GUNITE 7. Footings 58. Electrical Condult•Undrgrnd. a.•Foundation. 59. Gas Pipe, 0 Undrgrnd., Test 9: Water Pipe-Undrgrnd, 60. Backwash Lines, P -Trap, C3 Undrgrnd. 10. Structural Floor System 61. APPROVAL TO -DECK 11. Property Sewer Line & douse Connection 62. Backwash & Receptor -Final ' 12. Sewer Cap i 63, Heater & Vent -Final 13. Roof Drains 64. Plumbing System - Final 14. Rough Plumbing - 65. Electrical -Final -� 15. Rough Electrical -Conduit 6. Solar System -Final ' 16. Rough Electric Wiring _ ff�� 67, Fencing & Access Approval 17. Rough Wiring Sign 68• APPROVED FOR PLASTERING 18. Rough Electrical -T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVAL -S_ Permit # _ 20. Rough Factory Fireplace 21, Ducts,,in Structure - r 70. _lndergroynd Hydro 22. Ducts, Ventilatingr 71. Prod u ct Pi pi ng C1 Gas Oil 23. Gas Pipe -Rough & Test i ' 72. Underground FlUsh 24, Roof Framing - : 73.E Undergrnd. Storage. Tankt0 Gas 0 Oil 25. Roof Sheathing 74:` Overhead Hydro 26. T -Bar Ceiling (Structural) & Monocoat 75. Dry Chemical • 27. Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding < 77., FIXED SYSTEM FINAL 29. Insulation 79. FIRE PREV. FINAL 30. Drywall Nailing _ HEALTH DEPT. 0EQUIREMENT 31, Plaster Brown Coat '79. FINAL INSPECTION 32. Electrical Power Meter -Final T FOOD CERTIFICATE ISSUED 33, Final Electric tes: - 34. Final Heating & Air, Conditioning " 35. Final Gas Pipe -Test '36. Hood or Canopy J 37. Final Factory Fireplace - r 38. Final Plumbing -- - 39. Water Service -Final_ t - 40. Gas Service -Final 41. Solar Domestic -Final, r - 42. Backflow Preventer - f 43. Backflow Irrigation c - 44. Landscape Irrigation System ` 45. Sound Attenuation ' .. �• 46. handicap Regulations ,r . - 47, FINAL STRUCTURE & BUILDING - 48. FINAL PLANNING ' 49. Electric Release to Edison 50. Gas Release to Southern California Gas Co _ 51. CERTIFICATE OF OCCUPANCY No. _ Date ADDRESS OF BUILDING: 3333 BRISTOL ST LINT: 1509 WNER'SNAMEiFh Vft C J SEGERSTROM IDDREss: 3 315 FAIRVIEW RD COSTA MESA, CA 92626 ADPL. NAILING ADDRESS ARCNrmuORENftr m: BERMAN & BERTOLINI Lic.No,, C2674 ARCH. OR ENG.'S ADDRESS: 16027 VENTURA BL UNIT: 102 ENCINO CA 91436 OowmAcrowslfw WATSON CONSTRUCTION (714)662-7933 CONTRACTOR'SMALIUNO 1260 LOGAN AV I,Dwm: COSTA MESA92626 CA moo, 5465381 UNIT: LICENSED CONTRACTORS DECLARATION: I hereby affirm Wrier penalty of perjury that I am licensed under provisions of Chapter 0 (commencing. with Section 7000) of Division 3 of the Business and Professions Code, and my license is in to force and efled. 0.:047413 Lic.CLASS: B LIC. o.: 546538 P: 03/96 7.11.0�R �1 S Contractor: 1 9DECLARATION: I hereby affirm under penalty of perjury that 1 exempt from IM Contractors License Law for the ason (Section 70315 Buswesa end Prdessiws Code: Arty city « county which requires a pemtd to wnstnuct. aper. imprnro. emoiish, or repair arty structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant 10 the provisiorls of the Conlradom License Law (Chaptar 9 (commencirg with Section 7000) of Division 3 of the Business and Piolessions Code] or that he or she a exempt thereham and the basis for the epeged exemption. Any violn_tion of Section 7037,5 by any applicant for a permit subjects the applicant to a civil penalty of not more then five hundred dollen [5500D. - ❑ 1. sa owner of the property of my employees with wages as thew sole compensation, will do the work, and this structure is nor intended or offered for sale (Section 70". Business and Professions Code: The Contradon License Law does not apply to an owner of property who builds or enproves thereon. and who does such work himself or herself or through his or her Own employees. provided tlel such improvements are not intended or offered for soh. ff. however. the building or improvement is sold within one yew of completion. the owner -builder will have the burden of proving he or she did not build or improve for the purpose of salt). ❑ i, as owner of the picperty. am exdusivety contracting with licensed contractors to construct the Project (Section 7044. Business end Professions Cade: The Contractors License Law does not appy to an owner of property who builds or improves thereon and who contracts for such projects with a cordrsctorja) licensed pursuant to the Contractors License Lew). ❑ I am exempt under Section: S. A P.C., for this mason: Doh: Owner: I do hereby candy that I am aware of and understand the requirements at Cauomie Flub and Safety Code Sections 25505, 25533, and 25534, and der I or any future building ooduparrl will I will not (circle ore) reed to comply with said state oodes and the requirements for a perntw f« construction «modficwion from the Aw ry enagerters Distdd. Aesidert constnsiion appticatiom ova exampr from tFrese provisions. Date: Applicant: WORKER'S COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of go following dacfamfiors: ❑ I have and will maintain a certificate of corvem to sslfaim un for workers' compemelion. as provided Ion by Section 3700 of the Labor Code, for the pedom ante of the wok for which this parmh is issued. I neve and will maintain worker' oompersation insurance, as required by Section 3710 of the Labor Code, for the performance of the oak for which this permit is issued. My workers' rr�ln�lrlwrtWP4 c�ppr policy number are: EXPIRES Carrier. �J i t.iil7la Policy Number. NWIL302038 04/01/96 (This section need Tor be completed d the pwmi es Ar one hundred dollars 1$1001 w leas.) ❑ 1 certify that in the perforrn a of the work 1ff which this permit is issued. I shag. not employ any arty manner so as to Become subjed to the workers' compensation laws d Cardomia, and agree that f I should bec0rn t7jed to the workrs' mpansalion provisions of Sediun 37110 of the Labor Code, I fenhvwhh comply with i �navision Date: t l Appticem: W Ing: FrNure to sacvm workers' cormpersation covaraye is unlawful, a hall subject an smialoyer to crfmind panardaa and t RrxsJ up to ore hundred thousand dollars ($10Q 000), In addition to the1ciat of con msatlort darraip" as prorldod for In Section 3706 of the Labor Cods, Intsmst and attorney's fees. CONSTRUCTION LENDING AGENCY: I hereby affirm under penalty of perjury that them is a construction lending agency for the performance of the work for which the permit is issued (Section 3097, Civ. C). LENDER'S NAME: LENDER'S ADDRESS: I certify that I have mad this application and starts that the above information is correct. I agree to compy with all city and county ordinances and state laws mWng io building construction and hereby authorize representia"s. of this dry to enter upon the above-mentioned property for m7spedon purposes. WAYNE WATSON Print Name �ix (A l._�7fP� _ Data: {5151 -".WP) White -Building S Safety; Grear­Fie; Canary-ApprrcanL Pink -Revenue: Goldenrod -Assessor CITY OF COSTA MESA — BUILDING PERMIT PERMIT NO: E 075004 PLAN CHECK NO: N CONSTRUCTION TYPE: I FR PERMIT TYPE: ELE JOB DESCRIPTION : MINOR ALTERATION CLAIM VALUE: CALC --VALUE : PERM NO: E 075004 GOVT: N SUPP: N PURPOSE: ALT SQ FT: GROUP OCC: B-2 / COMMENTS: REF: B-74897 Z O N I N G R E Q U I R E M E N T S S E T B A C K S ------------ MAIN BUILDING ---------- --------- ACCESSORY BUILDING--------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN PARKING RE8: PROV: PARCEL: 00000000 ZNE: REF NO: PLANNING N TES> iF'IE iE iE iE •1E iE i4• >f � � iE iE iF iE iE iF iE iE iE iE iE �E iE iF iE •1E •IE iE i(- iE'lE �E iE iF iE iE 1E iE � iF iE N• * iF !E ME iE iE IElE �E iE')E'1(•'lt•'1E IE �E iF•'lE IE• �'lE iE )E• �E iE iE 9E dE �E iE iE iE ♦F * iE D E V E L O P M E N T S E R V I C E S R E Q U I R E M E N T S 'r ZONING APPROVED BY DATE: BUILDING APPROVED BY : DATE: [3 APPLICATION ISSUED BY: DATE: 17 )E �E iE if iE iE iE iF iF �F � � i(• 1E iE• 1E'1E iE iE � �E �E iE * iF * iE iF iE dF 1E iE � LEGALIZATION:N F E'E' S U M M A R Y STRUCTURAL S GM£ T:N BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT 4.50 50% SMIP/NON—RES PLAN ISSUE FEE 15.00 BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE TOTALS ---- > 4.50 15.00 0,00 19.50 19.50 .00 REVENUE DIVISION TOTALS--> COLLECTED: 19.50 OVER/SHORT: .00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK 19.50 * ltE• i6 iF iF � * iE � iF iF �E �E �E iE �(• �(- IE if• iF iE # iF � •lE iE �E �)E iE- iE iE iF iF �E'lE if iE iE iE iE !E �E iE iE iE iE iE iE iE iE-jF �F iF jE i4 iE •lE •1F iE iE * it• �E i(� iF � iP �E'lE �E �E IE iE iE !E �E• !E �E dE I N D I V I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST ELE 5 RECEPT/OUTLET 1 ST 20 EA. .75 3.75 ELE 1 RECEPT/SWITCH 1 ST 20 EA. .75 .75 END OF FEES 01 09193638-06193638 T 07J T DATE. il/32i91 TIC'rE: 14:43 ' CONSTRUCTiON-AND PLANNING APPROVALS Permit # Date Inspector PG SPA APPROVALS Y Permit # Date Inspector #. TemporarY Electrical Service or Pale 52. Pool & Equipment Location - . , 2. Soil Pipe•Undrgrnd. 53. Steel Reinforcement _ 1 3. Electrical 60 64-Uiility•Undrgrnd. Y 54, Forms �.4: •Pectrical-Cor dku t'-Ui drgrnd. 55. Electrical Bonding -•,5: Meet Reinfprdement 56, Rough Plumbing & Pressure Test { rElectricatUFE119nd. 57. APPROVAL TO COVER-GUNITE ` 7,gootings; i' 58. Electrical ConduiL-Undrgrnd. 8. Founclation _ 59. Gas Pipe, ❑ UnaFgrnd., Test 9. '*ater Pipe-Undrgrnd. - 60. Backwash Lines; P•Trap, 0 Ondrgrnd. 10. -Structural Floor-tystem _ 61. APPROVAL TO DECK 11. Property Sewer Line & House Connection 62. Backwash &,Receptor -Final 12. Sewer Cap 63. Heater & Vent -Final 13. Roof Drains _ 64, Plumbing System • Final } 14, Rough Plurnbfng 65. Electrical -Final } 15. Rough EI®ctricaI-Conduit 16. Rough Ej�ctriclViring•-. %. 1/ql `c Solar Systern-Final 7, Fencing & Access Approval 17. Rough Wiring Sign - _ 68. APPROVED FO..R PLASTERING 18, Rough Electrical -T Bar Cei€ing '69. POOL/SPA SYSTEMS FINAL 19, Rough Heating & Air Conditioning- ., � X FIRE,DEPT_AEQUIREMENT APPROVALS- P�f.mit # ' 20. Rough F.actorq Fireplace l�ti ` 21. Ducts, in Str0ture `" 70.'-Underg-round hydro 22. Duct, Vifitilatin9; * _ - 71. Product, -Piping CI bas © Oil 23. Gas Pipe ough &Test _ 72. Undergro'Und Flush 24. rRoof Framing' _ a 73. Undergrnd. Stara" Tank- ❑ Gas O^Oil 25, Roaf•Sheathing R" VW " - 74. Overhead Hydro , 26. -8aF Ceiling (Structural) & Monocoat'• .- 75. Dry Chemical ' 27.�*ramp arO Flashirj m 76. Dry Star�dpiper = " _7 28, Lathing & Siding `•' _ .. 77: FIXED SYSTEM- FINAL. r ' 29. Insulation I 78: FIRE PREV. FINAL k = - 30. Drywall'Nailing ., #: _IEALTHDEPT. REQUIREMENT 31. Plaster BcnwcrCoat 79. FINAL INSPECTION -' 32.,FlectricatPow.er Meier•F.inal 33. Finai=Electrig- - /i 8Ct. FOOD CERTIFICATE I��uED, Notes: 34. Final Heating & Air Conaitioning" " _ 35.,F,inal Gas Pipe:Test ' 36. Hond or Canopy _ :L .-t c.: ; 37. Final Factory Fireplace 38. Fina«Plumbing 39, Water Service -Final - - 40. Gas Service -Final 41. Solar Doniestic•Fina - T, f. ,. - •- G • d' * _. _ 42. Backflow Preventer 3. Backflow Irrigation 44, Landscape Irrigation System - '- 45. Sound Attenuation' � ' -•� :. �' � � � K 46. Handicap • Regulations r - 47. FINAL STRUCTURE & BUILDING 48. FINAL PLANNING - -49. Electric Release to Edison 50. Gas Release to Southern California Gas Co 51, CERTIFICATE OF OCCUPANCY No. Date ADDRESS OF BUILD11a' 3333 BRISTOL ST OWNER'SNANEIFKNOWN: C J SEGERSTROM ADORES& 3 315 F I ARV I EW RD C.M., CA 92626 ADPL. MAILING ADDRESS: ARCHITECTORENGINEER: BERMAN & BERTOLINI ARCH, OR ENG.•S ADORESS: 16250 VENTURA B L UNIT: 1509 1tm= C2674 DM: 316 ENCINO CA 91436 CONTRACT01rsNAME: SMALL COMB WIRING INCORPOR (714)556-8591 COIN RACTOR'S MAILING 136 E GARRY ADDRESS: SANTA ANA CA Lr—ND.: 145961 92707 UNIT. U LICENSED CONTRACTORS DECLARATION: I hereby affirm under penalty of per]ury that I am licensed tinder provisions of Chapter 9 f00mmencing with Section 70001 of DW on 3 of the Business and Professions Code, and my license is in full fora and effect. CITY LIC. NO.: 01/ 10 �0} 5 UC. Of ASS: C 10 LIC, NO.: 14 5 9 61 / /E,X� EXP: 08/96 Dat.: 1 2 -- �D �T Convect.- W i�r Lo_ OWNER BUILDER DECLARATION: I hereby affirm under penally of perjury that I em exempt from the Comrectors Liosnas Law for the ' Alowi g reason fSedion 7631.5 Business and Professions Code: Any city or county which requires a permit to oonsbum, after. Improve, rmolish, or repair any structure, prior to its issuance, also requiree the appricam for such pennd to file a signed stefemthat enl he or she a Ikernsed pursuant to the prv+iaione of the Contractors License Law ]Chaplet B (commencing with Section ?ODD) of Division 3 of the Business and Professions Code] or that he or she is exempt therefrom and the basis for the alleged exemption. Arry violation of Section 7631.5 by any applicant for a permit subjects the applicant to a rival penally of not more than five hundred ddlare {5500]]. p 1. as owner of the property or my employees with wages as their soh oomperraafion, w@I do the work. and IM stricture is not intended or offered for sold (Section 7044, Business and Professions Code; The Contractors License Law does not apply to an owner of property who builds or improves thereon. and who does such work himself or herself or through his or her own employees, provided that such improvements aro not irdended or offered for tab, 0. however. the building or improvernant is sold within one year of completion. the owner -builder will have the burden of proving he or she did not build or improve for the purpose d sale). ❑I. as owner of the property, am exclusively contracting with licensed contractors to construct the sg pnOjed (Section 7044 Business and Prolaskm Code: The Conlradors License Law does not appy to an owner of property who bus7ds or improves thereon and who contracts for such Projects with a oontrscta(s) licensed pursuant to the Contractors License Law). p I am exempt under Section: B. E P.C.. for this reason: ti Dale: Owner: ' I do hereby cediy that I am aware of and understand the requirements of California Health and Safety Code Sediom 25505.25533, are 25534, and that I or any knure building ocapem will / will rot (circle one) need to comply with said dale cedes and the requirements for a permd for construction or mods[ dm from the Ai Bair n anagament Dim nct. Residential o xmdnici on sppiuuions are exempt from these provisions. Date: Applicant: WORKER'S COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following derlaralio= p 1 have and w7 mairian a certificate of mnrserr to self-iroure for workers' oompemdian, as provided for by Section 3706 of the Labor Code, for the performance of the work for wtkb this permit is issued. QI have and wii momism workers* compensation insurance. as required by Section 3706 of the labor Coda, for the performance of the n work for which this pemrB is issued. My workers' compensation inarrance auger and poky number are: Carrier: CA CASUALTY EXPIRES Policy Number. WC, f, 4 ( ] 1)() l 1 l L) 1 10/01/96 (This socron reed nor he rnnpleted Y the perm r is lar one hundred dodam [$1001 or Iess.1 p I mrtdy mer in the perfomnarwca of the wok for which This pemh is issued, I eW rot employ any person in arty mama .o as io became subjed to the waken' cornpersaten taws of Cakforua, and agree that it 10xvA became subject to the wodkars' peruation poy. icons of Section 3700 of the Lobar Code. I shall�fo�rthwiitth comm* with ftes pf/rlo�vi�a-i0frs. Date: �12 r�zgC Apd�: y�cr,j .4 W w A A. Warning: FaMure to swum workers' eompenaadon eovetepe Is unlaa7ut, acrd shall subject an employer to AL penaltla and civil Ansa ups to acre hundred thousand dollars (5109000), M addldon to the cost of compensations damaysa as provded for In Section 3706 of the Labor Codi Inteml, end stromay's faea CONSTRUCTION LENDING AGENCY: I hereby affirm under penalty of perjury shat there is a construdion larx ig agenic for the performance of the work for which this permit is issued (Section 3097, Civ. C), LENDER'S NAME LENDER'S ADDRESS: I tardy that 1 have read this application and state that the above information is cared. I some to compy, with aft city and county ordinenoes and stale Tawe relating to building construction and hereby authorize representatives of this city to enter upon the sbovwrnerai red Property for inspection purposes. K J I N S CH EL I N @JLP�mN7 J., / Date /w -6-gr rs dF 0ww1AgenVApp5canVCodrador (5151.46.WP) White -Building & Safety; Green -File; Canary-Apgirara; Pink-ieverue: Goldsn"x:i� CITY OF COSTA MESA — BUILDING PERMIT ✓ PERM NO: E 074470 PERMIT NO: E 074470 PLAN CHECK NO: N GOVT: N SUPP: N CONSTRUCTION TYPE: I FR PERMIT TYPE: ELE JOB DESCRIPTION : ENGRAVING ROOM MINOR ALTERATION CLAIM VALUE: CALL—VALUE: PURPOSE: ALT SQ FT: GROUP OCC: B-2 / COMMENTS: "TIFFANY & CO" ENGRAVING ROOM ALT, RE:#874405 Z 0 N I N G R E Q U I R E M E N T S S E T B A C K S ------------- MAIN BUILDING '-------------------- ACCESSORY BUILDING-------_— FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN PARKING REQ: PROV: PARCEL: 41250105 ZNE: REF NO: PLANNING NOTES> > �E 3E # iE iF iE iE �E �E � if iF iE iF iE iE iF #F iF iE ie ffr iF � � iE iE iE 9F'1E � #E ;'E ib -Ik 3(- iE 3F �E �F iF iE !f- iE �E iE 3E iE -1F if iE � � iE iE � iE 3E iE• � * iE dE iE iE iE ?'E �E iE }E iE iE iE iE iE iF �E �f"IE D E V E L O P M E N T S E..,R V I C E S R E Q U I R E M E N T S ZONING APPROVED BY DATE: BUILDING APPROVED BY : DATE: APPLICATION ISSUED BY: — DATE: W LEGALIZATION:N F E E S U M M A R Y STRUCTURAL SEGMENT:N BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT 7.50 50t SMIP/NON—RES PLAN ISSUE FEE 15.00 BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE TOTALS ---- > 7.50 3.5.00 0.00 22.50 22.50 .00 REVENUE DIVISION TOTALS--> COLLECTED: 22.50 OVER/SHORT: .00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK 22.50 -lE iE � if iF 3E iE �E IF �F iE iE iE; �E # # iE iE 3E iE bF irF iF ie iE iF iE iE iE 3E iE �E �E IE �F iE if k: 3E ;'F dE iE iE �E iE iE iF iE i[• iF � iE � iE iF iE if iE iF iE �F � iE it: -)E iE �E iF iE iE iF iF iE r ->h � * iE iE I N D I V I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST ELE 3 FIXTURES, LIGHTING 1 ST 20 EA. ELE 5 RECEPT/OUTLET 1 ST 20 EA. ELE 2 RECEPT/SWITCH 1 ST 20 EA. END OF FEES .75 2.25 .75 1.50 01 00191601`0191609 T IDT '12.30 DATE: 10/135/'iS TIT: 14:56 tom, CONSTRUCTION AND PLANNING 21 APPROVALS Permit # Date Inspector POS SPA APPROVALS Permit 4#- Date Inspector 1. Temporary Electrical Service or Pole 52, Pool & Equipment Location 2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. 54. Forms 4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding ' 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6. Electrical UFER Grnd, 57. APPROVAL TO COVER-GUNITE 7. Footings 58. Electrical Conduit-Undrgrnd. 8. Foundation 59. Gas Pipe, © Undrgrnd., Test 9. Water Pipe-Undrgrnd, 60. Backwash Lines, P -Trap, © Undrgrnd. 10. Structural Floor System 61. APPROVAL TO DECK s 11. Property Sewer Line & House Con�ection 62. Backwash & Receptor -Final 12. Sewer Cap 63. Heater & Vent -Final ' 13. Roof Drains 64. Plumbing System - Final I 14. Rough Plumbing 65. Electrical -Final 15. Rough Electrical -Conduit Solar System -Final 16, Rough Electric Wiring 67. Fencing & Access Approval 17. Rough Wiring Sign fib. APPROVED FOR PLASTERING ' 18. Rough Electrical -T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit # 20. Rough Factory Fireplace 21, Ducts, in Structure 70. Underground Hydro 22. Ducts, Ventilating 71, Product Piping © Gas ❑ Oil 23. Gas Pipe -Rough & Test 72, Underground Flush 24, Roof Framing 73. Undergrnd. Storage Tank Il Gas ©Oil 25. Roof Sheathing 74. Overhead Hydro 26. T -Bar Ceiling (Structural) & Monocoat 75. Dry Chemical 27. Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding 77. FIXED SYSTEM FINAL 29. Insulation 78. FIRE PREY. FINAL 30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31, Plaster Brown Coat 79. FINAL INSPECTION 32, Electrical Power Meter -Final J FOOD CERTIFICATE ISSUED 33. Final Electric A901g Notes. 34. Final Heating & Air Conditioning 35. Final Gas Pipe -Test 36. Hood or Canopy 37. Final Factory Fireplace 38, Final Plumbing ' 39. Water Service -Final 40. Gas Service -Final 41. Solar Domestic -Final 42. Backflow Preventer 43. Backflow Irrigation 44. Landscape Irrigation System 45, Sound Attenuation 46, Handicap Regulations 47. FINAL STRUCTURE & BUILDING 48. FINAL PLANNING 49. Electric Release to Edison ~ .50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY No. Date VM A ADDRESS OF 9UILDINO: 3333 BRISTOL ST UNIT: 1509 oWNERSN ME IFKHM: C J SEGERSTROM ADDRESS: 3 315 F I ARV I EW RD C.M., CA 92626 ADPL. MAILING ADDRESS: ARCHITECT ORUaNEER: BERMAN & BERTOLINI uc.NO.: 02674 ARCH. OR E.Na's ADDRESS: 16250 VENTURA B L UNIT: 316 iENCINO CA 91436 CONTRACTOR'S NAME- SMALLCOMB WIRING INC (714)556-8591 CONTRACTORS MAJUNO 136 E GAR R Y AVE ADDRESS: SANTA ANA CA uc. NO.: 145961 92707 UNIT: LICENSED CONTRACTORS DECLARATION: 1 hereby affirm under penalty of perjury 11x1 I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Busirwm and Professions Code, and my license in in full force and effect. CITY LIC. NO.: 0 1 1 0 0 ]5 LIC. CLASS: C- 10 UC. NO.: 14 5 9 6. D EXP: 0'8 / 9 6 Dater "y Contractor OWNER BUILDER DECLARATION: I hereby affirm under penalty of perjury that I am exempt from the Contractors License Law for the following reason (Section 7031.5 Busirma and Professions Code: Any city or county which requires a permit to constnx:t, after, improve, 'smolish, or repair any structure, prgr to its issuance, also requires the applicant for such permit to file a signed statement that he or she , licensed pursuant to the provisions of the Contractors Litenas Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code] or that he or she is exempt therefrom and the basis tot the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty d not more than five hundred dollars (MI). -« ❑ 1, as owner of the property or my emplayeea wih wages as ihei ado compensation, will do the work, and the structure is nit intended or offered for sale (Section 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who buids or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. ff, however, the building or improvement is sold within one year of complelion, the owner -builder w411 have the burden of proving he or she did not build or improve for the purpose of sale). ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the projea (Section 7044, Busmess and Professions Code: The Contractors License Law does not appy to an owner of properly who buikls or improves thereon and who contracts for such projects with a contractors) licensed pursuant to the Convectors License Law). -11 ❑ 1 am exempt under Section: B. d P.C., for this reason: .yt n Dale: Owner: I do hereby certify, that I am aware of and understand the requirements of California Health and Safety Coda Sections 25505, 25533, and 25534, and that l or any future building ooatpant will / cif not (circle one) need to comply with said stele codes and the requirements for apenniltor construction or nwdificetion from the Air uaily�enpemant Dissrip. Residentid construction eppir�tiona aro exemptfrom these provisions. - Date: Applicant: WORKER'S COMPENSATION DECLARATION: I hereby affirm under penalty d perjury one of the following dedmelionc ❑ I have and will maintain a cenRicate d consent to seff4nsure for workers' compensation, as provided for by Section 3700 d the Labor Code, for the performance of the work for which this permit is issued. A1 have and will maintain workers' compensation irm name, as required by Section 3700 of the Labor Code. for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy number are: Carrier: C11 ('AS-TJALTY EXPIRES n!'+f)Policy Number: 4 4 J f -S 10/01/95 (This section need not be compfeted if the permit is for one hundred dollars Moo) or fen.) ❑ I certify that in the performance of the work for which this permit le Issued, 1 shall not employ any person in any manner so as to become subject to the workers' twmpensation laws d Calitnmia, and agree that 0 I Id become subject to the workers' compensationprovisions off'S$ectiron 3700 of the Lebor Code, I sh I forthwith cam with t rovisions. Date: r1 -q,^- `7 1,,,�, Applicant: Warning: FaNure Io secure worksn' compenseffon cov@PV* Is unlawful, and shall &*/set an employer to crfmfn ri penalties and civil ffnas up to arra hundred thousand dollars ($I00, 000), In sddillon to the cost of compensatlon, damages its prvvlded for In Section 3706 of the Labor Code, Interest and eftomey's fees. CONSTRUCTION LENDING AGENCY: I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work for which the permit is issued (Section 3097, Civ. C). LENDER'S NAME: LENDER'S ADDRESS: I certify that I have road this application and stats that the above information is correct. 1 agree to comply with all city and county ordinances and state laws relating to building construction and hereby authorize representatives of this city to enlar upon the above-mentioned property for inspection purposes. EV I N S C H E L I N Print Name Date: �r Signature of OwnarlAgent/ApplicanUContractor (5151.48.WP) Whito-Building 6 Safety: Green -FIs; Canary -Applicant; Pink -Revenue; Goidenrod-Assessor CITY OF COSTA MESA — BUILDING PERMIT ✓ PERM NO: E 074383 PERMIT NO: E 074383 PLAN CHECK NO: N GOVT: N SUPP: N CONSTRUCTION TYPE: I FR PERMIT TYPE: ELE JOB DESCRIPTION : ELECTRICAL FOR T.I. CLAIM VALUE: CALC—VALUE: PURPOSE: OTH SQ FT: GROUP OCC: B-2 / COMMENTS: "TIFFANY & CO" ELECTRICAL REF B-74283 Z O N I N G R E Q U I R E M E N T S S E T B A C K S ------------- MAIN BUILDING ---------- --------- ACCESSORY BUILDING ----------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN PARKING REQ: PROV: PARCEL: 41250105 ZNE: REF NO: PLANNING NOTES> �E �E iF # * )E 3E 3E iE * }E � -Yf- )F # � iE iF iE iE iE iE )E 3F �(- � iE iE iE iE iE iF iE iE dE iF iE iE iE -YE 3E iE 3E 9E iE IF * dF 1F * iF iF 3F if iE iF �E iE iE � # � }F dE iF iE iE iE iE iE iE iF .}E iE iE �E iE iE iE D E V E L O P M E N T S E.:R"V I C E S R E Q U I R E M E N T S ZONING APPROVED BY DATE: BUILDING APPROVED BY ; ,' DATE: APPLICATION ISSUED BY:— DATE: 109-93" -)E iE k -?E iE iE #E iE �E iE 3F )E iE -IF �F $E iF iF dE dE iE 3F ii 9E ifiE .��1F������E�E ��� iE iE iE iE iF iE iE 3E iF iE iF iE �h� E�3E IF iF iF Ik �E' LEGALIZATION:N F E E" S U M M A R Y STRUCTURAL SEGMENT:N BLDG PMT PLUMBING ELECTRIC +MECHANIC FIRE -SMTP/RES GRADING PERMIT 3.'0;0 ; f,,•5% .P SMTP/NON—RES PLAN ISSUE FEE 15. 69tr,, BUILDING—DIV—> PERMIT ISSUE PLAN:,CHECK TOTAL PAID DUE TOTALS ---- > 3.00 15,000:00 18.00 18.00 l en .00 REVENUE DIVISION f TOTALS--> COLLECTED: 18.00 OVER/SHORT: .00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK 18,00 r� J' if- it• }F iE If>7E iE 3E of �F iE 1F * dF dF 3E � 'IE iE 3E iF if iE * * * 9E � aE iF iE aE yE 3E"�E lf;i4= 3F iE iF i4 # �E dE iE 3E iE iE it i(" -lE }E * * iE iE iF �E iE ik � �E �E 9f 3E �E iF iF -?(- iE iE iF iE iE dE iE iF �r iE IND I V I D U A L� E E B R E A K D O W N fF TYPE QTY D E S C R I P T 1-0 N. UNIT COST TOTAL COST ELE 4 FIXTURES, LIGHTING f ST 20 EA. .75 3.00 END OF FEES i .Y ill 001.? 1135-13319113` TOT i� w Qii DATE: 0 /_27/93 TIME: 15:12 CONSTRUCTION AND PLANNING APPROVALS Permit # Date Inspector POO SPA APPROVALS Permit # Date I;nspef tar 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd. _ 53. Steel Reinforcement , 3. Electrical Conduit Utility-Undrgrnd. 54. Forms - 4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding 5. Steel Reinforcerhent 56. Rough Plumbing & Pressure Test 6. Electrical LIFER Grnd. 57. APPROVAL TO COVER-GUNITE 7. Footings 58. Electrical Conduit-Undrgrnd. 8. Foundation 59. Gas Pipe, © Undrgrnd., Test 9. Water Pipe-Undrgrnd. v 60. Backwash Lines, P -Trap, O Undrgrnd. 10. Structural Floor System 61. APPROVAL TO DECK 11. Property Sewer Line & House Connection 62. Backwash & Receptor -Final 12. Sewer Cap 63. Heater & Vent -Final 13. Roof Drains 64. Plumbing System - Final 3 14. Rough Plumbing 65. Electrical - Final 15. Rough Electrical -Conduit 1 66. Solar System -Final 16. Rough Electric Wiring �,/ car 7. Fencing & Access Approval 68. APPROVED FOR PLASTERING 17. Rough Wiring Sign 18. Rough Electrical -T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit # 20. Rough Factory Fireplace 21. Ducts, in Structure 70. Underground Hydro 22, Ducts, Ventilating 71, Product Piping 0 Gas ❑ Oil 23. Gas Pipe -Rough & Test 72. Underground Flush 24. Roof Framing 73. Undergrnd. Storage Tank © Gas © Oil 25. Roof Sheathing 74. Overhead Hydro 26. T -Bar Ceiling (Structural) & Monocoat 75. Dry Chemical 27. Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding 77. FIXED SYSTEM FINAL 29. Insulation 78. FIRE PREY. FINAL 30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat 79 INAL INSPECTION 32. Electrical Power Meter -Final 8 . FOOD CERTIFICATE ISSUED 33. Final Electric 34. Final Heating & Air Conditioning otes: 35. Final Gas Pipe -Test 36. Hood or Canopy 37. Final Factory Fireplace 38, Final Plumbing 39. Water Service -Final 40. Gas Service -Final ; 41, Solar Domestic -Final 42. Backflow Preventer 43. Backflow Irrigation 44. Landscape Irrigation System 45, Sound Attenuation 46. Handicap Regulations 47. FINAL STRUCTURE & BUILDING C 1 48. FINAL PLANNING 49. Electric Release to Edison 50. Gas Release to Southern California Gas Co 7 51. CERTIFICATE OF OCCUPANCY No. Date r PI;x OWNER'S 'S NAME! 333 3 BRISTOL S T OWNER'S NAME: C J SEGERSTROM ADDREss: 3 315 F I ARV I EW RD f C.M., CA 92676 UNIT: 1509 ARCHlEN EER: B ERMAN & BER TOL I N I REG.NO.:C ADORDREss: 16250 VENTURA BL UNIT, 316 PERMITTEE: ENC I NO CA 91436 ADDRESS: kii C (714)540-5330 jj��,, T "�%,'yt LICENSED CONTRACA ECLARA7I130� he affirm t�h�att I am licensed under provisions of haptel I �'6fninencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. CITY LIC.: STATE LIC.: CLASS: Date: Signature: WORKERS' COMPENSATION DECLARATIDW I hereby affirm that I have a certificate of consent to self -insure or a wilicate of Workers' Compensation Insr�ance. or a certif�copy �e�=Section 3800, Lab. C). POLICY NO.: S� ' ,P'lxP. DATE: 0 Y' -?Certified CerNY: t Certified cis hereby furnished. 13 Certified copy is filed with the city Building Division. r� Date: -777/U Applicant: EXEMPTION FROM WORKERS' COMPENSATION DECLARATION: his section need not he completed it the permit is tar one hundred (5100) or less). I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become Subject to the Workers' Compensation Laws of Cabfarnia. Date: Signature: NOTICE: 11, after making this declaration. you should become subject to the Workers' Compensation provisions of the Labor Code. you must lorthwith comply with such provisions or INS permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency lot the performance of the work for which this permit is issued (Section 3097. Civ. Cj. LENDER: ADDRESS: OWNER BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractors' State License Law for the Ionowing reason (Section 7031.5 Business and Professional Code: Any city of county which requires a permit to construct. alter, improve, demolish, or repair any structure, prior to its issuance. also requires the applicant for such permit to file a signed statement that helshe is licensed pursuant to the provisions at the Contractors' State License Law (Chapter 9 (commencing with Section 7001) Of Division 3 Of the Business and Prolessions Code) or that helShe is exempt therelrom and the basis for the alleged exemption. Any violation pf Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of not more than five hundred dollars (5500). I, a$ owner of the property or my employees with wages as their sole compensation, will do the work, and the ❑ structure is not intended or altered for sale (Section 7044, Business and Professional Code: The Contractors' State License Law opts nal apply to an owner of a property who builds or improves thereon, and who does such work himselllhersell or through his or her own employees, provided that such improvements are not intended or offered for sale. 11, however the building or improvement is sold within one year of completion, the owner will have the burden at proving he/she did not build at improve for the purpose of sale). I, as owner of the property, am exclusively contracting with licensed contractors to construct the project {Section 7044, Business and Professions Code: The Contractors' State License Law does not apply loan owner of property who builds or improves thereon and who contracts lot such projects with a contractOr(S) license pursuant to the Contractors' State License Law). I am aware that pmol of their Worker's Compensation insurance Should be provided to me. D I am exempt under Section: B. 8 P. C. [or this reasof p Date: / 7 I ! Owner: I do hereby certily that I am aware of and understand the requirements Jorma Rtalth and Safely Code Sections 25505, 25533, and 25534 and that I or any future building occupant will1will not (circle one) need to comply with said state codes and the requirements for a permit for construction or modification from the Air Ouaiity Management District. Residential construction apptications are exempt from these provisions. Dale: ApplieanL. I hereby cerltly that I have read this application and state that the above inlormation is correct. I agree to comply with all city and county ordinances and state laws relating to buitdmg construction and hereby authorize representatives of this city to enter upon the above•mentioned property for in lion p rposes, Dale: 7 7 Signature: Driver's License or Social Security # 1641-46 while—Building: Green—Code Enforcement: Canary—Applicant; pink—Revenue; Goldenrod—Assessor CITY OF COSTA MESA — BUILDING PERMIT PERM NO; 8 062924 PERMIT NO: B 062924 PLAN CHECK NO: 02281-93 A GOVT; N SUPP: N CONSTRUCTION TYPE: I FR PERMIT TYPE; STR PURPOSE: ALT JOB DESCRIPTION ; 10400SF RETAIL STORE T.I. SQ FT: 10,400 CLAIM VALUE: 150,000,00 CALC—VALUE; 150,800.00 GROUP OCC: B-2 / COMMENTS; "TIFFANY & CO" STORE T.I. iE ib * d4 it � � -IE !E iE �(• ik if- 9t ik �E iE it ik it- �t iF it• iE * * iE * * iE * � it ii ii- * TE * it * it• 3(- � at � N• it- iE � � -Ih � iE TE � it � !k it• iE Tt- * -K• � �- 1E 9E 9E 9t• if!F it it• �F iF i@ iE i4 �E Z O N I N G S E T B A C K S R E Q U I R E M E N T S ------------ MAIN BUILDING ---------- --------- ACCESSORY BUILDING--------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR; FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT; FT IN PARKING REQ• PROV• PARCEL; 41250105 ZNE: CIS REF NO: PLANNING N TES> TENANT IMPROVEMENTS FOR TIFFANY & CO, IN THE SOUTH COAST > PLAZA. iE f4 iE 9E fE le it iE it iE K• �F * * #F iE ME * .� * it• •>E * iE iE iE iE il- TE it �E � * dF iE iE ii• iE .� it ii- � ih TH it itic- �-IE it: �F 1h iF iF � � TE IF 1t •1E !E iE fE'lE #f• * it �t fit• Tf• TE � jE iE iE it TF * iF D E V E L O P M E N T S E R V I C E S R E Q U I R E M E N T S ZONING APPROVED BY P DATE: BUILDING APPROVED BY ; DATE: 6 2 9 q3 APPLICATION ISSUED BY: DATE; iL• iE iE iF iE ik * �k lE *'� � dE iE iE fb it iL• � 9E df• * TE it- iE .�. � iE iE• iE � � r >ti dE �f TE -IF iE iF TE 9E -1f �F 9f i6 � iE �F TF i(- �E'11- df !E -1E !E � TE �(• iE -lf• dE TI- 9!- -)F it iE iE TF T(• TE 94 iE T4- fir: 9f• 3E TETE iE i(- T(- iF iE• �E iF iF �E �E �E -ME 94 � �(- * fE iF iE 8t• k lt-'1(• TE i(• dE iE it -YE dE TE �E Tf # LEGALIZATION:N F E E S -U M M A R Y STRUCTURAL SEGMENT:Y BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMTP/RES GRADING PERMIT 818,00 SM IP /NON—RES PLAN 132.93 31,67 ISSUE. FEE BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE TOTALS ---- > 849,67 0.00 132,93 982,60 982.60 .00 REVENUE DIVISION TOTALS--> COLLECTED; 849.67 OVER/SHORT; .00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK 818.00 31,67 9t if iE iE � �E -IF �E iF iE •1E lE it it �E iE Tf �1E TE dE * � * iP � iE � dE 9E lf of dE 9E IE iE iE * iE �E �1- -1t jE iG * jE'1E iF i(- iE TE �E fP TE -1E �F if- iE * !4 iE if iF .� * iE �(•It� � iE iE iE iE �F !E TE TF 94 I N D I V I D U A L F E_E B R E A K D O W N TYPE QTY D E S C R I P T 1 0 N _- SFC SFC 10400 STO—INT. ALTER TYPE I II F.R. SFC 10400 E U—ALT COMM. SPRINKLkR SYS SFC 10400 E U—ALT COMM, AIR COND END OF FEES UNIT COST TOTAL COST —AVER 13,48 140,192,00 . —AVER ,33 3,432.00 —AVER ,69 7,176.00 01 00142402-09142403 Ti 849.67 DAVE: 07/07/93 TIME; 13:15 CONSTRUCTION AND PLANNING APPROVALS Permit Date Inspector K & SPA APPROVALS Permit_ Date Inspectors 1, Temporary Electrical Service or Pole "._ 52. Pool & Equipment Location ' 2, Soil Pipe-Undrgrnd. 53. Steel Reinforcement 3. Electrical Conduit Utility•Undrgrnd . 54, Forms 4, Electrical Conduit-Undrgrnd. 55. Electrical Bonding 5. Steel Reinforcerttent 56. Rough Plumbing & Pressure Test S, E?ectrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE 7. Footings c 58. Electrical Conduit-Undrgrnd. B. Foundation 59. Gas Pipe, 0 Undrgrnd., Test 9. Water Pipe•Llndirgjd. + 60. Backwash Lines, P -Trap, O Undrgrnd. 1 10. Structural Floor+System 61. APPROVAL TO DECK 11. Property Sewer_Virie & House Connrction 62. Backwash & Receptor -Final 12. Sewer Cap :' : , 63. Heater & Vent -Final 13. Roof Drains 64, Plumbing System - Final 14. Rough Plumbing .' 65. Electrical -Final 15. Rough Electrical -Conduit 66, Solar System -Final 16. Rough Electric Wiring 5 67. Fencing & Access Approval 17. Rough Wiring Sign '. 68. APPROVED FOR PLASTERING ' 18. Rough Electrical -T Bar Ceiling 69, POOL/SPA SYSTEMS FINAL 19, Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit # 20. Rough Factory Fireplace 21. Ducts, in Structure 70, Underground Hydro 22. Ducts, Ventilating 71. Product Piping © Gas O Oil 23. Gas Pipe- Rough & Test - 72. Underground Flush 24, Roof Framing" 73. Undergrnd. Storage Tank O Gas O Oit 25. Roof Sheathing 74. Overhead Hydra 26. T -Bar Ceiling IStructuratl & Monocoat 75. Dry Chemical 27. Ffar.he-arnd Flashing 76. Dry Standplpe. 28. Lathing & Siding 77. FIXE17 SYSTEM FINAL 29, Insulation 78. FIRE PREY. FINAL 30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat I ,�� 79• FINAL INSPECTION 32. Electrical Power Meter -Final i f 80. FOOD CERTIFICATE ISSUED 33, Final Electric 1 i Notes: 34. Final Heating & Air Conditioning 35. Final Gas Pipe -Test 36. Hood or Canopy t ff 37, Final Factory Fireplace 38. Final Plumbing 39. Water Service -Final 40. Gas Service -Final i 41. Solar Domestic -Final ' 42, Backflow Preventer 43. Backflow Irrigation 44. Landscape Irrigation System 45. Sound Attenuation 46, Handicap Regulations 47. FINAL STRUCTURE & BUILDING f 48. FINAL PLANNING 49. Electric Release to Edison f 50. Gas Release to Southern California Gas Cb 51. CERTIFICATE OF OCCUPANCY No. Date PRIMECT ADDRESs: 3333 BRISTOL ST UNIT: 1 So 9 — OWNER'S NAME:C J SEGERSTROM ADDREss:3315 FIARVIEW RD C.M, CA 92626 ARCHIENGINEER:BERMAN & BERTOLINI REG.NO.:C ADDRESs:16250 VENTURA BL UNIT: 316 ENCINO CA 91436 PERMITTEE: ACADEMY MECHANICAL (714)841-6222 ADDRESS: 7592 REYNOLDS CIRCLE HUNTINGTON BEACH CA 92630 LICENSED CONTRACTOR DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 {commencing with Section 70001 of Division 3 at the Business and Professions Code, and y liceLsinll force and effect. CITY LIC.:O 3 9 6 2 0 STATE L1C.:�5 7 04 — 3 6 000, Dom,, ,7_nZ! `'� Signature: _ WORKERS' COMPENSATION DECLARATION: I hereby firm that a a certificate of consent to self -insure or a certificate of Workers' Compensalio ur 2 r,a e f C hereof (Section 3800. Lab C). POLICY NO.: `' E 1 � � �� I " EXP. DATE: 11 / 15 / 9 3 COMPANY: UNITED PACIFIC Certified copy is hereby furnished. LD Certilied copy i led with th Pvlly Building 'cion, o 1' mate % Applicant — '"1 ✓ Y T� EXEMPTION FROM WORKERS' COMPENSATION DECLARATION: (This section need not be completed it the permit is for one hundred (5100) or less). I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Wo}kers' Compensation Laws of California. W Date'. Signature: NOTICE: If. afler,making this declaration, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such previsions or this permit shall be deemed revoked. CONSTRUCTION LENOiNG AGENCY: I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Section 3097, Civ. C). LENDER:' ADDRESS: OWNER BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractors' State License Law for the following reason (Section 7031.5 Business and Professional Code: Any city of county which requires a permit to construct, alter, improve, demolish, or repair any structure. prior to its issuance, also requires the applicant for such permit to file a signed statement that he/she is licensed pursuant to the provisions of the Contractors' State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Prolessrons Code) or that he/she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500). 1, as owner of the property or my employees with wages as their sole compensation, will do the work, and the ❑ structure is not intended or offered for sale (Section 7044, Business and Professional Code: The Contractors' State License Law does not apply to an owner of a property who builds or improves thereon, and who does such work himself/herself or through his or her own employees. provided that such improvements are not intended or offered for sale. If, however the building or Improvement is sold within one year of Completion, the owner will have the burden of proving he/she did not build or improve or the purpose of sale). I, as owner of the properly, am exclusively contracting with licensed contractors to construct the project (Section 7044, Business ❑ and Professions Code: The Contractors' state License Law does not apply to an owner of property who builds or improves thereon and who contracts far such projects with a contractur(s) license pursuant to the Contractors' State License Law)- I am aware that proof of their Worker's Compensation insurance should be provided to me. ❑ 1 am exempt under Section: B. & P. C. for this reason Date: Owner: I do hereby certify that I am aware of and understand the requirements of California Health and Safety Code Sections 25505, 25533, and 25534 and that I or any future building occupant willlwill not (circle one) need to comply with said state codes and the requirements fora permit for construction or modification from the Air Cualrty Management District, Residential construction applications are exempt from these provisions. Date: Applicant: I hereby certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and slate laws relating to budding Construction and hereby aulhorizyepresentatives of this city to enter upon the above-mentioned property Sof inspection purposes. Signalur Driver's License or Social Security . 1641.46 white—Building; Green—Code Enlorcemenl Canary—Applicant: Pink—Revenue; Goldenrod—Assessor CITY OF COSTA MESA — BUILDING PERMIT PERMIT NO: P 063032 PLAN CHECK NO: N CONSTRUCTION TYPE; I FR PERMIT TYPE; PLU JOB DESCRIPTION ; 10400SF RETAIL STORE T.I. CLAIM VALUE; 3,000.00 CALC—VALUE; ERM NU;' UbJU-i./ G . N Sunk': N PURPOSE; ALT SQ FT: GROUP OCC; B-2 / COMMENTS: "TIFFANY & CO" STORE T.I. REF:B62924 �•�•�-�����•**#���-� x• *#* �•*����•K•*�#�•�•#�•�•#�cic-���# �•�c•�• x•�c **�•�•#�•��-��c ��•�#a����•#�tK• ��*K-��c-•��c-���� Z O N I N G R E Q U I R E M E N T S S E T B A C K S ------------ MAIN BUILDING ----------- ----------- ACCESSORY BUILDING ----------- FRNT; FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT; FT IN RGHT: FT IN PARKING REQ• PROV: PARCEL: 41250105 ZNE: REF NO: PLANNING N TES> > �t # �(- # jk ik # # # # # # # it it # .�t # # i(iF # i4• i( * # tk XE # # # !(* # �(• x• # # -tE # # # # # if it iE 3h K d(• it 3t• iF'.F # aE !t- tf 3E .* iE'IE iE K- �E �F # lt- it• iE if•'X# iE # K # iC• it• D E V E L O P M E N T S E R V I C E S R E Q U I R E M E N T S ZONING APPROVED BY DATE; BUILDING APPROVED BY DATE: APPLICATION ISSUED BY: n DA'Z'E,: !F # � � � it >E iF iE # # !F # iE !E K• K• iE !E it• -!f � +t• -if• •)[- !F i( ii• � iE ii 74.x• fr x• - - •re ie•.K �!• ]f 9k aE dL ah dG �E iE dE l dF'lE K IE it,• K K # K !F # # iE �E dF !E !E !E 1F 1P if K i(# !E }L xF IE ii # 1E- '!f• fi4 if 3E K X i! K K iC iE 3f i4 # K # �f iE jE'aF # D{ Jf if ai ii• At 3i 4E # # 1f• (�E LEGALIZATION:N F E: E S U M M R Y STRUCTURAL SEGMENT:N BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT 42.00 PLAN 25% SMIP/NON—RES ISSUE FEE 20.00 BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE TOTALS ---- > 42.00 20.00 0.00 62,00 62,00 .00 REVENUE DIVISION TOTALS--> COLLECTED: 62,00 OVER/SHORT; 00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN --CHECK 62.00 # iE �(� iE ciE dt• �E �l- 9E ik 9k �t �F * 3E iE K• * * if• 1f iE # !r iE # K• iE * it,• iF # •!E i(• # iF iE iE •iE it• # it• * iF # K # K• �• � it• !F at• at• # � # � 1E i(- K• � .�(. # 3f• 3E # �E 3F # # fit• dE # # �C• .� -!E I N D I V I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N-- UNIT COST TOTAL COST PLU 2 SINK KITCHEN 7,00 14.00 PLU 2 WATEk HEATER .AND/OR VENT 7,00 14.00 PLU 1 SINKS FLOOR 7.00 7,00 PLU 1 FIK'ruAE SET/TRAP W/PIPING & BACKFLOW 7,00 7,00 END OF FEES GI 00142840-GO14294G Til T (52.00 GATE: 07/14/93 TIME: 13.20 CONSTRUCTION AND FILANNiNG 'APPROVALS Permit # Date Inspector Pa SPA �: APPROVALS Permit # Date ' inspector 1. Temporary Electrical Service or Pole 52. Pool & Equipment Locat;on 2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. 54. Forms j 4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding t ! 5. Steel Reinforcement 56, Rough Plumbing & Pressure Fest 6. Electrical UFER Grnd. 57. APPROVAL TO COVER•GUNITE 7. Footings 58. Electrical Conduit•Undrgrna. 1 8. Foundation 59. Gas Pipe, 0 Undrgrnd., Test 9. Water Pipe-Undrgrnd. 60. Backwash Lincs, P•Trap, 0 Undrgrnd. I 10. Structural Floor Systerr 61. APPROVAL TO DECK 11, Property Sewer Line House Connection 62, Backwash & R^ceptor•Finai 12. Sewer Cap 63. Heater 8e Vent -Final 13, Roof Drains 64, Plumbing System - Final 14. Rough Plumbing 65. Electrical -Final 15. Rough Electrical -Conduit, 66, Solar System -Fina! r 3 16. Rough Electric W'aing 67. Fencing & Access Appfcival i 17. Rough Wiring Sign 68, APPROVED FOR PLASTERING J 18. Rough Electrical -T Bar Ceiling 69, POOL/SPA SYSTEMS FINAL i 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit # i 3 20. Rough Factory Fireplace 21. Ducts, in Structure 70, Underground Hydro -y 22. Ducts, Ventilating 23. Gas Pipe -Rough & Test 71. Product Piping C3 Gas C1 Oil 72. Underground Flush 24. Roof Framing 73. Undergrnd. Stoiage Tank 0 Gas 0 Oil 25. Roof Sheathing 74. [Overhead Hydro - 26. T -Bar Ceiling (Structural', & Monocoat 75, Dry Chemical 27. Frame and Flashing 76. Dry Standpipe 2& Lathing & Siding r 77. FIXED SYSTEM FINAL � 29. Insulation ' 78. FIRE PREY. FINAL 30. Dryvvall Nailing ! HEALTH DEPT, REQUIREMENT --- 3. faster Slc.vn Coat I f , - 79. FINAL INSPECTION - - 32. ~ :tr,cai Power Meter -Final 33. f n.l Electric j ` 80. FOOD CERTIFICATE ISSUED Notes:- -- - I 34. Final Heating & Air Conditioning 35. Final Gas Pipe -Test 36, Hood or Canopy ; 37. Final Factory Fireplace I 38. Final Plumbing 39. Water Service -Final I - 40, Gas Service -Final 41, Solar Domestic -Fina! I 42, Backflow Preventer r 43. Backflow Irrigation ; 44. Landscape Irriqation System , 45. Sound Attenuation _ 46. Handicap Regulations i 47. FINAL STRUCTURE & BUILDING 48. FINAL PLANNING r ` -- 49, Electric Release to Edison 50. Gas Release to Southern California Gas Co i 51. CERTIFICATE OF OCCUPANCY No. Date `-- -- PROJECTADDRIl 3333 BRISTOL ST OWNER'S NAME: C J SEGERSTROM ADDREss: 3 315 FIARVI EW RD C.M., CA 92626 UNIT: 1509 ARCHIENGINEER: BERMAN & B ERTOL I N I REG.NO.:C ADDRESS:16250 VENTURA BL UNIT: 316 ENCINO CA 91436 PERMITTEE: PACIFIC AIR COMFORT (714)937-1333 ADDRESS: 1894 S SANTA CRUZ ANAHEIM CA 92806 LICENSED CONTRACTOR DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 at the Business and Professions Code, and my license is in full force and effect. CITY LIC.: 0 4228 1 STATE LIC.:S 0 0 2 3 6 CLASS: C 2 0 Date: — — Signature: �L— WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to sell -insure ora certificate of Workers' Compensation Insurance, or a certified copy thereof (Section 3800. Lab. C). POLICY NO.: EXP. DATE: COMPANY: ❑ Certified copy is hereby furnished. n Certified copy is tiled with the city BuiWing Division. Date, Applicant: EXEMPTION FROM WORKERS' COMPENSATION DECLARATION: (This section nee not be completed if the permit is for one hundred (Sli or lessl, I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California, Date:' I � -/ � Signature: NOTICE: II, after making this declaration• you should become subject to the Workers' Compensation provisions of the Labor Code. you must forthwith comply with such provisions or this permit Shall be deemed revoked, CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance at the work for which this perm8 is issued (Section 3097• Civ. C). LENDER: ADDRESS: OWNER BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractors' State License Law for the lorlowing reason (Section 7031.5 Business and Professional Code: Any city of county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to life a signed statement that helshe is licensed pursuant to the provisions of the Contractors' State License Law (Chapter 9 (commencing with Section 7000) o1 Division 3 of the Business and Professions Code) or that belshe is exempt therefrom and the basis for the alleged exemption. Any violation o1 Section 7031.5 by any applicant lot a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500). I, as owner of the property or my employees with wages as their sole compensation, will do the work, and the ❑ structure is not intended or altered for sale (Section 7044, Business and Professional Cade: The Contractors' State License Law does not apply to an owner of a properly who builds or improves thereon, and who does such work himselllhersefl or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however the building or improvement is sold within one year of completion, the owner wll have the burden of proving he/she did not build or improve for the purpose of sale). f, as owner of the property, am exciusivefy contracting with licensed contractors to construct the project (Section 7044, Business ❑ and Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon and who contracts for such projects with a contractors) license pursuant to the Contractors' State License Law). I am aware that proof of their Worker's Compensation insurance should be provided to me. ❑ I am exempt under Section: B. & P. C. for this reason: Date: owner: Ii hereby certify that I am aware of and understand the requirements of California. Health and Safety Code Sections 25505, 25533, and 25534 and that I or any future building occupant wilUwill not (circle one) need to comply with said state codes and the requirements for a permit for construction or modification from the Air Duality Management District. Residential construction applications are exempt from Ihese provisions. Date: Applicant: I hereby certily that I have read this application and state that the above information is correct. I agree t0 comply with all city and county Ordinances and slate laws relating to building construction and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. �/1 1/11w Date: Signature: ��'-��+ - Driver's License or Social Security M. 1641-46 White—Building: Gruen—Code Enlorcement Canary—Applicant Pink—Revenue: GDldenrod—Assessor CITY OF COSTA MESA — BUILDING PERMIT PERMIT NO: M 063048 PLAN CHECK NO: N CONSTRUCTION TYPE; I FR PERMIT TYPE; MEC JOB DESCRIPTION : 10400SF RETAIL STORE T,I„ RE#B62924 CLAIM VALUE: CALC--VALUE : PEKM NO; M = GOVT; N SUPP: PURPOSE: ALT SQ FT: GROUP OCC: B-2 / COMMENTS: "TIFFANY & Cl STORE T.I. ��•�F�F�FiF���r��F*��ic•�-��•�F*�r**����r��t�r�F�F��TF��r���-x�x-�r�x��r�-���•�•�-•>E�r�r�l•�rTe•��•��•��c•��x•�-:���e•�-*•x•*•�� Z 0 N I N G R E Q U I R E M E N T S S E T B A C K S — ^' — MAIN BUILDING ---------- --------- ACCESSORY BUILDING --------- FRNT:FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RIGHT; FT IN PARKING REB• PROV; PARCEL: 41250105 ZNE: REF NO: PLANNING N T ES> iE iE iE iE iF 9f �E iE iE iF 9i• it �F i(• fE -ME iF iF iE !i -.x. * jk 1k �(- iF �{• •3F iF jI- f(- di• 3f• iF lC• !F 94• TE'K � iN iF a4 �k !F iE iF'ir?:iE .� iF iF •)<• �(• it• •iF iE JE � � iF � �E •!4 � � � # �F 9F 1F iE •IF'1F iF iF i(• �{?F D E V E L O P M E N T S E R V I C E S i'R E Q U I R E M E N T S ZONING APPROVED BY DATE; BUILDING APPROVED BY DATE; APPLICATION ISSUED BY; DATE: to iF �F jE if iE iE !F 1F 9F iF �! 1F 9F TF illi IE * * ik fe iF iF * 1F iF iF 9F �F iF iF �E iF �F iF �• iE iF• il• TE if * jE iF iE iE iE if- �E �f• ii it• •lE �(- IF !I- iF iF iE it- gE'lE iF iE jL # � jE jC TFT( .� iE jE iF'1i��G iF �F .� iF -IF �E• df• -x3F iE iF �(• �(• iF iF ![• !�• �k TF iE iF jF � iF iF iF iE iE 9E it 9E LEGALIZATION;N F E E S U M M A'R Y STRUCTURAL SEGMENT;N BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT 20.00 25t SMIP/NON—RES PLAN ISSUE FEE 15.00 BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE TOTALS ---- > 20.00 15.00 0.00 35.00 35.00 .00 REVENUE DIVISION TOTALS--> COLLECTED: 35.00 OVER/SHORT; ,00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK 35,00 9F ir; dE )F iF dE iE TF dF �F �f• # iF IF 9F 'K * iF'1F iF iF �F iF iF 1F TF dF •iF ilk 3F •)E �F iE •►F � •i4- �(• TF iE 9c• # 9F fE �( >E iF iF )F � -!E iF jF �F iF iF j4• i(• iF 9F 9(- iF �F iF iF 34 •1F �E �F 4.3E �F �F iF iE iE * jE i(;f I N D I V I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST MEC I REFRIGERATION SYSTEM <= 100 K BTU/H MEC 1 VAV BOX MEC 1 VENTILATION FAN CONN TO SINGLE DUCT END OF FEES 9,00 9.00 6,50 6,50 4,50 4.50 01 00142420-00142920 T13 T 35.00 DATE; 07/15/43 TIME: 11:59 CONSTRUCTION AND -PLANNING I i APPROVALS Permit # Date Inspector POOL & SPA APPROVALS Permit Date Inspector 1. Temporary Electrical Service dr Pole 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement N, 3. Electrical Conduit Utility-Undrgrnd. 54, Forms 4. Electrical Conduit -Undrgrnd. 55. Electrical Bonding 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6. Electr;cat LIFER Grnd. 57, APPROVAL TO COVER-GUNITE 7. Footings 58. Electrical Conduit•Undrgrnd. l 8. Foundation 59. Gas Pipe, 0 Undrgrnd., Test j 9. Water Pipe-Undrgrnd. 60. Backwash Lines, P -Trap, 0 Undrgrnd. l 1Structural Floor System 61, APPROVAL TO -DECK 11. Property Sewer Line & House Connection f 62. Backwash & Receptor -Final 12. Server Cap 63. Heater & Vent -Final 13. Roof Drains 64. Plumbing System - Final 14. Rough Plumbing 65. Electrical -Final 15. Ro,:gh Electrical -Conduit 66, Solar Systerrm•Final 16. Rough Electric Wiring 67. Fencing & Access Approval 17. Rough !'firing Sign 68. APPROVED FOR PLASTERING 18. Rough Electrical -T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit # _- 20. Rough Factory Fireplace 21. Ducts, in Structure 70. Underground Hydra 22. Ducts, Ventilating 71. Product Piping DGas 00 i 7r _3. r,,,- Ptpe-Rough & Test 26., Ror,f Framirg 72. Underground Flush 73. Undergrnd. Storage Tank 0 Gas n OiI 25 Hoof Sheathing 74. Overhead Hydro f 26. T-3ar Ceiling (Structural} & Monocoat 75. Dry Chemical i 27. F a,ne and Flashing 76, Dry Standpipe 28. Lath no & Siding I 77. FIXED SYSTEM FINAL i 79. in;ulat.cn i 78. FIRE PREY. FINAL Drvv.all Nailing ( HEALTH DEPT, REQUIREMENT 31, Piaster Brown Coat 32. Electrical Power Meter -Final � 79. FINAL INSPECTION 80. FOOD CERTIFICATE ISSUED 33. Final Electric ! ! Notes: 34. Final Heatsng & Air Conditioning I ' 35. Final Gas Pipe -Test 36. Hood or Canopy k 37. Final Factory Fireplace t 38. Final Plumbing--- i I 39. Water Service -Final 40. Gas Service -Final i 41, Solar Domestic -Final l 42. Backflow Preventer ' I 43. Backflow irr•sgation 44. Landscape irrigation System 45. Sound Attenuation 4G. Handicap Regulations 47. FINAL STRUCTURE & BUILDING 48. FINAL PLANNING r 49, Electric Release to Edison , 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY Na. Date FIMLECT ADDRESS: 3333 BRISTOL ST OWNER'S NAME: C J SEGERSTROM AODREss: 3 315 F IARVI EW RD C.M., CA 92626 UNIT: 15 0 9 ARCHIENGINEER: B ERMA N & BER TOL I N I REG.NO-:C AODRESS:1620 VENTURA BL UNIT: 316 ENCINO CA 91436 PERMITTEE: SMALL COMB WIRING INC. (714)556-8591 ADDRESS: 136 E. GARRY Af1E SANTA ANA CA 92707 LICENSEDCONTRACTOR DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 70001 of Division 3 of the Business and Professions Code. and my license is in full force and elect. CITY LIC.•:-0� 1100 5 STATE LLC -:l 4 5 9 61 CLASS -C—' 0 Date: T Z-23 Signature: Jile WORKERS' COO-IMpPENSATION DECLARATION: I hereby afat I have a certificate of consent to self -insure or a certificate of Workers' POLICY ati t!r6gg„prd t Iiy py,Lllr�eol {Sect EXP. DA00, TE: / 0 1 /93 COMPANY: CC I E U �! 4 3 V �fi I Certified copy is hereby lurnished. n Certilied copy Pill with the cityg 01 on q r Date: ! 3 _ Applicant: , EXEMPTION FROM WORKERS' COMPENSATION DECLARATION: (This section need not be completed if the perp it is tot one hundred (5100} or less(. 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become' subject t0 the Workers' Compensation Laws of California. Date: Signature: NOTICE: If, after making this declaration, you should become subject to the Workers' Compensation provisions ohthe Labor 1 Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. ' ,,e CONSTRUCTION LENDING Al I hereby allum that there is a construction sending agency for the performance of the work for which this permit is issued (Section 3097. Civ. Q. LENDER: ADDRESS: OWNER BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractors' State License Law lot the following reason (Section 7031,5 Business and Professional Code: Any city of county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he/she is licensed pursuant to the provisions or the Contractors' State License Law (Chapter 9 (commencing wilh Section 7000( of Division 3 of the Business and Prolessions Code] or that helshe is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than live hundred dollars (E500P. I, as owner of the property or my employees with wages as their sole compensation, will do the work, and the ❑ structure is not intended or offered for sale (Section 7044, Business and Professional Code: The Contractors' State License Law does not apply to an owner of a property who builds or improves thereon, and who does such work himselflhersell or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however the building or improvement is sold within one year of completion, the owner will have the burden at proving he7she did not build or improve for the purpose at sale►. I, as owner of The property. am exclusively contracting with licensed contractors to construct the project (Section 7044, Business ❑ and Prolessions Code: The Contractors' State License Law does not apply to an owner a$ property who builds or improves thereon and who contracts for such projects with a oontractor(s) license pursuant to the Contractors' State License Law(. I am aware that proof of their Worker's Compensation insurance should be provided to me_ I am exempt under Section: B. & P. C. for this reason: Bate: Owner: I do hereby certify that I am aware of and understand the requirements of Calitornia,Health and Safety Code Sections 25505, 25533, and 25534 and that I or any future building occupant willlwill not (circle one) need to comply with said state codes and the requirements for a permit for construction or modification from she Air Quality Management District. Residential construction applications are exempt from these provisions. Date; Applicant: I hereby certify [hat I have read this application and state that the above information is correet. I agree to comply with all city and county ordinances and state laws relating to budding construction and hereby authorize repre ntati of this city to enter upon the above-mentioned property loi Inspection purposes. Dare: _ -117- - Signature: Driver's License or Social Security 164146 While—Building; Green --Code Enforcement; Canary—Applicant: Pink—Revenue; Goldenrod—Assessor CITY OF COSTA MESA - BUILDING PERMIT PERMIT NO; E 062932 PLAN CHECK NO: CONSTRUCTION TYPE; IFR SP PERMIT TYPE: ELE JOB DESCRIPTION : COMMERCIAL T.I. (RETAIL SALES STORE) CLAIM VALUE; CALC-VALUE; N PURPOSE; 0TH SQ FT; GROUP UCC; B-2 / COMMENTS; THE "TIFFANY & CO.” STORE TENANT IMPROVEMENT, Z 0 N I N GS ERTEBQAC]CIKRSE M E N T S -------------- MAIN BUILDING ---------- --------- ACCESSORY BUILDING------------ FRNT; FT IN REAR; FT IN FRNT: FT IN REAR: FT IN LEFT; FT IN RGHT; FT IN LEFT; FT IN RGHT: FT IN PARKING REQ• PROV: PARCEL; 41250105 ZNE: REF NO: PLANNING N TES> iEiti[•if���it#E**iEiEiEiEit**iEitit#E*3E�•lf-stat-•IEiE•x•itii•iEit-lF•>t�*�*ihi[•i(-it it-*ielElEit�iEit�iriEdf�ik��ii•���I•aEkiF*iE*i(*lE�it•�# D E V E L O P M E N T S ESR V I C E S R E Q U I R E M E N T S ZONING APPROVED BY '' DATE; BUILDING APPROVED BY ; Yof DATE.- ATE;APPLICATION APPLICATIONISSUED * k !E if if if Xh dE �t iE � TE f@ iF'rf BY; !' !E * iE * Tt LI• !! DATE; l2 9E -It• df iE T! it 3E !E iE iE iE iE 1E !F iE � •IE iE iE �E �t iE iE iE iF it• iE !E il• � iE -lE �!• � if.�• iE 4E 1F iE it �E �• 9t'1E �[• ic• iE � � * � it it ii• iE iE iF �E iE '�E 9t•'1E iE iE iE * * it 9E •1F iN it � iE iH �(• lE � if if iE it # it �t �k it• iE LEGALIZATION F ErE S U M M A R STRUCTURAL SEGMENT;N BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT 195,20 50% SMIP /NON --RES PLAN ISSUE FEE 15,00 BUILDING --DIV-> PERMIT ISSUE PLAN -CHECK TOTAL PAID DUE TOTALS ---- > 195,20 15.00 0,00 210,20 210.20 ,00 REVENUE DIVISION TOTALS--> COLLECTED; 210,20 OVER/SHORT; ,00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN -CHECK 210.20 � !E * iF !! it if * * # Tt iE * it• iE * � �F iE � it iI• * iF iE iI• # .* * it jt •14 ![• iE � * if- it * .�. !6 ir- it * ft• iE �(• � TF iE'lt !( i[ �E 3E � lF � T[• yi- iL•'1F'1(• 3k -1E !C !4 !{ �( 3E �E �E iF � #(• �E 3C �E of I N D I V I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST ELE 20 FIXTURES, LIGHTING 1 ST 20 EA. ,75 15,00 ELE 161 FIXTURES LIGHTING ADDITIONAL EA. ,45 72,45 ELE 20 RECEPT/ObTLET 1 ST 20 EA, ,75 15,00 ELE 145 RECEPT/OUTLET ADDITIONAL EA, .45 65,25 ELE 18 RECEPT/SWITCH 1 ST 20 EA, ,75 13,50 ELE 1 SUB -PANEL 11,00 11,00 ELE 1 MOTOR/POWR APPARATUS 0.0 - 1,0 HP 3,00 3,00 END OF FEES 01 00142666-00142656 T O T 210.20 MATE. £7/12/93 TIME• 14:41 '- 1 4 - CONSTRUCTION AND PLANNING ` APPROVALS Permif ` 1, Temporary Electrical Service7r Pole Date Inspector PO ;l SPA APPROVALS Permit # 52. Pool & Equipment Location Date Inspector 2. Soil Pipe-Undrgrnd, a 53, Steel Reinforcement 3. Electrical Conduit Utility-Uot!rgrnd. i 54. Forms 4„ 4. Electrical Conduit-Undrgrnd. 55, Electrical Bonding 5, Steel Reinforcement 56. Rough Plumbing & Pressure Test 1 6. Electrical LIFER Grnd 57- APPROVAL TO COVER•Gt_INITE 7. Footings 58. Electrical Conduit-Undrgrnd. --� 8. Foundation ',-s 59- Gas Pipe, ©Ursdrgrnd., Test 59. 9. Water Pipe-Undrgrnd. ! 60. Backwash Lines, P -Trap, 1-7) Undrgrnd, 10, Structural Floor System 61. APPROVAL TO DECK ' 11. Property Sewer Line & Hodse'Connection -- 62. Backwash & Receptor -Final 12. Sewer Cap - 63. Neater &Vent -Final lI ` 13. Roof Drains i �> 64. Plumbing System Final 14. Rough Plumbing 65. Electrical -Final 1 I 15. Rough Electrical -Conduit 16. Rough Electric Wiring 7' 66, Solar System -Final 67. Fencing & Access Approval 17, Rough Wiring Sign 68. APPROVED FOR PLASTERING ' 18. Rough Electrical -T Bar Ceiling 69, POOL/SPA SYSTEMS FINIAL 19. Rough Heating &Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit # �I ' 20. Rough factory Fireplace 21. Ducts, in Structure 22. Ducts, Ventilating 70. Underground Hydro 71. Product Piping E] Gas 0 011 23, Gas Pipe -Rough & rest 72, Underground Flush 24. Roof Framing 73. Undergrnd. Storage Tank 0 Gas , 0iI 25. Roof Sheathing • 74. Overhead Hydro 4 26- T -Bar Ceiling (Structural) & Monocoat 75. Dry Chemical 27. Frame and Flashing 76- Dry Standpipe 28. Lathing & Siding 1 77. FIXED SYSTEM FINAL 29. Insulation( 78. FIRE PREY. FINAL 30. Drywall Nailing HEALTH DEPT. REQUIREMENT I 31, Plaster Brown Goat 32. Electrical Power Meter Final 33. Final Electric I dd cc�l�h// I 79, FINAL INSPECTION I 80. FOOD CERTIFICATE ISSUED i 34. Final Heating & Air Conditioning 35. Final Gas Pipe -Test Y 36. Flood or Canopy I { 37. Final Factory Fireplace 3$. Final Plumbing k -- 39. 1Vater Service -Final 40. Gas Service -Final i -� 41. Solar Domestic-Finai 42. Backflow Preventer 1 E 43. Backflow Irrigation --i i I 44. Landscape Irriqation System 45. Sound Attenuation 46. Handicap Regulations r i 47. FINAL STRUCTURE & BUILDING - 48. FINAL PLANNING 49. Electric Release to Edison 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY No. Date PROADDRESS, 3333 B R I S TOL S T UNIT: 1509 OWNEWNE R'S NAME: C . J , SEGERSTROM & SONS AOORESS:3315 FIARVIEW RD i C.M., CA 92626 ARCHIENGINEER: (714)546-01.10 REG,li ADDRESSC UNIT:: 16250 VENTURA BL 316 PERMITTEE: ENCINO CA 91436 ADDRESS: FIRE PROTECTION (714)993-2822 4740 BRYSON ST ANAHEIM CA 9288-1 LICENSED CONTRACTOR DECLARATION: I hereby affirm that I am licensed under provisions of hapter 9 (commencing with Section 7000) o1 Division 3 of the Business and Prolessions Code, and my ilcense is in full force and effect. CITY LiC.: STATE LIC.: CLASS' 0 8? / 316324 C1.6 Date:.—._ _1Signature: WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate ofconsent to sell -insure or a Certificate of Workers' Compensation Insurance, or a certified copy thereof (Section 3800, Lab. C). POLICY NO.: rjWC 2 0 6 8 9 8 Ill DATE: 10 0 1/ 9 3 COMPANY:GOLDEN EAG. F' Certified copy her y furnished. JCertified copy is filed iih the city Building Division. Date: f? Applicant: �� — EXEMPTION FROM WORKERS' COMPENSATION DECLARATION: (This section need not be completed i1 the permit is for one hundred ($100) or less). I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California. Date: Signature: NOTICE: 11, alter making this declaration, you should become subject to the workers' Compensation provisions of the Labor Code. you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY: i hereby affirm that there is a construction lending agency for the performance Of the work for which this permit is issued (Section 3097, Civ. C). LENDER: ADDRESS: OWNER BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractors' State License Law for the following reason (Section 7031,5 Business and Professional Code: Any city of county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to life a signed statement that he/she is licensed pursuant to the provisions of the Contrac¢ors' State License Law (Chapter 9 {commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he/she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than live hundred dollars (5500). I. as owner of the property or my employees with wages as their sole compensation, will do the work, and the 0 structure is not intended or offered for sale (Section 7644, Business and Professional Code: The Contractors' State License Law does not apply to an owner of a property who builds or improves thereon, and who does such work himsefflherself or through his Cr her own employees, provided that such improvements are not intended or offered for sale. If, however the building or improvement is sold within one year of completion, the owner will have the burden of proving helshe did not build or Improve for the purpose of safe). I, as owner of the property, am exclusively contracting with licensed contractors to Construct the project (Section 7D44, Business ❑ and Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon and who contracts for such projects with a conlractor(s) license pursuant to the Contractors' State License Law). I am aware that proof of their Worker's Compensation insurance should be provided to me. ❑ I am exempt under Section: B. 8 P. C. for this reason: Date: Owner I do hereby cemfy that I am aware of and understand the requirements of California Health and Safety Code Sections 25505. 25533, and 25534 and that I or any future building occupant will/will not (circle one) need to comply with said state codes and the requirements for a permit for construction or modification from the Air Duality Management District. Residential construction applications are exempt from these provisions. Dale Applicant: I hereby certily that I have read this application and state that the above information is carred. I agree to comply with all city and county ordinances and state laws relating to building construction and hereby authorize representatives of this city 1a enter upon the ahove-mentinned property fol in ecti purposes, Dale: 3 Signature: �•1�'+^ "' Driver's License or Social Security #: 164146 White—Building: Green—Code Enforcement: Canary—Applicant: Pink—Revenue: Goldenrod—Assessor r CITY OF COSTA MESA - BUILDING PERMIT PERMIT NO: F 063372 PLAN CHECK NO: 02709-93 L CONSTRUCTION TYPE: IFR SP PERMIT TYPE: FIR JOB DESCRIPTION : FIRE SPRINKLER SYSTEM CLAIM VALUE: 2,900.00 CALC-VALUE: PERM Ni F 063372 GOVT; N SUPP: N PURPOSE: OTH SQ FT: GROUP OCC: B-2 / COMMENTS: "TIFFANY E. CO" STORE T.I. / RE: B62924 Z O N I N G S E T B A C K S R E Q U I R E M E N T S - MAIN BUILDING ----------- --------- ACCESSORY BUILDING --------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN PARKING RES; PROV: PARCEL: 41250105 ZNE: REF NO: PLANNING N TES> > #############9F IE#####1E##############i(•if##!E#-I4-lt•�t•itiFit#i4 TF�F#iEi(-*iEiEiE�EiE�E�FiFiE#i(�t•#!E######3E3F#iE D E V E L O P M E N T S E R V I C E S R E Q U I R E M E N T S ZONING APPROVED BY DATE: BUILDING APPROVED BY : DATE: T APPLICATION ISSUED BY: DATE: TF#iE###i(•#0k# LEGALIZATION:N F E E S U M M A R Y STRUCTURAL SEGMENT:N BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT 54500 5% SMTP/NON-RES PLAN 35.10 ISSUE FEE BUILDING -DIV->' PERMIT ISSUE PLAN -CHECK TOTAL PAID DUE TOTALS ---- > 54.00 0.00 35.10 89.10 89.10 .00 REVENUE DIVISION TOTALS--> COLLECTED: 54.00 OVER/SHORT: ,00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN -CHECK 54,00 ###*#0(-•II••1E######-1t######TE##•1E####BE-1E9F*#######*####*#*3'v##1F***•l*x•#Nr-1Eat######*-1E##•?t•***l *.X- I .XI N D I V I D U A L F E E D R E A K D O W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST FIR 54 FIRE EQUIP FEE (FROM BLDG VAL TABLE) END OF FEES r 1.00 54.00 01 00144299-00144299 TOT 54.00 DATE: 08/05/93 TIME: 13:29 1 - CONSTRUCTION AND PLANNING A�FPROVALS Permit # -1. Temporary Electrical Service or Pole 2. Soil Pipe-Undrgrnd. i 3. Electrical Conduit Ut;lity-Undrgrnd. 4 Electrical Conduit-Undrgrnd. 5 St?r i Re;nfo,cement G Elsctr,cai UFER Grnd. 7 Footings B. Foundation 9. Water Pipe-Undrgrnd, � i - i 10. Structural Floor System 11. Property Sever Line & House Connection 12. Sewer Cap 13 RLjs Drams , r- 14. Rough Plumbing l 15 Rough Electrical -Conduit 16. Rough Electric Wiring 1 7. ROLC n :',ir�ng S�gn 18. Rough Electrica["T Bar Ceiling 19. Rough Heating & Air Conditioning 20 9o_n Factory Fireplace 21. Ducts, in Structure ?2. Ducts, Ventilating 23. Gas Pipa-Rough & Test PO. & SPA Date Inspector APPROVALS Perm:t 0- Date Inspector E 52. Pool & Equipment Location 53. Steel Reinforcement 54. Forms 55. Electrical Boridtng fi 56. Rough Plumb ng & Pressure Test 57. APPROVAL TO COVER•GUNITE 5$. Electrical Conduit-Undrgrnd. r 59. Gas Pipe, 0 Undrgrnd.. Test _ 60. Backwash Lines, P•Trap, L7 Undrgrnd. / 61. APPROVAL TO DECK 62. Backwash & Recaptoi-Final 63. Heater & Vent -Final 64. Plumbing System - Fi-rwl 1 65. Electrical -Final , 66. Solar System-Fi+tai 67. Fencing & Access Approval 68, APPROVED FOR PLASTERING 69, P00LJSPA SYSTE;%".S F INAL FIRE DEPT. REQUIREMENT � i APPROVALS Permit 70. Underground Hydro 71. Product Piping F] Gas L Oil 72. Underground FiLiO 24. Roof Framing 73. Undergrnd. Storago Tank 13 Gas �., Oil 25. Roof Sheathing 16. T -69r Ceilir.9 (Structural & M.o-iocoat 27. F.arr^: and Flashing 28. Lathing & Siding 23. !nsuiatlon 3,3. Drywall Trailing 31. Piaster Brown Coat 32 Electrical Poser Nieter-Final 33 Final Electric 34. Final Heating & Air Conditioning 35. ;trial G?s Pipe•Test 36. Hood or Canopy 37. Final Factory Fireplace 38. Final Plumbing 38. Water Service -Final - - I ^10. Gas Service -Final 41, Solar Domestic -Final l 12�. Backflow Preventer 43. Backflow Irrigation 4C. Landscape Irriqation System 1-44,613 74. Overhead "':•^' :7 � 75. Dry Chem'cal 76. Dry Standpipe 77, FIXED SYSTEM FINAL 78. FIRE PREV. FINAi- HEALTH DEPT. REQUIREi0ENT 79, FINAL INSPECTION l 1 $0, FOOD CERTiFICA1 E ISSUED - -- 1 Notes: i I s I 45. Sound Attenuation 46. Handicap Regulations t I 47. FINAL STRUCTURE & BUILDING l 48 FINAL PLANNING � I 49. Electric Release to Edison I - 50 Gas Release to Southern California Gas Co i 51. CERTIFICATE OF OCCUPANCY Na. Date ,.. IT CITY OF COSTA MESA CONSTRUCTION PERMIT ,C Project Address � y7 f s-ro -T l FI y N Applicant's Mailing Address J O oy- 5_%-3g� T OUS�g Owner's Name AJ L V' Phone Address Arch/Eng. License No. Address Contractor's Namef�VIE:Arr TQC [till ` Phoria Address (mailing) Ph6� ��Wosg y� City License No. LICENSED CONTRACTOR DECLARATION I hereby affirm that I -am licensed under provisions of Charter 9 (commencing with section 7000) of Division 3 of the Business and Professions Code, and my license is in fl force ffect. Z5�-I License �cCl,Ss License No. Date rh_ 3 �+� Signature RS'COMPENSATION DECLARATION reby affirm that I have a certificate of consent to self -insure or a certificate wdrkers' Compensation Insurance, or a certified copy thereof (Section 3800, Lab. ) P licy No qy1- �Z'CompanyJ�1 Certified copy is hereby furnished. Certified py is filed with the city Bai�hur mon. Date Il"}- g, —`t( � Applicant �� EXEMPTION FROM WO RKERS'COMPE14S4TrON DECLARATION (This section need not be completed if the permit is for one hundred ($100) or less). I certify that in the performance of the work for which this permit is issued I shall not employ any person in any manner so as to become subject to tNe Workers' Compensation Laws of California. Date Signature NOTICE: If, after making this declaration, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is 'issued (Section 3097 Civ. C.) Lender's Name Lender's Address OWNER BUILDER DECLARATION I hereby affirm that I am exempt from thIC ontractor's License Law for the following reason (Section 7031,5 Business anProfessional Code: Any city or county which requires a permit to construct, alter, improve, demolish or repair any structure, prior to its issuance, also requires the applicant for such permit to file a'signed statement that he/she is licensed pursuant to the provisions of `he Contractor's License Law (Chapter 9 (commencing with Section 7000),of ision 3 of the, Business and Professions Code) or that he/she is exempt refrom and the basis for the alleged exemption. Any violation of Section .,31.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500). El I, as owner of the property,or my employees with wages as their sole compensation, will do the work, and the structure is not intended or -offered for sale (Section 7044, Business and Professional Code: The Contractor's License Law does not apply to an owner of a property who builds or improves thereon, and who does such work himself/herself or through his ocher own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of com- pletion, the owner will have the burden of proving he/she did not build or im- prove for the purpose of sale). ❑ 1, as owner of the property, am exclusively contracting with licensed con- tractors to construct the project (Section 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon. and who contracts for such nroiect5 with a con- tractor(s) license pursuant to the Contractor's License Law). 1 am aware that proof of their Worker's Compensation insurance should be provided to me.' ❑ 1 am exempt under Section B. & P. C. for this reason Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations. PErRMIOt �a TRACT NO. LOT NO. UNIT NO. A.P Date Owner I hereby certify that I have read this application and state that the above information is correct. I a ee to comply with all city and county ordinances and state laws lating t uilding construction, and hereby authorize repre- sentatives of tttllity nter u on the above-mentioned property for . Inspection ems/ [% le' 'T,Q� Sipectic /%/ DateL Drivers' Li TYPE OF CONSTRUCTION LJ NEW LJ ADD L-JLTERATI ❑ CONVERSION ❑ DEMOLISH � OTHER DESCRIPTION OF WQRKJUSE OF BLDG._ TYPE'OF PERM,LT/ I_J GRADI ❑ TENANT -99ZLECTRICA ❑ -OTHER PROJECT DESCRIPTION SQ. FT CON ST RUCTION TYPE ZONE G Remarks: ar Sink ackflow Preventer ackflow Irrigation Bathtubs Clarifiers Dishwasher Drinking Fountains Floor Drains Floor Sinks . Gas Service ' Outlets Interceptors Kitchen Sink Lavatories P --Trap Roof Drains REPAIR NG LJ FOUNDATION LJ STRUCTURAL L ❑ PLUMBING ❑ MECHANICAL OCCUPANCY VALUATION $ RADINGCU.YDS. ACRES Reinspection Fee 1 $15 Boiler Duct- Under Ground Duct - Structural Duct - Ventilating Exhaust System ❑ Multiple ❑ FireplJFact. Bit. ICBG 4h Heating System & Ducting (710-100,000 BTU 11100,000 BT Reinspection Fee 1 $15 0865-46, rev. 5/88 White - Building; Canary - Applicant; Pink - Accounting; Goldenrod - Assessor PLUMBING Showers Service Sink - Sewer Cap Sewer Connection Solar Collectors Solar Piping Solar Tank Swimming Pool w/Spa Urinal Water Closet Water Heater Water Service " Auto -Wash Laundry Trays Issue Fee Hood or Type I ❑ Canopy Type 11 ❑ Refrigeration System ❑0-100,000 BTU ❑100,000 BTU System Repair/Alteration Fire Dampers Registers i Issue Fee S Main Building: E T Front A Rear C Right K S Left Ping. Hof. + 'Planning Notes: Accessory Building: Parking Req./Provided ELECTRICAL FEES Automatic Washer SUMMARY OF FEES Construction Pole Sub. $ Cooking Unit PLAN CHECK Dishwasher PERMIT Dryers ❑Gas ❑Electric $ Fan :f F.A.U. ENERGY P.C. Fixtures f Device Boxes PLAN CHECK 50% Outlets MICROFILM Switches $ Garbage Disposal PLAN CHECK 25% Generator ❑0-5 KW El 5-15 KW Zone Transformer ❑ 15-50 KW ❑ 50+KW Meter LJup to 100 amps Meter ❑over 100 amps Sub Panel Motors ❑0.1 HP ❑ 1'G - B Inc.ISolar ❑9-15 HP 016-15+ Microwave Pole Light Range. Sign Standing Sections Trash Compactor Reinspection Fee $15 Issue Fee $ 3 DEVELOPMENT SERVICES REQUIREMENTS: Zoning Approved By FEES Building Approved By = Application Issued By — $ 3 to to t $ Z O N N G R E Q M T S. 01 000 16307•-00016307 T 0 T' 22.50 DATE: 10/05/88 TInE: 14144 SUMMARY OF FEES BUILDING PERMIT $ SMIP PLAN CHECK $ PERMIT PLUMBING $ ISSUANCE PLAN CHECK 25% $ ENERGY P.C. ELECTRICAL $ GRADING PLAN CHECK 50% $ MICROFILM MECHANICAL $ TOTAL FEE PLAN CHECK 25% $ . to to t $ Z O N N G R E Q M T S. 01 000 16307•-00016307 T 0 T' 22.50 DATE: 10/05/88 TInE: 14144 CONSTRUCTION AND PLANNING f APPROVALS Permit # ; Date Inspector PO : SPA APPROVALS Permit :#- Date Inspector 1. Temporary Electrical Service or Pole 52. Pool & Equipment Location 2. Soil Pipa-Undrgrnd, _ 53. Steel Reinforcement 3� Electrical Conduit Utility-Undrgrnd. 54. Forms 4.IElectrica) Conduit-Undrgrnd. ', I 55. Electrical Bonding 5:ISteel;Re`inforcement t,. 56. Rough Plumbing & Pressure Test 6. Electrical LIFER Grnd-'� 57. APPROVAL TO COVER-GUNITE 7.• Footings, ; , s 58. Electrical Conduit-Undrgrnd, 8. Foundation 59. Gas Pipe, © Undrgrnd., Test 9. Water Pipe-Undrgrnd. 60. Backwash Lines, P -Trap, ❑ Undrgrnd. 10. Structural Floor System 61. APPROVAL TO DECK 11.• Property Sewer Line. & House Connection 62. Backwash & Receptor -Final 12. Sewer Cap 63. Heater & Vent -Final 13. Roof Drains 64. Plumbing System - Final 14' -Rough Plumbing 65. Electrical -Final 15. Rough Electrical -Conduit 66. Solar System -Final 1i6. Rough Electric Wiring 67. Fencing & Access Approval 17. Rough,Wiring Sign 68. APPROVED FOR PLASTERING 18. Rough Electrical -T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning - .r FIRE DEPT. REQUIREMENT APPROVALS Permit # 20. Rough Factory Fireplace 21. Ducts,•in'Structure 70. Underground Hydro - 22. Ducts, Ventilating 71. Product Piping []Gas ❑ Oil 23: Gas Pipe Rough & Test 72. Underground Flush 24. Rborf Framing 73. Undergrnd. Storage Tank ❑ Gas ❑ Oil 25. Roof Sheathing 74. Overhead Hydro 26. T -Bar Ceiling (Structural) & Monocoat 75. Dry Chemical 27. Frame and Flashing 76. Dry Standpipe r 28. Lathing & Siding 77. FIXED SYSTEM FINAL 29, Insulation 78. FIRE PREY. FINAL -30.' Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat 79. FINAL INSPECTION 32. Electrical Power Meter -Final 0. FOOD CERTIFICATE ISSUED 33. Final Electric .10 Notes: 34. Final Heating & Air Conditioning 35. Final Gas Pipe -Test 36. Hood or Canopy 37. Final Factory Fireplace 38. Final Plumbing 39. Water Service -Final 40. Gas Service -Final 41. Solar Domestic -Final 42. Backflow Preventer 43. Backflow Irrigation i 44. Landscape Irrigation System 45. Sound Attenuation 46. -Handicap Regulations 47. FINAL STRUCTURE & BUILDING 48. Special Requirements Completed 49. Electric Release to Edison rf 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY No. Date --• ' f ffr� CITY OOST4 MErr�SSA CONSTRUCTION PERMIT Pr6jeci dress /, v Applicant's Mailil,b Address 2 �A% t° /�� P. Owner's Name T�r�.syY 7 Gam. -Phone Address J{- e -, -_T 4 I o /^106 22 Arch/Eng.Aer'l&', QyToI%int (_ 7y License No. Address L E,1V61 i1 o Contractor's !Name (r- LLAy G� h $7 ' Phon' 6 Address (mailing) _ZAd9_9 6,/A ll -e &d City License No. �_ 00 K 2 .9 •% LICENSED CONTRACTOR DECLARATION I hereby affirm that I am licensed under provisions of Charter 9 (commencing with section 7000) of Division 3 of the Business and Professions Code, and MY license is in full fg ce and effect. J,2 6 �l Z 6 License Class y Lf I Ice_nse No• Date Sl Signature ' 'r WORKERS' COMPENSATION DECLARATION .000 I h@reby affirm that I have a certificate of consent to self -insure or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Section 3840, Lab. C.) 5'- �.++ Policy No. �T: ` company ✓ZV-L,zlrri5'_ �.I Certified copy is hereby furnished. � Certiflied� py_is filed with the city Bu' ding ivislon. Date �— i3Y-oV Applicant EXEMPTION FROM WORKERS' COMPENSATION OALARATION (This section need not be completed if the permit is fo one hundred ($100) or less). I certify that in the performance of the work for which this permit is issued, 1 $hall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California. Date Signature NOTICE: If, after making this declaration, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith cornply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I heareb,� affirm that there is a construction lending agency for the performance of the work for whicrl this per it is issued (Section 3097 Civ. C.) bender's Name A-, 7 b i -r , M, h /� Lender's Address 16 I- 1/ +9 0- _ OWNEIR BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5 Business and Professional Code: Any city or county which requires a permit to construct, alter, improve, demolish or repair any stritcture, prior to its issuance, also requires the applicant for such permit to file a signed statement that he/she is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division .3 of the Business and Professions Code) or that he/she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil enalty of not more than five hundred dollars ($500). 1, as owner of the property or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for. sale (Section 7044, Business and Professional Code: The Contractor's License Law does not apply to an owner of a property who builds or improves thereon, and who does such work himself/herself or through his or her own employees, Provided that such improvements are not intended or offered for Sale. If, however, the building or improvement is sold within one year, of Com- pletion, the owner will have the burden of proving he/she did not build or im- prove for the purpose of sale). i, as owner of the property, am exclusively contracting with licensed'con- ractors to construct the project (Section 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a con- tractors)license pursuant to the Contractor's License Law). I am aware that proof of their Worker's Compensation insurance should be provided to me, ❑ 1 am exempt under Section B. & P. C. for this reason Date Owner I hereby certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances 4:Yd state laws relating to building construction, and hereby authorize repre- sentatives of this city to enter upon the above-mentioned property for inspection purpo S. .�-7-1c, / Signature Date • Drivers' License or SS spiieant to fill in all spaces except those within heavy border lines and sign all appropriate declarations. P MIT NO. TRACT NO. LOT NO. UNIT Nb. .3 12g= 10 JFM 94 -• aq !s �T t F FAN Li , s TYPE OF CONSTRUCTION LJ NEW LJ ADD ><ALTERATION LJ REPAIR 6 ❑ CONVERSION ❑ DEMOLISH ❑ OTHER A.P.+ w ZoneG 1 S DESCRIPTION OF WORK/USE OF BLDG. -A� A° Ta,� + $ Main Building: Accessory Building; TYPE OF'PERMIT GRADING FOUNDATION STRUCTURAL T Front' 0 ❑ TENANT ❑ ELECTRICAL ❑ PLUMBING ❑ MECHANICAL B Rear N ❑ OTHER A I PROJECT DESCRIPTION SQ. FT. OCCUPANCY 'lK Right G '- CONSTRUCTION OTYPE , VALUATION $ �� *2 S Left R ZONE _ GR DING CU.YDS. ACRES Ping. Ref. �6` Parking Re[l.lProvided E ^ [ O Remarks:,- Planning Notes: S M W I L I. fDAii 3 T .. _ S' Reinspection Fee 1 $15 Boiler Duct - Under Ground Duct - Structural Duct - Ventilating Exhaust System ❑ Multiple ❑ Firepl/Fact. Bit. ICBO # Heating System & Ducting 1:10-100,000 BTU ❑ 100,000 BT Reinspection Fee 1 $15 CMF 0865-46, rev. 10/84 White - Building; Canary - Applicant; Pink - Accounting; Goldenrod - Assessor, Issue Fee Hood or Type I ❑ Canopy Type 11 ❑ Refrigeration System ❑0-100,000 BTU ❑100,000 BTU System Repair/Alteration Fire Dampers Registers Issue Fee PLUMBING FEES ELECTRICAL FEES Bar Sink Showers Backflow Preventer Service Sink $15 I Issue Fee Automatic Washer Construction PofeSub. Transformer ❑ 15-50 KW El 50 + KW Backflow Irrigation Sewer Ca P Bathtubs Sewer Connection Date •3 ` Date• Date 7 JW Cooking Unit' Meter ❑up to 100 amps Clarifiers Solar Collectors BUILDING PERMIT PLAN CHECK PLUMBING PLAN CHECK 25% ELECTRICAL PLAN CHECK 50% MECHANICAL PLAN CHECK 25% Dishwasher Meter Dover 100 amps Dishwasher Solar Piping _ Dryers ❑Gas ❑Electric Sub Panel Drinking Fountains Solar Tank Fan Motors 00-1 HP❑1/s-8 Floor Drains Swimming Pool vv/Spa F.A.U. Inc. Solar 13 9-15 HP Ell 6-15+ Floor Sinks Urinal Fixtures Microwave Gas Sirvice Outlets , 'Weiter Closet Device Boxes Pale Light Interceptors i r /Wafer Heater Outlets Range Kitchen Sink v Water Service Switches Sign Lavatories - Auto -Wash Garbage Disposal Standing Sections P -Trap- r Y' rEaundry Trays Generator 00-5 KW 115-15 KW Trash Compactor Roof Drains - _ _ Reinspection Fee 1 $15 Boiler Duct - Under Ground Duct - Structural Duct - Ventilating Exhaust System ❑ Multiple ❑ Firepl/Fact. Bit. ICBO # Heating System & Ducting 1:10-100,000 BTU ❑ 100,000 BT Reinspection Fee 1 $15 CMF 0865-46, rev. 10/84 White - Building; Canary - Applicant; Pink - Accounting; Goldenrod - Assessor, Issue Fee Hood or Type I ❑ Canopy Type 11 ❑ Refrigeration System ❑0-100,000 BTU ❑100,000 BTU System Repair/Alteration Fire Dampers Registers Issue Fee i1 Reinspection Fee $15 I Issue Fee $ 3 FEES DEVELOPMENT SERVICES REQUI M NTS: Zoning Approved By Building Approved By Application Issued By • 55C2 Date •3 ` Date• Date 7 JW BUILDING PERMIT PLAN CHECK PLUMBING PLAN CHECK 25% ELECTRICAL PLAN CHECK 50% MECHANICAL PLAN CHECK 25% SUMMARY OFF $ ,00 S $ $ $ $ $ $ S SMTP PERMIT ISSUANCE ENERGY P.C. GRADING MICROFILM TOTAL FEE Q $ f 0 $ $ $ $ Q $ t� l ' $ 3 01 013DU775_0000 77? TOT .1340193 i1 r POOL & SPA ONSTRUCTION AND PLANNING Permit #fit' Date } Inspector,, APPROVALS Permit # Date .Inspector /APPROVALS 1'. `Temporary Ele ical'Service or Pole 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd. V 53, Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. 54. Forms f} 4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding 5. Steel Reinforcement, '. 56. Rough Plumbing & Pressure Test r� 6. Electrical UFER Grnd.'% 57. APPROVAL TO COVER-GUNITE 7. Footings `� . �" i 58. Electrical Conduit-Undrgrnd' �. 8. Foundation rt -�r , ; 59. Gas Pipe, ❑ Undrgrnd., Test 9. Water Pipe-U6drgrn&. {, 60. Backwash Lines, P -Trap, ❑Undrgrnd. i. 10. Structural Floor Systemr/ 61. APPROVAL TO DECK 11. Property Sewer Line& House Connection 62. Backwash & Receptor7Final U 12. Sewer Cap 63. Heater & Vent -Final V _- ' !_ 13. Roof Drains 64. Plumbing System - Final I '" 14. Rough Plumbing 65. Electrical -Final 15. Rough Electrical -Conduit 66. Solar System -Final it 1 16. Rough Electric Wiring 67, Fencing & Access Approval 17. Rough Wiring Sign 68. APPROVED -FOR PLASTERING 18. Rough Electrical -T Bar Ceiling ' 69. POOL/SPA SYSTEMS FINAL �I 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit =/h_- -21. 20. Rough Factory Fireplace 21. Ducts, in Structure 74. Underground Hydro - (1 22. Ducts, Ventilating 71. Product Piping ❑ Gas ❑ Oil 23. Gas Pipe -Rough & Test 72. Underground Flush, - 24. Roof Framing 73. Undergrnd. Storage Tank'�CJ Gas ❑ Oil 25. Roof Sheathing' j& 74. Overhead Hydro -''�✓ 26. T -Bar Ceiling (Structural) Monocoat 75. Dry Chemical f+•" , fit• . 27. Frame and Flashing _ 76. Dry Standpipe "�I '-x 28. Lathing & Siding 77. FIXED SYSTEM FINAL - �& 29. Insulation 78. FIRE PREV. FINAL r 30. Drywall Nailing - 3 HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat 79. FINAL INSPECTION 32. Electrical Power Meter -Final 80 FOOD CERTIFICATE ISSUED 1, 33. Final Electric Notes: al f,e W C 34. Final Heating &Air Conditioning i' ��Akc f't7 35. Final Gas Pipe -Test o W-40 36./Hood or Canopy 37.. Final Factory Fireplace 3$1 Final Plumbing 39: Water Service -Final / j • s Z; ,. t, ' ,,) ": { .40. Gas Service -Final 41. Solar Domestic -Final ° X12. Backflow Preventer � LV ,43• Backflow Irrigation 1,�� _ ; _ : ✓�' �' X44. Landscape Irrigation System �� �� �' f1.1 X45 Sound Attenuation -46. Handicap Regulations 47'. FINAL STRUCTURE & BUILDING w1 r - , orf It 4$) Special Requirements Completed 1 }`, 49. Electric Release to Edison 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY No. Date ' PAM R.;, Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations. bF, COST r�NS R C ION P R IT P M NO. TRACT NO. LOT NO, UNIT NO. nrf a.a� '�` `�rTsS0�l L An is c i Applicant's Mallin d Qvvner's Name '?Address -- - Arch/Eng. License No. Address Contractor's Nam 3 t �t- PhoeC��r Address Imailinal City License No. LICENSED CONTRACTOR DECLARATION I nereby affirm that I am licensed under provisions of Charter 9 (commencing with section 7000) of Division 3 of the Business and Professions Code, and my incense is in fu€CoroeZarJH effect. � 3<3i5 f Livens I L J 1Q No. � kb 10 Date Signature WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self -insure or a certificate of Workers' Compensation Insurance, or a certt iecl copy thereof WCeliied. ab. C. ;,_,L)t *4C_ . o`rComp nyfied copy is hereby furnished,i led with the citQu Date� Appl€Cant- - - EXEMPTION FROM WORKERS' COMPENSATION DECLARATION ((This section need not be completed if the permit is for one hundred ($100) or fess). I certify that to the Performance of the work for which this Permit is issued i shall not employ any person in any manner. So as to become subject to'the Workers' Compensation Laws of California. DateSignature NOTICE: If. after making this -declaration, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY i1 I hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is issued (Section 3097 Civ. C.) Lender's Name Lender's Address - - OWNER BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractor's License LaW for the following reason (Section 7031.5 Business and Professional Code: Any city or county which requires a permit to construct, alter, improve, demolish or repair any structure, prior to Its issuance, also requires the applicant for such permit to file a Signed statement that he/she is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he/she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit Subjects the applicant to a civil enalty of not more than five hundred dollars ($500). I, as owner of the property or my employees with wages as their sale Compensation, will do the work, and the structure is not intended or offered for sale (Section 7044, BuSiness and Professional Code: The Contractor's License Law does not apply to an owner of a property who builds or improves thereon, and who does such work himselt/herself or thrOugri his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or Improvement Is sold within one year of com- p€etion, the owner will have the burden of proving he/she did not build or Im - rove farr the purpose of sale). I, as owner of the property, am exclusively contracting with licensed con- tractors to construct the project (Section 7044, Business and Professions Code: The Contractor's License t.aw does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a con- tractor(S) license pursuant to the Contractor's License Law), I am aware that proof of their worker's Compensation insurance should be provided to me. ❑ 1 am exempt under Section B. & P. C. for. this reason Date Owner I hereby certify that I have rea information is correct. 1 agree to and state ws r ting bu!1tltr sentatives inspection p es. Signature Drivers' License or Sf I this application and state that the above com ly with all city and county ordinances g structlon, and hereby authorize repre- ��t7l)r the above-mentioned pro ert �_- TYPE OF CONSTRUCTION Ll NEW Li ADD L ALTERATION LJ REPAIR ❑ CONVERSION ❑ DEMOLISH ❑ OTHER A.P.; Zone DESCHIP ION OF WORK/USE OF BLDG. t4f0 S Main Building: Accessory Building: E Z TYPE OF -PERMIT GRADING FOUNDATION STRUCTURAL T Front O ❑ TENANT ❑ ELECTRICAL 1 PLUMBING LJ MECHANICAL B N ❑ OTHER A Rear I Right PROJECT DESCRIPTION SQ. 1=T. oCCUPANCY K G CON 5TRUCTION TYPE VALUATION $ S Left R ZONE G ADING CU. YDS. ACRES— Ping. Ref. # Parking Req,/Provided E n Remarks:-, Ir Planning Notes: M II-AlRa r &t� 1 T S PLUMBING FEES Bar Sink Showers ELECTRICAL FEES Backflow Preventer Service Sink Automatic Washer Transformer ❑ 15-50 KW Backflow Irrigation Sewer Cap Construction Pole Sub. ❑ 50+ KW _ Bathtubs Sewer Connection Cooking Unit Meter El up to 100 amps Clarifiers Solar Collectors Dishwasher Meter Dover 100 amps Dishwasher Solar Piping Dryers ❑Gas ❑Electric Sub Panel Drinking Fountains Solar Tank Fan Motors 00.1 HP 01%a- 8 Floor Drains Swimming Pool w/Spa F.A.U. I . Solar 139-15 HP 01r.,15+ Floor Sinks Urinal Fixtures Microwave Gas Service Outlets Water Closet Device Boxes Pole Light Interceptors Water Heater oe Outlets.. Range Kitchen Sink Water Service 2..00 Switches Sign Lavatories Auto -Wash Garbage -Disposal Standing Sections P -Trap Laundry Trays Generator ❑0-5 KW 05-15 KW Trash Compactor Roof Drains ? Reinspection Fee $15 Issue Fee $ 3 Reinspection Fee $15 Issue Fee $ 3 MECHANICAL FEES Boiler Hood or Type I ❑ DEVELOPMENT SERVICES REQUIREMENTS: Canopy Type I I ❑ zoning Approved By note Duct - Under Ground Building Approved By Date Duct - Structural Refrigeration System Application Issued By s Dat Duct - Ventilating 00,000 BTU 0100,001) BTU SUMMARY OF4FEESV Exhaust System ❑ Multiple ❑ System Repair/Alteration BUILDING PERMIT $ SMW $ PLAN CHECK $ PERMIT Firepl/Fact. Bit, ICBO is Fire Dampers ISSUANCE $ PLUMBING $ Heating System & Ducting Registers PLAN CHECK 25% $ ENERGY P.C. $ ❑0.100,000BTU ❑100,000BT GRADING $ ELECTRICAL $ � a PLAN CHECK 50% $ � • 5-10 MICROFILM $ MECHANICAL S TOTAL FEE $ �� ` p Reinspection Fee $15 Issue Fee $ 3 PLAN CHECK 25% $ CMF 0865-46, rev. 14184 White - Building; Canary - APPlicanl; Pink - Accounting-, Goldenrod - Assessor 01 00009036-00009037 -f 6 t 35.sa CONSTRUCTION AND PLANNING POOL & SPA _ r APPROVALS Permits# Date Inspector APPROVALS Permit +_ Date Inspector •� f 1,fTemporary ElectricaliService or Pole 52. Pool & Equipment Location 2� Soil Pipe-Undrgrnd.'�l 7{i�$� e.F� 53. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. 54. Forms 4. Electrical Conduit-Un`drgrrnd. 55. Electrical Bonding 5. Steel Reinforcement�� ._ 56, Rough Plumbing & Pressure Test 6• Electrical LIFERGrrnd�� 57. APPROVAL TO COVER-GUNITE 7. Footings 58, Electrical Conduit-Undrgrnd, 8. FourOation 1 r' 59. Gas Pipe, ❑ Undrgrnd., Test 9. VlFateL Pipe-Undrgrnd 60. Backwash Lines, P -Trap, ❑ Undrgrnd, J� 10. Structural Floor System 61. APPROVAL TO DECK 11, Property Sewer Line KI -Douse Connection 62. Backwash & Receptor -Final 12. Sewer Cap 63. Heater & Vent -Final 13. Roof Drains 64, Plumbing System - Final 14. Rough Plumbing Sge-F jV-S--Ay 65. Electrical -Final 15. Rough Electrical -Conduit 66. Solar System. -Final 16. Rough Electric Wiring 67. Fencing & Access Approval 17. Rough Wiring Sign (; ; (F 68" APPROVED FOR' ,PLASTERING 18, Rough Electricai-T Bar Ceiling i� c� 69.-)POOL/SPA SYSTEMS FINAL � 4i r� ,FIRE 19. Rough Heating & Air Conditioning DEPT. REQUIREMENT ` I' APPROVALS Permit # ^ } of v 20. Rough Factory Fireplace 21. Ducts, in Structure 70. Underground Hydro r�(� 22. Ducts, Ventilating 71. Product Piping ❑ Gas 0 Oif. 23. Gas Pipe -Rough & Test 72. Underground Flush SFr-' 1 ll s 24. Roof Framing 73. Undergrnd. Storage Tank (;W ❑ Oil 25, Roof Sheathing , 74. 'Overhead Hydra, 26. T -Bar Ceiling (Structural) & Monocoat 75. Dry Chemical f 27. Frame and Flashing 76. Dry Standpipe 28. Lathing &,Siding 77. FIXED SYSTEM FINAL 29. Insulation 78. FIRE PREV. FINAL�7-� 30. Drywall Nailing HEALTH DE _,REQUIREMENT �'� V-1 31. Plaster Brown Coat 79. FINAL INSPECTION 32. Electrical Power Meter -Final 80. FOOD CERTIFICATE ISSUp 33. Final Electric Notes: &,*s t/460r-oe. [.Eo 17 34. Final Heating & Air Conditioning (✓;"7 35. Final Gas Pipe -Test - ^' 36. Hood or Canopy 37..Final Factory Fireplace + , 38: Final Plumbing` - 39. Water Service -Final 40. Gas Service -Final Y - t - J'.l•.r t 541. Solar Domestic -Final 42.1 Backflow Preventer 43: Backflow Irrigation 44. 'Landscape Irrigation System} 45. Sound Attenuation 46. Handicap Regulations 47, INAL STRUCTURE & BUILDING 48._Special Requirements Completed `1 +�F`"' f ( ITJ 17 49.`Electric Release to Edison 50. Gas Release to Southern California Gas Cc 1 `� 51. CERTf FICATE OF OCCUPANCY No. Date Al &7 l%.... f-�+G� O Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations. $15 Issue Fee ' CITY OF.GOST.Ky�M..��E��SA CO�+N�S-TRUC ION PERMIT PE iT N t TRACT NO. LOT NO. UNIT NO. A.P. # _ Dryers E]Gas ❑Electric Sub Panel Fan Motors 004 HP E3 11/2'. 8 _ ys 7� �! Fixtures Microwave ' Device Boxes Pole Light l Project Addresa� 39Q_ OL UIi 1 .2CJ q. 1 Garbage Disposal Standing Sections . Generator ❑0-5 KW 05-15 KW Trash Compactor S Main Building: Applicant's Mailing Address r t d 4 �( TYPE OF CONSTRUCTION New ADD ALTERATION REPAIR ❑ CONVERSION ❑ DEMOLISH ❑ OTHERT E Front Owner's Name / �"(�� �� Phone i7 -r DESCRIPTION OF WORK/USE OF BLDG. �- B Rear Address r?'�' 6��--- �:lzC t LS� 1 A. Right Arch/Eng. License No. TYPE OF PERMIT GRADING FOUNDATION STRUCTURAL ❑TENANT ❑ ELECTRICAL ❑ PLUMBING MECHANICAL K S Left Address �.�g_�t� W- Contractor's NamPg� i� ��� PhonetJiL�+' ❑'OTHER Ping. Ref. # Address [mailingl -M .,_--,. Z- dsuo — PROJECT DESCRIPTION SQ. FT. OCCUPANCY Planning Notes: CONSTRUCTION TYPE VALUATION $ �``�� City License No. 2� ZONE GRADING CU.YDS. ACRES LICENSED CONTRACTOR DECLARATION I hereby affirm that I am licensed under provisions of Charter 9 (commencing . with section 7000) of Division 3 of the Business and Professions Code, and my license is in full fo c and effect. License C as Lhiense Date Signature WORK RS' COMPENSATIONE? N D RTION I hereby.affirm that I have a cern ate of Aconsent to Self -insure or a certificate of Workers' Compensation Insura ce, or a certified copy thereof (Section 3800, Lab. ^y' Policy No. Company 4K.! ©-Certified copy is h reby furnished. Certifi o i tied with the city B in ivi n, y DateApplicant IJ Y EXEMP IO FROM WORKERS' C ENSATION D CLARATION (This section need not be completed i r he permit is for one hundred ($100) or - less). I certify that.in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become Subject to the Workers' Compensation Laws of California. Date Signature NOTICE: If, after making this declaration, you Should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply ,with- such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDINGAGENCY- I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is Issued (Section 3097 Civ.. C.) Lender's Name- Lender's Address - - OWNER BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section -7031.5 Business and Professional Cade: Any city or . county which requires a permit to construct, alter, improve, demolish or repair 'any -structure, prior to its issuance, also requires the applicant for such permit '-to file a signed statement that°he/she is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he/she is exempt therefrom -and ,the basis for the alleged exemption. Any violation of Section 7031,5 by any applicant for a permit subjects the applicant to a civil enalty of not more than five hundred dollars ($500). 1; as owner of the property or my employees with .wages as their sole ,compensation, will do the work, and the structure is not Intended or.offered for sale {Section .7044. Business and Professional Code: The Contractor's License taw does not apply to an owner of a property who builds or improves thereon; and' who does such work himself/herself or through his or her own employees, provided that Such improvements are not intended or offered for sale. If„however, the building or -improvement is sold within one year of com- pletion,rthe owner will have the burden of proving he/she did not build or !m - Hrove for the purpose of Sale). I, -as owner of.the property, am exclusively contracting with licensed can - tractors to construct the project (Section 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and -who contracts for such aroiectS with a con- tractor(Sl license pursuant to the Contractor's License Law). I am aware that proof of their Worker's Compensation insurance should be provided to me.' ❑ `I am exempt under Section B. & P. C. for this reason Date Owner. I hereby certify that .I have read this application and state that -the above information is Correct. I agree to comply with all city and county ordinances and state laws relating to building nstruction, and hereby authorize repre- sentatives of t ty ente pan the above-mentioned pro ert for inspection p se . SI riot eDa Remarks: Bar Sink Backflow,Preventer Backflow Irrigation Bathtubs Clarifiers Dishwasher* ; Drinking Fountains Floor Drains Floor Sinks Gas Service Outlets Interceptors Kitchen Sink Lavatories P -Trap Roof Drains Reinspection -Fee $15 Boiler Duct - Under Ground , Duct - Structural Duct - .Ventilating Exhaust System ❑ Multiple ❑ FirepllFact- Bit. ICBO * Heating System & Ducting ' ❑ 0-100,000 BTU ❑ 1 oo,000 Bf g ur Drlvars' ense or SS I Reinspection Fee 0865.46, rev. 5/88 White - Building; Canary - Applicant; Pink - Accounting; Goldenrod - Assessor JMBING Showers - Service Sink Sewer Cap Sewer Connection Solar Collectors Solar Piping Solar Tank Swimming Pool w/Spy Urinal - Water Closet Water Heater . Water Service Auto -Wash Laundry Trays Issue Fee - Hood or Type I ❑ I4 Canopy Type I I ❑ Refrigeration System ❑0-100,000 BTU ❑ 100,000 BTU Syitem Repair Iteration Fire Dampers RegisserS` Issue Fee zone Accessory Building: 0 1 N R Parking Req./Provided E Q t M S. ELECTRICAL FEES $15 Issue Fee FEES Automatic Washer. Transformer LJ 15-50 KW Construction Pale Sub. ❑ 50 + KW , $ .3E Cooking Unit Meter El up to 100 amps _ j- Dishwasher Meter [Dover 100 amp's ; BUILDING PERMIT PLAN CHECK PLUMBING PLAN CHECK 25% ELECTRICAL PLAN CHECK 50% MECHANICAL PLAN CHECK 25% _ Dryers E]Gas ❑Electric Sub Panel Fan Motors 004 HP E3 11/2'. 8 - F.A.U. Inc. Solar C19-15'HP ❑16-15+• ' �! Fixtures Microwave ' Device Boxes Pole Light l Outlets Range $ 5.13 Switches Sign Garbage Disposal Standing Sections . Generator ❑0-5 KW 05-15 KW Trash Compactor Reinspection fee $15 Issue Fee $ 3 DEVELOPMENT SERVICES REQUIREMENTS: Zoning'Approved By Date Builcl Approved By, Date Application Issued By Dat $ .3E FEES BUILDING PERMIT PLAN CHECK PLUMBING PLAN CHECK 25% ELECTRICAL PLAN CHECK 50% MECHANICAL PLAN CHECK 25% SUMMARY OF FEES $ SMIP $ $ PERMIT $ ISSUANCE $ $ ENERGY P.C. $ . $ GRADING $ $ MICROFILM $ , $ ” TOTAL FEE $ $ - 1�. �! 01 00009904-00009905 . TILT $ 5.13 3, CONSTRUCTION AND PLANNING APPROVALS Permit #Date ;' /4 Inspector POOL & SPA APPROVALS Permit # Date - Inspector 1 . Temporary Electrical Service or Pole ,,' : • - 52. Pool &Equipment Location ; 2.', Soil.Pipe-Undrgrnd. irl 53. Steel Reinforcement G T1 Electrical Condui�4Utility-Undrgrnd. 1 x r� 54. Forms.1 4� Ele trical Conduit-Undrgrnd. r - - - z 55. Electrical Bonding �. `5r.Steel Reinforceriilerft."i_' 56. Rough Plumbing & Pressure Test r6j Electrical UFER,Grndf /"' L 57. APPROVAL TO COVER-GUNITE Footings w� "� _ 58. Electrical Conduit-Undrgrnd. 8. Foundation `{ �^ r 59. Gas Pipe, ❑ Undrgrnd., Test 9? Warer Pipe -Un v 60. Backwash Lines, P Trap, ❑Undrgrnd, 1M 10. , tr.ctural Floor System j 61. APPROVAL TO DECK 1r1U;Property Sewer Line & House Connection ;f )p 62. Backwash &Receptor -Final f 12. Sewer Cap 1 u l "_1 c. ' _` ... .1, ' 63. Heater& Vent -Final .1Lq*5oof DrainsL ' ; 4 64. Plumbing System - Final 14. Rough Plumbing 65. Electrical Final 15. Rough Electrical -Conduit 66. Solar System -Final 1.6. Rough Electric Wiring 67. Fencing & Access Approval 17, Rough Wiring Sign 68. APPROVED FOR PLASTERING V18. Rough Electrical -T Bar Ceiling r -- 69. POOL/SPA SYSTEMS FINAL 119. Rough Heating &Air Conditioning Y Z"Y LCJ) FIRE DEPT. REQUIREMENT APPROVALS Permit # t,20. Rough Factory Fireplace G` r 21. Ducts, in Structure 70. Underground Hydro 22. Ducts, Ventilating 71. Product Piping ❑ Gas © Oil 23, Gas Pipe -Rough & Test 72. Underground Flush . �s 24, Roof Framing 73. Undergrnd. Storage Tank ❑ Gas ❑ Oil -I 25. Roof Sheathing 74. Overhead Hydro 26. T-Bar-ECeiling (Structural) & Monocoat 75. Dry Chemical 27.1rFrame and f. lashing 76. Dry Standpipe /' 1 28. LatPing & Siding s. 77. FIXED SYSTEM FINAL 29. Insulation f 78. FIRE PREY. FINAL �•� ' :} 30. Dryuvall Nailing HEALTH DEPT. REQUIREMENT J. 31. Plaster Brown Coat' 79. FINAL INSPECTION n 32. Electrical Power Meter -Final 80. FOOD CERTIFICATE ISSUED a� i 33. Final Llectric Notes -.9-I f_ Or_ DIZCfS !Fj 34. Final Heating & Air Conditioning Q -f rib Leo V 35. Final Gas Pipe -Test 36. Hood or Canopy r 37. Final Factory Fireplace 38. Final Plumbing 39. Water Service -Final 40, Gas Service -Final 41. Solar Domestic -Final 1 ' ' 42. Backflow Preventer 43. Backflow Irrigation ~r 44. Landscape Irrigation System 45. Sound Attenuation 46, Handicap Regulations 47. FINAL STRUCTURE & BUILDING 48. Soecial Requirements Completed 49, Electric Release to Edison t' 50. Gas Release to Southern California Gas Co,, 51. CERTIFICATE OF OCCUPANCY, No. Date Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations. CITY OF COSTA MESA CONSTR L TION PERMIT Project Address ,_Applicant's Mailing Address Owner's Namer7-. a' Phone Address -^�'1�C ArchlEng./0 SW License No. Address ��,�- .- - Contractor's Name ,5ffl�*&A=C&01j S Mgt&A Phone�j l Address (mailing) � . � 4 7DNI SLA . • 2�� City License No. LICENSED CONTRACTOR DECLARATION I hereby affirm that I am licensed under provisions of Charter 9 (commencing with section 7000) of Division 3 of the Business and Professions Code, and my license is in full ;Arcr and effect. Licen a Class 0 Date a-� - .Signature WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self -Insure or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Section 3800, Lab++��C,,.)��// ����pp�������// w Policy No.fku!�rZLri� Company Certified c�d}pY is heed withrthehCltyiiding Divretlon Date-�-�-q Applicant EXEMPTION FROM WORKERS' COMPENSATION NSATION DECLARATION (Thissection need not be cornPieted if the permit is for one hundred ($100) or less). I certify that in the performance of the work for which this permlt is issued I shall not employ any person In any manner so as to become subject to the Workers' Compensation Laws of California. Data Signature NOTICE: If, after making this declaration, you should become subject to the Workers' Compensation provisions of the tabor Code, you must forthwith comply with such provisions Or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit IS Issued (Section 3097 Civ. Gy-` Lender's Name Lender's Address OWNER BUILDER DECLARATION I hereby affirm that I am e%empt from the Contractor's License Law for the fallowing reason (Section 7031.5 Business and Professional Code: Any city or county which requires a permit to construct, alter Improve, demolish or repair any structure, prior to Its issuance, also requlres the applicant for such permit to file a signed statement that he/she Is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he/she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permlt subjects the applicant to a civil enalty of not more than five hundred dollars ($540). 1, as owner of the property or my employees with wages as their sole compensation, will -do the Work, and the structure is not intended or -offered for sale (Section 7044, Business and Professional Code: The Contractor's License Law does not apply to an owner of a property who builds or improves thereon, and who does such work himself/herself Or through his or her own employees, provided that such Improvements are not Intended or offered for sale. If, however, the building or improvement is sold within one year of com- pletion, the owner will have the burden of proving he/she did not build or im- prove for the purpose Of sale). , ❑ I, as owner of the property, am exclusively contracting with licensed con- tractors to construct the project (Section 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon• and who contracts for such oroiects with a con- tractor(s) license pursuant to Ine Contractor's License Law), 1 am aware that proof of their Worker's Compensation insurance should be provided to me. ❑ 1 am exempt under Section B. & P. C. for this reason Date owner 1 hereby certify that I have read this application and state that the above Information iscorrect. I agree to comply with all city and county ordinances and state laws relating to buildingstruction, and hereby authorize repre- sentatives of this city to enter o the above-mentioned property O Inspection p poses. Signature Date Drivers' Litt. or SS :p 0865-46, rev, 5/88 Whi 3 1 Ulyl 17, U. lj A.P. :0-- - - Zone S Main Building: Accessory Building: TYPE OF CONSTRUCTION 0 NEW El ADD ALTERATION El REPAIR ❑ CONVERSION ElDEMOLISH 1:1OTHE�j DESCRIPTION OF WORK/USE OF SLOG. —r �+U� - E T Front 2 O A Rear N C Right N TYPE OF PERMIT LJ GRADING 1-1TENANT 1-1ELECTRICAL❑ ❑ -OTHER FOUNDATION El STRUCTURAL PLUMBING 1:1 MECHANICAL g Left G R Ping, Ref. Parking Req./Provided E PROJECT DESCRIPTION SQ. FT. OCCUPANCY- CONSTRUCTION TYPE VALUATION $ ZONE GRADING CU.YDS. ACRES Planning Notes: Q M T S. Remarks: Q ITM rT p r ELECTRICAL FEES PLUMBING FEES Automatic Washer Construction Pole Sub. Transformer ❑ 15-50 KW Cl 50 + KW Bar Sink Showers Backflow Preventer Service Sink Cooking Unit Meter 0 u to 100 amps Backflow Irrigation Sewer Cap Dishwasher Meter El over 100 amps Bathtubs Sewer Connection Dryers ❑Gas ❑Electric Sub Panel Clarifiers Solar Collectors Fan Motors ❑0.1 HP ❑ 154 - B Dishwasher Solar Piping F.A.U. Inc. Solar 09-15 HP L1 16,15+ Drinking Fountains Solar Tank Fixtures Microwave Floor Drains Swimming Pool vv/Spa Device Boxes Pole Light Floor Sinks Urinal Outlets Range Gas Service Outlets Water Closet Switches Sign Interceptors Water Heater Garbage Disposal Standing, Sections K- en S' k Water Service Generator ❑0.5 KW ❑5-15 KW Trash Compactor Lavatories Auto -Wash P -Trap Laundry Trays �• Roof Drains Reinspection Fee $15 Iss de F J 11F 44,570 $� DEVELOPMENT SERVICES REQUI zoning Apprdved By-- y Building Approved By Application Issued By ME TS: pate at Reinspection Fee $15 Issue Fee $ 3 MECHANICAL MECHANICAL FEES Boiler Hood or Type I Canopy Type 11 ❑ SUMMARY OF FEES BUILDING PERMIT $ SMIP $ PLAN CHECK $ PERMIT PLUMBING $ ISSUANCE $ PLAN CHECK 25% $ ENERGY P.C. $ ELECTRICAL $ I ,Sb GRADING $ PLAN CHECK 50% $ MICROFILM $ MECHANICAL $ TOTAL FEE $ PLAN CHECK 25% $ Duct - Under Ground Duct Structural Refrigeration System 00-100,000 BTU El 100,000 BTU Duct - Ventilating Exhaust System ❑ Multiple ❑ System Repair/Alteration FirepilFact.Bit. ICHO Fire Dampers Heating System &Ducting ❑0100,000 BTU 0100,000BT Registers Reinspection Fee $15 Issue Fee $ 3 y - pplicant: Pink - Accounting; Goldenrod - Assessor L ��-' p ���- 01 00015209-00015209 TOT 19.50 (k"K DATE: 09/22/82 TIME: 14:14 CONSTRUCTION AND PLANNING 1 POOL & SPA APPROVALS Permit # __ Date Inspector APPROVALS Permit # date Inspector 1. TemporJry, Electrical Service or Pole '��� p 52. Pool& Equipment Location _ 4" I . � l 2. Soil Pipe-Qndrgrnd, s53. Steel Reinforcement 1 fl 3� Elec ical Ctondui4Vtililty-Undrgrn6. f 54. Forms i 4.1 Eleceical Conduit-Undrgrnd. `7 , 55. Electrical Bonding r 5 Steej.Reirif�rcement Is j 56. Rough Plumbing & Pressure Test `+ v f.,i t r1 6.! Electrical UFEF�G,r.��l� � +` 57. APPROVAL TO COVER-GUNITE t" 7,^ Footings -•'� `r 58. Electrical Conduit-Undrgrnd. } 8- Foundation - 59.. Gas Pipe, ❑ Undrgrnd., Test 9. Water Pipe-Undrgrnd. f,s 7 60. Backwash Lines, P-Trap, ❑ Undrgrnd. f 10 Structural Floor Syktem �" ;� 61. APPROVAL TO DECK 11. Property Sewer Line & House C6-ni ction .7 62. Backwash & Receptor-Final .y 12.lSewer Cap F^ „� r�; �r1 63. Heater & Vent-Final 13.• Roof Drains ,r r- 64. Plumbing System - Final 14. Rough Plumbing. 65. Electrical-Final 15. Rough Electrical-Conduit 66. Solar System-Final 16. Rough Electric Wiring 67. Fencing & Access Approval !1`7. Rough Wiring Sign 68. APPROVED FOR PLASTERING 18. Rough Electrical-T Bar Ceiling'_ 7 69. POOL/SPA SYSTEMS FINAL .19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT n APPROVALS Permit # 2Q. Rough Factory Fireplace 21. Ducts, in Structure �,� 70. Underground Hydro 22. Ducts, Ventilating - 71. Product Piping O Gas ❑ Oil 23. Gas Pipe-Rough & Test 72, Underground Flush 24. Roof Framing <� 73. Undergrnd. Storage Tank ❑ Gas ❑ Oil 25, Roof Sheathing ,74. Overhead Hydro .y 26. T-BarPiling (Structural) & Mor ocoat 75. Dry Chemical 27/Frame'and Flashing 76. Dry Standpipe r 28. Lathing & Siding s 77: FIXED SYSTEM FINAL 29. Insulation 78. FIRE PREV. FINAL 30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31,. Plaster Brown Coat 79. FINAL INSPECTION 32: Electrical Power Meter-Final 0. FOOD CERTIFICATE ISSUED 33. Final Electric otes: 34. Final Heating & Air Conditioning 35. Final Gas Pipe-Test 36. Hood or Canopy 37. Final Factory Fireplace 38. Final Plumbing 39, Water Service-Final �] 40. Gas Service-Final r I 41. Solar Domestic-Final } , 42. Backflow Preventer 43- Backflow Irrigation. ry 44. Landscape Irrigation System J ~` 45. Sound Attenuation 46- Handicap Regulations a I,U 47. FINAL STRUCTURE & BUILDING +' 1 48. Special�Requirements Completed {� 49. Electric Release to Edison 50. Gas Release to Southern California Gas CoI!kl ., .. CERTI F ICATE OF OCCUPANCY kn No. Date f' i Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations. ' CITY OF COST_ MESA ONSTRUCTION PERMIT Project A`�dress 7733 its ] 5U! l�C 5�,2 PER MI NO � �) 3 �G TRACT NO. LOT NO. UNITSNi�a ! TYPE OF CONST U NEW LJ ADD ALTERATION LJ REPAIR - ❑ CONVERSION ❑ DEMOLISH ElOTH DESCRIPTION OF WORKIUSE OF BLDG. Applicant's Mailing A ress r -- N Owner's am. 1 iAy_ q: Co'._ Phone Address Arch/Eng ¢ License No. Address ., r �p ��•-� Contractor's Nam Phone,.t.a.zi� Addre55(mailinai -3 Er_w S q� 7 Cit License No. —f City r�r�-n'���� _ LICENSED CONTRACTOR DECLARATION I hereby affirm that I am licensed under provisions of Charter 9 (commencing with section 7000) of Division 3 of the Business and Profession; Code, and my license is In fuLt force and effect. f License Clas-s7 C� b ice 'No._ I, ` ~f tell1 CC\�• Date Signature •� A. P. SIE zone S Main Building: Accessory Building: TYPE OF PERMIT GRADING D FOUNDATION STRUCTURAL ❑ TENANT ELECTRICAL ❑ PLUMBING ❑ MECHANICAL ❑ OTHER PROJECT DESCRIPTION SQ. FT. OCCUPANCY CONSTRUCTION TYPE VALUATION $ ZONE GRADING CU.YDS, ACRES E T Front % Z 0 B A Rear N I C Right N K S Left G Ping. Ref.` Parking Req.IProvided E Remarks:%( 4- Planning Notes: M �' _ T S PLUMBING FEES / ' WORKERS' COMPENSATION D CLARATION I hereby affirm that I have a certificate Of consent tq self-Insure or, a certificate ELECTRICAL FEES Bar Sink Showers Backflow Preventer Service Sink Automatic Washer Construction Pole Sub. Transformer '© 15-50 KW ❑' 5D + KW of Workers' Compensation Insurance, or a certified copy thereof (Section � `3800, Lab ) Policy No. ��'(O ra —9 Company ����t `"� } P 'Q C tified copy is hereby furnished. tnr-c-e-r�ifi co is filed with the city�•uiltling D• si Backflow Irrigation Sewer Cap Bathtubs Sewer COnneCtiOrl Cooking Unit Meter El up to 100 amps Dater `"� �f Applicant, EXEMPTION FROM WORKERS' COMPENSATION DECLARATION (This Section need not be completed if the permit is for one hundred ($100) or less). I certify that in the performance of the work for which this permit Is issued,.l, shall not employ any person in any manner so as'to become-subject to the Workers' Compensation Laws of California. Date Signature Clarifiers Solar Collectors . Dishwasher Dishwasher Solar Piping Dryers ❑Gas ❑Electric Sub Panel Drinking Fountains Solar Tank Fan Motors -1 HP ❑l V. - 8 Floor Drains Swimming Pool vv/Spa F.A.U. Inc. Solar ❑9-15 HP 016-15+ - NOTICE. It, after making this declaration, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance Floor Sinks Urinal 7J Fixtures Microwave ' Gas Service Outlets Water Closet - Device Boxes 1 is• le Light .. $tj Inter6e tors p Water Heater Outlets Switches `> nge r' Sign " of the work for which this permit is Issued (Section 3097 Civ. C.) Lender's Name Lender's Address OWNER BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5 Business and Professional Code: Any city or county which requires a permit to construct, alter, Improve, demolish or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed Statement that he/she is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9(commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he/she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil enalty of not more than five hundred dollars ($500). I, as owner of the property or my employees with wages as their sole Compensation, will do the work, and the structure Is not intended or Offered for sale (Section 7044, Business and professional Code: The Contractor's License Law does not apply to an owner of a property who builds or improves thereon, and who does such work himself/herself or through his or her own employees, provided that such improvements are not intended or Offered for sale. If, however, the building or improvement is sold within one year of Com- pletion, the owner will have the burden of proving he/she did not build or im- prove for the purpose of sale). ❑ I, as owner of the property, am exclusively contracting with licensed con- tractors to construct the project (Section 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a con- tractor(s) license pursuant to the Contractor's License Law), I am aware that proof of their Worker's Compensation insurance should be provided to me, ❑ 1 am exempt under Section B. & P, C. for this reason Kitchen Sink Water Service -. Lavatories Auto-Wash ' Garbage Disposal Standing Sections - P—Trap Laundry Trays ' Generator ❑D 5 KW ❑5 15 KW Trash Compactor Roof Drains - Reinspection Fee $15 Issue Fee $ 3 z 1 Reinspection Fe:.. $15 Issue Fee MECHANICAL FEES DEVELOPMENT SERVICES REQUIREMENTS: Zoning Approved By - Date Building Approved By Date Application Issued By _- Dat - - Boiler Hood or Type I ❑ Canopy Type II ❑ Duct - Under Ground Duct - Structural Refrigeration System 00.100,000 BTU 0100,000 BTU Duct - Ventilating BUILDING PERMIT PLAN CHECK PLUMBING -- PL." ni *• GIjF!! K 25% ELECTRICAL PLAN CHECK 50% ME6Fi,orW+E'+-1- PLAN CHECK 25% -- •— —•- SUMMARY OF FEES $ _ SMIP $ $ PERMIT �- \ISSUANCE _ $ $ $ :z O� ENERGY P.C. $ GRADING $ $ MICROFILM $ $ S%•� `TOTALFEE $ h $ [1 Exhaust System 11 Multiple 11 System Repair/Alteration _ Firepl/Fact. Bit. ICBO Fire Dampers Date Owner I herebycertify that I have read this application and stale that the above inis correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize repre- sentafives o this city o ter upon the above-mentioned property for inspection pose, .7 _`� Signature Date Drivers' License or 55 Heating System & Ducting ❑ o. 100,000 BTU ❑ 100,000 B7 Registers rl Reins etion Fee pe $15 Issue Fee $ 3 Goldenrod - Assessor , 1 01 00O03'935 ©000936 T 0 T 435.70 J CMF 0865-46, rev. 10/84 White - Building; Canary - Applicant; Pink - Accounting; �' CONSTRUCTION AND PLANNING' ; �` r ',' ' g POOL &SPA 1 -- r, ri APPROVALS Permit # Date ,�' Inspector f�' �� r-APRROVALS Permit # �1.��� Date Inspector! ^,;,i i"J , rlil 01 t; -Tem ovary Electrical Service or Pole p _ ' ` • -52. Poq� &Equipment Location rrr • '2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. { 54. Forms 4. Electrical Conduit-Undrgrnd. 55. Electeical Bonding r, S. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6. Electrical UFER Grind. 1 57�' APPROVAL TO COVER-GUNITE r: . - r 7 .- Footings 58. Electrical Conduit-Undrgrnd. !I 1 8 f1Founaaation ,a. Ii_• r f r�i r' 59. Gas Pipe, ❑ Undrgrnd., Test I .� 9. Water.'Pi-pe-Undrgrnd.= - 60. Backwash Lines, P Trap, ❑Undrgrnd. �-...l.r r r. 10. St `dural Floor System 61. APPROVAL TO DECK 11. Property Sewer Line & House Connection �� 62. Backwash & Receptor -Final 12, Sewer Cap � r C+ 63. Heater & Vent -Final 13.1 Roof 6rains464. Plumbing System - Final 14.1 RoughiPlumbing 65. ElectricakFinal 15.' Rough'Eiectrical-Conduit 66. Solar System -Final 16. Rough Electric Wiring 67. Fencing & Access Approval 17. Rough Wiring Sign ! 68. APPROVED FOR PLASTERING 18. Rough Electrical -T Bar Ceiling 9, POOL/SPA SYSTEMS FINAL -. 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit #� L 20. Rough Factory Fireplace 21. Ducts, in Structure 70, Underground Hydro 22, Ducts, Ventilating 71. Product Piping ❑ Gas ❑ Oil, 23. Gas Pipe -Rough & Test 72. Underground Flush 24. Roof Framing 73, Undergrnd. Storage Tank ❑ Gas ❑ Oil = 25. Roof Sheathing 74, Overhead Hydro ` 4- 26, 26. T -Bar Ceiling (Structural) & Monocoat 75. Dry Chemical 27. Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding 77. FIXED SYSTEM FINAL- ' 29. Insulation 78. FIRE PREY. FINAL 30. Drywall !Nailing HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat 79. FINAL INSPECTION 32. Electrical Power Meter -Final 80. FOOD CERTIFICATE ISSUED " 33. Final Electric N tes: P-4,,58 s�: rcz,- 34. Final Heating &Air Conditioning • cif Wa S, 35. Final Gas Pipe -Test 36. Hood or Canopy 37. Final Factory Fireplace ' 3! 38.' Final Plumbing70 rP kkat, 39'. Water Service -Final 40. Gas Service -Final /) 4 " 41. Solar Domestic -Final `r '• 4-17 rvA2. Backflow Preventer _ Ca40 �* r X43. Backflow Irrigation 11 k I �' • 1 f r V,,44.. Landscape Irrigation System - t;-�-- F. Sound Attenuation ' 46. Handicap Regulations U 47. FINAL STRUCTURE & BUILDING - r . }, �• i r 48. Special Requirements Completed 49:. Electric Release to Edison r ± 50. Gas Release to Southern California Gas Co -7 51. CERTIFICATE OF OCCUPANCY No. Date--- - { V ., • Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations. CITY O .e-ner I CONSTRUCTION PERMIT PE IT O TRACT NO. LOT NO, UNIT NO. Project Address Applicant's Mailing Address Owner's Name I Phone Address 535-6, Arch/Eng.' License No. Address Contractor's Name Phone � Address (mailing) City License No. LICENSED CONTRACTOR DECLARATION I hereby affirm that 1 am licensed under provisions of Charter 9 (commencing with section 7000) of Division 3 of the Business and Professions Code, and my Iicense,is in full force and effect. License Class License No. Date2l"y�% Signature +* WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to salt -insure or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Section 3800, Lab. C.)�-�'�7J�f �r Policy No- %«�'Js+•� Company���� ❑ Nif!etl ccoppy' ll.`s herebyfurnished. Buil ng Divlsi ' Date��^ Applicant L r EXEMPTION FROM WORKERS' COMPENSATION DECLARATI (This section need not be completed if the permit is for one hundred ($100) or less). I certify that in the performance of the work for which this permit is issued, I .hall not employ any person In any manner so as to become subject to the Workers' Compensation taws of California. Date Signature NOTICE_ If, after making this declaration, -you should become subject to the. Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a Construction lending agency for the performance of the work for which this permit Is issued (Section 3097 Civ. C.) Lender's Name Lender's Address OWNER BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5 Business and Professional Code: Any city or county which requires a permit to construct, alter, Improve, demolish or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he/she is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division, 3 of the Business and Professions Code) or that he/she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7 03 1.5 by any applicant for a permit subjects the applicant to a civil enalty of not more than five hundred dollars ($500). I, as owner of the ',property or my employees with wages as their sole Compensation, will do the work, and the structure Is not intended or offered for sale (Section 7044, Business and Professional Code: The Contractor's License Law does not apply to an owner of a property who builds or improves thereon, and who does such work himself/herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of Com- pletion, the owner wilt have the burden of proving he/she did not build or Im- prove for the purpose of sale). ❑ I, as owner of the property, am exclusively contracting with licensed con- tractors to construct the project (Section 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such projects with a Con- tractor(s) license pursuant to the Contractor's License Law), I am aware that proof of their Worker's Compensation insurance should be provided to me. ❑ 1 am exempt under Section B. & P. C. for this reason Date Owner I hereby certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize repre- sentatives of this ' y to enter upon the above-mentioned property for inspection purposes f•e,.� Signature Drivers' License or SS 4(p3I . BUILDING PERMIT PLUMBING-" FEES TYPE OFCONSTRUCTION, 71 NEW LJ ADD F—I.Al REPAIR Backflow Irrigation E CONVERSION ❑ DEMOLISH ❑ OTHER Bathtubs A.P. DESCRIPTION OF WORK/GSE)DF BLD Solar Collectors 4 Solar Piping. Drinking Fountains 5 Main Building: Swimming Pool WJSpa Floor Sinks E Gas Service 'Outlets TYPE OF PERMIT DGRADING LJ FOUNDATION LJ STRUCTURAL T Front ❑ TENANT ❑ ELECTRICAL ❑ PLUMBING ❑ MECHANICAL B Roof Drains ❑ OTHER — f- 7 A Rear PROJECT DESCRIPTION SQ. FT,_ ,�' OCCu NCY r— C K Right CONSTRUCTION TYPE E VALUATION [. ..0595:y�l g Left ZONE GRADING CU. YDs. ACRES Ping. Ref. Vk Remarks: FT. en o C fi . %7.,2,8.f -" 11 71 rffW Planning Notes: MECHANICAL FEES Boiler BUILDING PERMIT PLUMBING-" FEES Bar Sink Backflow Preventer Showers Service Sink Backflow Irrigation Sewer Cap Bathtubs Sewer Connection Clarifiers Solar Collectors Dishwasher Solar Piping. Drinking Fountains Solar Tank Floor Drains Swimming Pool WJSpa Floor Sinks Urinal Gas Service 'Outlets Water Closet Interceptors Water Heater Kitchen Sink Water Service Lavatories P—Trap Auto -Wash Laundry Trays Roof Drains Reinspection Fee $15 Issue Fee $ 3 MECHANICAL FEES Boiler BUILDING PERMIT Hood or Type I ❑ Canopy Typell ED PLAN CHECK Duct -Under Ground Duct - Structural $ ISSUANCE Refrigeration System ❑0.100,000 BTU 0100,000 BTU $ ENERGY P.C. Duct - Ventilating $ GRADiNG Exhaust System ❑ Multiple © $ MICROFILM System Repair/Alteration $ TOTAL FEE Firepl/Fact. Bit, ICBO # Fire Dampers Heating System & Ducting ❑ 0.100,000 BTU E1100 OOOBT Registers Reinspection Fee 1 $15 CMF 0865-46, rev. 10/84 White - Building; Canary - Appllc nt; Pink - Accounting; Goldenrod - Assessor Issue Fee $ 3 Automatic Washer r JUL 26 Parking Req./Provided ELECTRICAL Construction Pole Sub. Cooking Unit Dishwasher Dryers ❑Gas ❑Electric Fan F.A.U. Fixtures Device Boxes Outlets Switches Garbage Disposal Generator 00-5 KW 05-15 KW Reinspection Fee I $15 Zone - Transformer ❑ 15-50 KW ❑'50+ KW Meter ❑up to 100amps Meter [Dover 100 amps Sub Panel Motors 00.1 ,HP C11% - 8, tnc.Soler 09-15 HP ❑16.15+ Microwave Pole Light Range Sign Standing Sections Trash Compactor Issue Fee DEVELOPMENT SERVICES REQUIREMENTS: Zoning Approved By Building Approved By Application Issued By. PLAN CHECK 25% $ M FEES I $3 )ate )ate )ate $ 7,43 $ Z O N 1 N G R E O M T S SU A Y�F FEES BUILDING PERMIT $ SMIP PLAN CHECK $ PERMIT PLUMBING $ ISSUANCE PLAN CHECK 25% $ ENERGY P.C. ELECTRICAL $ GRADiNG PLAN CHECK 5046 $ MICROFILM MECHANICAL $ TOTAL FEE PLAN CHECK 25% $ M FEES I $3 )ate )ate )ate $ 7,43 $ Z O N 1 N G R E O M T S CONSTRUCTION ANQ PLANNING i' APPROVALS . Permit # Date I nspector POOL & SPA APPROVALS Permit # Date Inspector i 1. Temporary Electrical Service or Pole 52, Pool & Equipment Location 2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. 54, Forms ; 4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding 5. Steel Reinforcement • 56. Rough Plumbing & Pressure Test 6• Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE 7. Footings 58. Electrical Conduit-Undrgrnd. 8. Foundation i 59. Gas Pipe, ❑ Undrgrnd., Test 9. Water Pipe-Undrgrnd, 60. Backwash Lines,'P-Trap, ❑ Undrgrnd. 10. Structural Floor System 61. APPROVAL TO DECK 11. Property Sewer Line & House Connection 62. Backwash & Receptor -Final 12. Sewer Cap 63. Heater & Vent -Final 13. Roof Drains 64. Plumbing System - Final 14. Rough Plumbing 65. Electrical -Final 15. Rough Electrical -Conduit 66. Solar System -Final 16. Rough Electric Wiring 67. Fencing & Access Approval 17. Rough Wiring Sign 68. APPROVED FOR PLASTERING 18. Rough Electrical -T Bar Ceiling 69. POOUSPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit # 20. Rough Factory Fireplace 21. Ducts, in Structure 70, Underground Hydro 22. Ducts, Ventilating 71, Product Piping ❑ Gas ON 23, Gas Pipe -Rough & Test 72. Underground Flush 24. Roof Framing 73. Undergrnd. Storage Tank ❑ Gas ❑ Oil 25. Roof Sheathing 74. Overhead-Hgzlro 26. T -Bar Ceiling (Structural) & Monocoat 75, Dry Chemical 27. Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding 77, FIXED SYSTEM FINAL'" 29. Insulation 78. FIRE PREY. FINAL 30. Drywall Nailing HEALTH DEPT. REQUIREME T 31. Plaster Brown Coat 79. FINAL INSPECTION 32. Electrical Power Meter -Final 80. FOOD CERTIFICATE ISSUED 33. Final Electric Notes: 34, Final Heating & Air Conditioning 35. Final Gas Pipe -Test 36. Hood or Canopy 37. Final Factory Fireplace 38. Final Plumbing b ! , 39. Water Service -Final 40. Gas Service -Final 41. Solar Domestic -Final 42. Backflow Preventer 43. Backflow Irrigation 44. Landscape Irrigation System 45: Sound Attenuation 46. Handicap Regulations 47. FINAL STRUCTURE & BUILDING 48. Special Requirements Completed 49. Electric Release to Edison 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY No. Date E . 'r Cr, Y OF COSTA MF -A Development Services, Division of Building and Safehj Ac: CERTIFICATE OF OCCUPANCY This certificate is issued pursuant to the requirements of the Uniform Building Code, Section 308 adopted by the City of Costa Mesa certifies that at the time of its issuance the buildingstructu`re herein below described was inspected and approved for occupancy as follows: 3333 Bristol St.,. Building Address Bldg. Permit.Number Retail Home/'Clothing (70,332 s.f':} ` Use B06•-01738 rt 1r-T'R NXXXXX Group Type of Construction Fire Zone Use Zone _ South Coast Plaza SAKS FIFTH AVENUE Owner of Building cla ralluin a Tenant Address ._. 750 Lakeshore Parkway, Bixmirigham, AL 35,Z BUILDING OFFICIAL-Khanh Q. Nguyen, _C.B.O.- By `• Date 05/06/ REQUIRED TO BE POSTED IN A CONSPICUOUS PLACE PDC •t City of Costa Mesa Development Services Department Building Safety Division CERTIFICATE OF OCCUPANCY No. ., i(j P. O. Box 1200 Costa Mesa, California The Building located at� �� 2 M -4 ol-nl Cf•r-mf- _ alas been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group E12 Occupancy. Use of Building Legal Description No-01_nq (See reverse side for Metes and Bounds) Building Permit No, B 34173 Electrical Permit No_ E 34594 Plumbing Permit No. Mechanical Permit No ISSUED TO: Saks Fifth Avenue 3333 Bristol Street sbsta Mesar CA 92626 Number of apartments and/or guest rooms Building Official Cwt:ae Edyniston by Date (k-!-otaQr 16. 9$9 This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. CMF 101546 rev. 1/83 White - Owner; Carl—V - Numerical File; Pink • Bldg. Permit File City of Costa Mese Building Safety Department CERTIFICATE OF OCCUPANCY P.O. Sox 1200 Costa Mesa, California The Building located at 3333 Bristol Stteot - Costa Masa. California has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group F-2 Occupancy. Use of Building Commercial - Retail Department Store Legal Description A. Q. Ab. 140=052-11 (See reverse side for "dates and Bounds) Building Permit No E'5320 Electrical Permit No1W'1 7,()/A A.-77 Plumbing Permit No.74 ' Number of apartments and/or guest rooms r ISSUED TO: Building Official/ ^Ti'TH AV1?MIM Victor C. AT�taton-Director Building Tx* sion Date Wirpmhe r 11 1 Q70 This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 306 fel U.B.C. Form BU 34 Rev, 11n0 - CITY OF COSTA MESA BUILDING DIVISION �r f77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 www.ci,00sta-m sa/F07-00277 FOR INSPECTIONS CALL: (714) 754-5626 FIRE SUPRESSION PERMIT .lob Address: 3333 BRISTOL ST Status: APPROVED Suite: SAKS Applied: 0920/2007 Vicinity: GUCCI Issued: 09202007 Parcel Nunmber: 41 249105 Zoning: Applicant: LOONEY, SHEILA Address: Phone: 714-993-2822 Zip: i ;. Owner: SOUTH COAST PLAZA CALWIN REALTY 11 INC Address PROPERTY TAX DEPARTMENT BIRMINGHAM, AL Phone: 750 LAKESHORE PARKWAY Zip: 3521.1-4400 Contractor: ALERT FIRE PROTECTION INC Address: 5200 E HUNTER AV _ SUITE B Phone: 714-993-2822 ANAHEIM, CA Zip: 92807 License: 316324 'SCOPE OF PERMIT - FIRE SUPPRESSION PERMIT TO RELOCATE ADD 2 NEW AND RELOCATE 3 EXISTING FIRE SPRINKLER HEADS FOR A 495 S.F. INTERIOR TENANT IMPROVEMENT FOR VENDOR SHOP, "GUCCI", WITHIN EXISTING STORE, "SAKS FIFTH AVENUE". REF#: B07-00724. FEE'SUMMARY' Plan Check: $37.06 Calc Valuation: $1,600.00 Permit: $57.05 _ Claimed Valuation: $1,600.00 Other: $0.00 Total: $94.13 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and f1hal approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE I, INSPECTION TYPE DATE [N ALS CODE I INSPECTION TYPE DATE I_NM LS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention T �� 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Budding/Occupancy WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations:. ; ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the p rforrnance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by ection 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carie (this section need nor4xrEompfe1&d �d the pemtdpis vakted at one h red da6ars (S100) or less.) Potlr.y Number: %:Ll - ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California. and agree that if I should become subject o he workers' compensation provisions of Section 3700 of the Labor Code all fprt th comp)y with these provisions Zd-d7 Applitant's Signature U (_,___Datel WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effec . L'ic, /&3--X C6ntractoi s Signature _ . Dale CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction tending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to lite a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500),): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one. year of completion, the owner -builder will have the burdeh of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec; 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). . ❑ I am exempt under sec. Business and Professions Code for this reason: Signature Date 3057-46 43/07) Owner ID verified by drivei nse, ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property lax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than Thirty-six (36) feet high, (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Division of Industrial Safety Permit Number: Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department, 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits), 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. It a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes '[I No 8. (If 'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given -above -is correct, I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature tate CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. i fuse of L 1 Chmerls) AnClor Authorfzed'Appllcant Date CITY OF COSTA MESA BUILDING DIVISION f 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 - Fax (714) 754-4856 • www.ci.costa-mesa.ca.us `�•� ; FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER. BC07-00169 PERMIT TYPE: B_COMBO STATUS: ISSUED Sub Type: COM—ALT DATE ISSUED: 09/04/2007 ISSUED BY: JOB ADDRESS: 3333 SAKS BRISTOL ST CM Suite/Unlit , _SAVS APN: 41249105 Zoning: Vicinity: SAKS SECOND FLOOR',,"," Primary Occ: '? Const Type: I -FR SQ, FT: 346 Valuation: $50,000.00 SCOPE OF WORK: 346 SF INTERIOR T.L, FOR "M1U MIU" WITHIN THE SAKS FIFTH (2ND.FL) AVENUE WITH ELECTRICAL AND MECHANICAL WORK. OWNER: SOUTH COAST PLAZA CALWIN REALTY II INCAddress: PROPERTY•TAX DEPARTMENT Unit: BIRMINGHAM, AL r Phone: City/State/Zip: 750 LAKESHORE PARKWAY. APPLICANT: PROFFITT, JIM Address: Unit: Phone: 817-896-9881 CitylStatelzZip: CONTRACTOR: WESTWOOD CONTRACTORS CORP License No. 618438 Phone: 817-877-3800 Address: 777 MAIN STUnit:.` + ; STE 950 Cell: 817-334-1279-CitylState: FORT WORTH, TX'_' ZipCode 76102 ARCHITECT: CALVIN COATSWORTH ` . License No.C14388 r PHONE:949 833-1930 ENGINEER: License No. PHONE: COMBINTATION PERMIT FEE SUMMARY Building Plan Check: $418.76 Building Fees: $644.25 Electrical Fees: $51.00 Mechanical Fees: .$37.20 Plumbing Fees: $0.00 SMIP Residential: $0.00' SMIP Commercial: $10.50 TOTAL FEES: $1,161.71 - "Refer to fee receipts for all fees paid for project r NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes,and I required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this pe CODg 0 INSPECTION TYPE DATE INTiTlAL COPE i IHSPECTI4M TYPE 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical B Z 201 Final Slock/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy I� , WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the "l-forrpance of the work for which this permit is issued. L have and will maintain workers' compensation insurance, as required by tion 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: {This section need nor be completed d the permit is vatued at one hundred dollarsfS 100) or less-) Policy Number: ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation )aws of California,- and agree that if I shou)d become subject to the workers' compensation provisions of Section 3700 of he Labor Code, I shall forth ly with these provisi s. .11,11111, 9/Y -/0-7- 'r- Applicant's Si t e Date WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE., INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing With Section 7000) of Division 3 of the Business and Professions Code, and my license is in fuff frorce and effect. j� Lic. # l Class # L/ tCV 0 Contractor s Signature t to UCTION LENDING AGENCY: ❑ . 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, after, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under.sec.. Business and Professions Code for this reason: +46 43107) \ C Owner ID verified by drive, ise. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed):. DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation frre (5) or more feet in depth into which a person is required to descend, wiff be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code), ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicants Signature Date Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of,3 hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be fumished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If "yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that urider penalty of perjury the information, given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature of Lego t And/or Authorize p [ant--0- CITY OF COSTA MESA BUILDING DIYISIOM 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us FOR INSPECTIONS CALL: 1714) 754-5626 PERMIT NUMBS BC07-00104 I ' PERMIT TYPE: B COMBO STATUS: FINALED Sub Type: COM ALT DATE ISSUED: 09125!2007• ISSUED BY: RMID JOB ADDRESS: 3333 SAKS BRISTOL ST CM Suite/Unit:-E; SAKS s' APN: 41249105 Zoning: Vicinity: LOUIS VUITTON WkTHIN SAKS 5TH AVE ,.:,Primary Occ: ..?j Const Type: I -FR SQ. FT: 0 •-+Valuation: $400,000.00• 11 ij If SCOPE OF WORK: 1350SF INTERIOR TE FOR "LOUIS VUI_TTON" WITHIN;THE SAKS FIF�THI�AVENUE STORE. WORK TO INCLUDE 77 LIGHT FIXTS, 10 OUTLETS, 3 SWITCHES; 2 -MOTORS TOA'HP, 5 COMM DRO f SUB PANEL AND.2 VAV BOX. OWNER: SOUTH COAST PLAZA CALWIN REALTY II INCAdtlressa ; " i` PROPERTY -TAX DEPARTMENT -Unit: BIRMINGHAM, AL r,,,_ ,f..`,r.:L•'M,,,±::,1� y = Phone: { `4 CitylState/Zip: '•-750 LAKESHORE-PARKWAY,, i APPLICANT; PORZIO, LEONARD it ' - Address:: w 1 + Unit: Phone: 714,658-858w6� CitylState/zZip; .� • .: w CONTRACTOR:' CANL'CONSTRUCTIOIV INC L'jcense No. 873825 Phone: _ '714-7.98-404• r iF� � .j ' Address: �-15581 PRODUCT LANEUnit: Cell: r,r�,. • CitylState: l�UNTING70N BEACH, CA ZipCode 92649 jty - r T e 4� r: ARCHITECT: , PAUL L BOSOSMAN ARCHITECT License_No.C7254 PHONE:650-269-8911 ;..v`= .ti. i ENGINEER:: 4fi t 7 PHONE: License �Jo.' ) i:. COMBINTATION PERMIT FEE•SUMMARY'. Building,Pian Check: '' "= :A, $434.49 T' ' Puiiding•Fees: h ti= : r ,; , = -$2; 7,3.75Y Electrical Fees: Mechanical Fees: t s tom.+1 �.`4l %t $44:80 Plumbin' ftes: SMTP Residential: 1:T _ ��'s. $0:00 SMIR Commercial: �J' r' __;;184.00 T0TAL`FEES3 -';'' ' ' $3,383.95 1 Refer to fee ieceipts for all fees paid for project �,�_..4•, ,ate.: f,.: ` _"t �. ���L+�=�` NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-26, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE r-; Its_ DIMMOK 1 -DAM INMALS isle' 'Fixed Sgstem Final Fire Prevention Zoo- Final Mechanical 1268'Pool Spa Final�+', 208 ` Final Plumbing, r L4_ , _ a, j 1 ` r t` r I2007 tt Final Re -Room } 210: Final Electricals ' 20' Final Block/Retaining Wall { - - ! 212; Final Fire Pravanfion t r 202 Final Factory Fire Place F `'a' `k f - - + 220 Final Planning Approval 203' 'Final Sig - `r' ti r f + 222. Final Site 204 Final Demolition 250 Final BuildinglOccupancy ,P,%I WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the fu,. wing declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: (This sectvn need not be completed rrthe permitis valued at ane hundred dollars (5100) or less ) Policy Number: ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Cafifomia, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, t shall forthwith comply with these provisions. Applicant's Signature Dale WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJE=CT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic. # Class # Contractor's Signature Date CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that t am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to r,Etrnrl alter, imprvye. demnligh or ronair any qln irtiorP nrinr to ifq issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractors) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: S�gnalure Dale 305746 (3f07) Owner ID verified by drive rise. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by {type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature 'Date Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Depanment by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4, if an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from (Section 65850.2 of the California Goverment Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'fres", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No, 8. (If 'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Smnalure Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state taws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signalure of Legal Owner(s) Dale Andlor Authonzed Applicant Dale CITY OF COSTA MESA BUILDING DIVISION 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 - Fax (714) 754-4856 • www.ci.costa-me a. s �. FOR INSPECTIONS CALL:. (714) 754-5626 F07-00278 0 FIRE SUPRESSION PERMIT Job Address:- 3333 BRISTOLST-Status: ISSUED Suite: SAKS-�_._, ',,,�•., n Applied: 09/20/2007 Vicinity: INSIDE SAKS Issued: 10/29/2007 Parcel Nunmber: 41249105 ;:i .•kf~. l '.:Zoning:. Applicant: LOONEY SHEILA Address: r r - r Phone:- =,714-993-2822 Zip: / j Owner: SOUTH COAST PLAZA CALWIN=REALTY-II I -NC.:. Address PROPERTY TAX DEPARTMENT' BiRMINGHAM,'AL Phone: ��'r 7501 LAKESHORE'P,A�RKWAY. Zip: 35211-4400 Contractor: ALERT FIRE, -PROTECTION INC -l"' Address: 5200 E HUNTER'AV SUITE SB Phone: 714-993-26.22'!-' ANAHEIM CA :s, .c Zi J 92807 s� s License: 316324 -` ;.<., SCOPE OF PERMIT FIRE SUPPRESSION PERMIT TO RELOCATE 2 EXISTING FIRE SPRINKLHER HEADS FOR A 1089SF INTEIOR STORE'T "GI GIO`ARMANI COSMETICS" WITHIN THE EXISTING SAKS FIFTH AVENUE. REFCD7-0022 Ct _ Plan Check: $19.24 Permit: $29.60 Other: $0.00 Total: $48.84 FEE SUMMARY; Calc Valuation: Claimed Valuation $700.00 $700.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE X. INSPECTION TYPE 1616 Fixed System Final Fire Prevention 1266 Pool Spa Final 200 Final Re -Root 201 Final Block/Retaining Wall 202 Final Factory Fire Place 203 Final Sign 204 Final Demolition DATE INTITIAL5 CODE p INSPECTION TYPE 206 Final Mechanical 208 Final Plumbing 210 Final Electrical 212 Final Fire Prevention 220 Final Planning Approval 222 Final Site 250 Final Building/Occupancy DATE INTITIALS /17 0 WORKERS' COMPENSATION DECLARATION: Owner ID verified by driveAe. ❑ Yes ❑ No I hereby affirm under penalty of perjury one of the following declarations: Driver's License No. Expires: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' Verification of Ownership by (type of document, i.e. - property tax bill or deed): compensation, as provided for by section 3700 of the Labor Code, for the p rformance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required .by ec ion 3700 of the Labor Code, for the performance of the work for which this DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: permit is issued. My workers' compensation insurance carrier and policy ❑ I hereby certify that no excavation five (5) or more feet in depth into which a number are: is required to descend, will be made in connection with work authorized �person this permit, and that no building structure, scaffolding, falsework, or demolition P g g. Carrier: - - - -- C ^= dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp (This section need not be feted d rhe perm t is valued at one hundred dolfars (S 100) or less.) ��DODQ� �1 �✓V �' Art 2, Sec. 341, Title 8, California Administrative Code). Policy Number: V ❑ As owner -builder, I will not employ anyone to do work which would ❑ I certify that in the performance of the work for which this permit is require a permit from the Division of Industrial Safety, as noted above, unless issued. I shall not employ any person in any manner so as to become subject such person has a permit to do such work from the division. to the workers' compensation laws of California, and agree that if I should become subje t o the rkers' c mpensation provisions of S ction 700 of Applicant's signature Dale the Labor Co shall f hwith ply with these provisions. Z A licant's Si nature Date Division of Industrial Safety Permit Number: pp 9 WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: 1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in f II force and ffect. Lic. #% a -1 6 CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction tending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file --a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some xceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feel of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required fo register acutely hazardous materials with the Fire Department. Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property,.am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature 3057-46 (3107) Date 4. If an RMPP 'is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? []Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for ricin -residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If 'fres", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: 1 certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. n re of Le caner{s) /Date And/or Aulhonzed Applicant Date IJ CITY OF COSTA MESA / BUILDING DIVISION f 77 FAIL DRIVE, COSTA MESA, CA 92626 - (714) 754-5273 - Fax (714) 754-4856 - www.ci.c0sta-mesa.caA FOR INSPECTIONS CALL: (714) 754-5626 F07-00275 FIRE SUPRESSION PERMIT Job Address: 3333 BRISTOL ST - Status: ISSUED Suite: SAKS Applied: 09/20/2007 Vicinity: 2ND FLOOR MIU MIU,,,- - `. Issued: 09/20/2007 Parcel Nunmber: 41249105 § r Zoning: Applicant: LOONEY,' SHEILA • ". Address: Phone: -.714-993-2822 t.� Zip: r Owner: SOUTH COAST PLAZA CALWIN REALTY It INC Address PIROPERTY TAX DEPARTMENT BIRMINGHAM, AL Phone: 750 LAKESHORE PARKWAY .Zip: 35211-4400 Contractor: ALERT FIRE PROTECTION INC Address: 5200 E HUNTER AV _ SUITE B - ' 'Phone: 714-993-28.22 ANAHEIM, CA , ' Zip: 92807 License: 316324 SCOPE OF PERMIT FIRE SUPPRESSION PERMIT TO RELOCATE (2) EXISTING FIRE SPRINKLER HEADS AND 3 PLUG HE ADS F 34 F INTERIOR T.I. FOR "MIU MIU" WITHIN THE SA_ KS FIFTH (2ND FL) AVENUE RI -F:# BC 07-00169. +EE -SUMMARY Plan Check: $31.14 Calc Valuation: $1,300.00 Permit: $47.90 Claimed Valuation: $1,300.00 Other: $0.00 Total: $79.04 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE I• INSPECTION TYPE OAT' INTMALS CODER INSPECrON M�F DATE Nlnl L �� 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Root 210 Final Electrical 201 Final 6locklRetaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy WORKERS' COMPENSATION DECLARATION: 1' I hereby affirm under penalty of perjury one of the following declarations: . ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as'provided. for by section. 3700 of the Labor Code, for the Ar formance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by tion 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: mer: f T�rls section need not he completed d the pefrit is valued atpoL hundred dollars ($100) or fess.) Policy -Number: ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become sub' t to the workers' compensation provisions of Section 3740 of the Labor Co shall fo with c ply with these provisions, err' q zd-� '•Apphcant's SignatureDate_1 WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lich# Contractma Signature ate— CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -GUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, business and Professions Code: Any city or county which requires a permit to Construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption, Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): d 1, as owner of the property, or my employees with wages as their sole Compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sate. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that'he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature 3057-46 (=7) Date Owner ID verified by drive,, ,se. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property.lax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:' ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I wilt not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Division of Industrial Safety Permit Number: Date HAZARDOUS MATERIALS AND EMISSIONS CERTfFICATfON: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. if an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (if 'yes-, attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that tinder penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. ignatur f Legal ner(s) j ___!And/or Aufhanzed Applicant Date Date CITY OF COSTA MESA BUILDING DIVISION i 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca FOR INSPECTIONS CALL: (714) 754-5626 07-00289 FIRE SUPRESSION PERMIT Job Address: 3333 BRISTOL ST _ :r _ r Status: ISSUED Suite: SAKS�� Applied: 10/11/2007 Vicinity: DOLCE AND GASBANA WITHIN FSAKS STH AVE, T Issued: 10/29/2007 Parcel Nunmber. 41249105 :„ Zoning ` ; x �. a n � r, Applicant: LOONEY;SFiEILA` y;.. Address: 5200 E HUNTER SUITE B . =` Phone: e714-993-2622 ANAHEIM, CA Zip: 92607 Owner: SOUTH COAST PLAZA CALWIN.REALTY ,II INC Address PROPERTY TAX -DEPARTMENT,:.' BIRMINGHAM,'AL-' Phone: 75b LAKESHORE PARKWAY „ ,..,.., ,;Zip:__ x_ „352! 1-4400. I Contractor: ALERT FIRE PROTECTION INC;-= s :r I Address: 5200'EHUNTER AV. SUITE B Phone: 714-993-2822---. ur ANAHEIM, CA a I' a Zip: 92807 f�13 License: 316324;_--, ; SCOPE OF PERMIT RELOCATION OFA EXISTING SPRINKLER HEADS AND ADDITION OF 1, NEW HEAD IN CONJUNCTION WITH THE 410 SF INTERIOR T.LFOR "DOLCE.GABANNA",WITHINTHE SAKS;FIFTH AVENUE STORE. REI": BC07-00211 �,1 1� • : j N �y � � � � : =�' ,.: T ;�ty,,;.� },fir ,, Plan Check- $37.08 Permit: $57.05 Other: $0.00 Total: $94.13 FEE SUMMA" ,t '' " 1 - - a �` •Calc Valuation: $1,600.00 Claimed Valuation: $1,soo.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE C. INSPECTION TYPE 1616 Fixed System Final Fire Prevention 1266 Pool Spa Final 200 Final Re -Roof 201 Final BlockJRetaining Wall 202 Final Factory Fire Place 203 Final Sign 204 Final Demolition DATE INTIrALS CODEC INSPECTION TYPE 206 Final Mechanical 208 Final Plumbing 210 Final Electrical 212 Final Fire Prevention 220 Final Planning Approval 222 Final Site 250 Final Building/Occupancy DATE INTMALS WORKERS' COMPENSATION DECLARATION: Owner ID verified by driver's, .e. ❑ Yes ❑ No I hereby affirm under penalty of perjury one of the following declarations: Driver's License No. Expires: ❑ I have and.will maintain a certificate of consent to self -Insure for workers" Verification of Ownership by (type of document, i.e. - property tax bill or deed): compensation, as provided for by section 3700 of the Labor Code, for the p rformance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as, required by ection 3700 of the Labor Code, for the performance of the work for which this DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: permit is issued. My workers' compensation Insurance carrier and policy ❑ I hereby certify that no excavation five (5) or more feet in depth into.which a number are:� h person is required to descend, will made in connection with work authorized by this permit, and that no building structure. scaffolding, falsework, or demolition Carrier: ! Lt_ f or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp (Thissedponneed not becmpf�d+rthepem7�v��onehndreddollars($100)orless.) Art 2, Sec 341 Title 8, California Administrative Code). Policy Number: 3 0 00 b !n ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become sub,' ct to the worker ' compensation provisions of Section 3700 of. the Labor C 1 aha orth ' comply with th�rovisions. 10 _J_ 63 Applicant's Signature r Date WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Division of Industrial Safety Permit Number: _ Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of LICENSED CONTRACTORS DECLARATION: 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas I hereby affirm that I am licensed under provisions of Chapter 9 (commencing at standard temperature and pressure). with Section 7000) of Division 3 of the Business and Professions Code, and 2. Does or will the applicant or present or future building occupant need to file my license is in full force and effect. a registration form for acutely hazardous materials? ❑ Yes ❑ No 3,1 a Lic. # class # (_ �`�' ; (Section 25533 of the California Health and Safety Code, with some �Jf exceptions, requires registration with the Costa Mesa Fire Department by business time has hand each which at any one on a quantity of acutely ontraclor's Signature Date hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard CONSTRUCTION LENDING AGENCY: temperature and pressure). ❑ 1 hereby affirm that there is a construction lending agency for the 3. Does or will the applicant or present or future building occupant need to performance of the work for which this permit is issued. (Sec. 3097, Civil Code). prepare an RMPP (Risk Management and Prevention Program for acutely Lender's Name: hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Lender's Address: Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. Signature Date 4. If an RMPP is presently required, has Section 25534 of the California OWNER -BUILDER DECLARATIONS: Health and Safety Code been fully complied with? ❑ Yes ❑ No I hereby affirm that under penalty of perjury that i am EXEMPT FROM THE 5. Does or will the applicant or present or future building occupant require for CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, the work which is the subject of this application a permit for such construction Business and Professions Cade: Any city or county which requires a permit to or modification from the South Coast Air Quality Management District or from construct, alter, improve, demolish, or repair any structure, prior to its any other air pollution control district or agency? ❑ Yes ❑ No issuance, also requires the applicant for such permit to file a signed statement (Section 65850.2 of the California Government Code requires that the requested that he or she is licensed pursuant to the provisions of the Contractors information be furnished on applications for non-residential building permits). License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and 6. Will any part of the facility to be constructed under this permit be within the basis for the alleged exemption. Any violation of Section 7031.5 by any 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No applicant for a permit subjects the applicant to a civil penalty of not more than (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 five hundred dollars ($501 of the California Health and Safety Code). ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). - ❑ I, as owner,of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractors) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Date 3057-46 (3107) 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Si at ed -Leg er(s) Date ` And/or Authonzed Applicant Date CITY OF COSTA MESA BUILDING DIVISION 4 y 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714} 754-5273 - Fax (714) 754-48'56'- www.ci.costa-mesa.ca-us h FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BC07-00226 PERMIT TYPE: B_COMBO STATUS: ISSUED Sub Type: COM—ALT DATE ISSUED: 10/09/2007 - s _ ISSUED BY:. RMD JOB ADDRESS: 3333 SAKS BRISTOL ST CM Suite/Unit: ' SAKS APN: 41249105 Zoning: Vicinity: GIORGIO ARMANI MENS WITHIN SAKS Primary Occ: Const Type: II -1 SQ. FT:'} 1089 Valuation: $175,000.00 SCOPE OF WORK: 1089SF INTEIOR STORE TI FOR "GIORGIO ARMANI MENS" WITHIN THE EXISTING SAKS FIFTH AVENUE. WORK TO INCLUDE ELEC AND MECH., OWNER: SOUTH COAST PLAZA CALWIN REALTY it INCAddress: PROPERTY TAX DEPARTMENT Unit: BIRMINGHAM, AL ` Phone: -City/State/Zip: 750 LAKESHORE, PARKWAY APPLICANT: PROFFITT, JIMAddress: Unit: Phone: 817-896-9881 City/State/zZip: , CONTRACTOR: WESTWOOD CONTRACTORS CORP- License No. 618438 Phone: 817-877-3800 w Address: 777 MAIN STUnit: STE 950 Cell: 817-334-1279 City/State: •FORT WORTH, TX ZipCode 76102 ARCHITECT: CALVIN COATSWORTN r License No.C14388 PHONE:949-833-1930 ENGINEER: License No. PHONE: COMBINTATION PERMIT FEE "SUMMARY Building Plan Check: $229.74 Building Fees:)t $1,413.75 Electrical FeesA $180:50 Mechanical Fees:)( $37.20 Plumbing Fees: $0.00 - SMIP Residential: ` $0.00 SMIP Commercial: $36.75 TOTAL FEES: $1,897.94 "Refer to fee receipts for all fees paid for project NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval wilt result in the expiration of this permit. COVE >f. INSPEtnofl rnE DATE tNn71AL5 cooE0 INEPECIlgN TYPE S^ 4 - 1616 Fixed System Final Fire Prevention 206 Final Mechanica rw,+Jw^-���•' It i+I! 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical /D 7 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy �2 i WORKERS' COMPENSATION DECLARATiON40 I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number a 1 Carrier: (This need nor he ted i The pemr► S vatmd er on hrxtdred 1.1tain (Sf 00) or Polic`y.Nu ber. ❑ 1 certify that in the performenge of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Cade, hall forth 'th corppl with these provisions. AU!plr rs Si�, m lr__7:) ING: FAILURE TO S CURE WORKERS' COMPENSATION COVERAGE UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL ENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed uncler provisions of Chapter 9 (commencing with Section 7004) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Llc-#--% i/ 19A13SCIC g 4� ,vCantractor's Sig roll —'f f�^Date. ISTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lenders Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property. am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ t am exempt under sec. Business and Professions Code for this reason: Signature 3057.46 (3107) Date 1 Owner 10 verified by dri+. ❑ Yes [INo Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, fatsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Date Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure), 2. Does or will the applicant or present or future building occupant need to file a registration fort for acutely hazardous materials? D Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? []Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? O Yes ❑ No (if 'yes the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If 'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty,of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. . . Sigralure Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature of Legal�nl I Date L And/or Authorized A `rte---� Date ` —� �. CITY OF COSTA MESA w• BUILDING DIVISION ► 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa,ca.us r ` FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: 'BC07-00224 PERMIT TYPE: B_COMBO STATUS:, ISSUED ` Sub Type: COM_ALT DATE ISSUED: 10/24/2007 ISSUED BY: SOK J013ADDRESS: 3333 SAKS BRISTOL -ST CM", SuitelUnif---,SAKS APN: 41249105 Zoning: Vicinity: GORG10 ARMANI COSMETICS WITHIN SAKS�5TH- =. PrimaryOcc:•.'� '.: Const Type: I -FR SQ. FT: 232 Valuation:, $125,000.00 SCOPE OF WORK: 232 SF INTERIOR T.I. FOR "GORGIO ARMANI COSMETICS" STORE WITHIN THE SAKS FIFTH AVENUE STORE. WORK TO ALSO INCLUDE ELECTRICAL AND MECHANICAL. OWNER: SOUTH COAST PLAZA CALWIN REALTY II INCAddress: 1. S PROPERTY., TAX DEPARTMENT Unit: BIRMINGHAM, AL .. Phone: "City/State/Zip: 1750 LAKESHORE'PARKWAY,-� , APPLICANT: BRYAN RICHARDS I Address: ?. `r `t< 'i ;t^. Unit: Phone: 817-729-1022, City/State/zZip: ' l `t `I .' CONTRACTOR: WESTWOOD CONTRACTORS CORP License,No' 618438, . Phone: 817-877-3800 Address: 951 W 7TH STUnit: Cell: 817-334-1279 City/Stale:- FORT WORTH, TX.,. ZipCode 76102 ARCHITECT: CALVIN COATSWORTH : License No.C14388 ' PHONE 949-833-1930 ENGINEER: License No. — PHONE f COMBINTATION PERMIT FEE SUMMARY Building Plan Check: $184.24 Building Fees:)( $1,133.75 Electrical Fees:X $45.50 Mechanical Fees;x $37.20 Plumbing Fees: . " 'Woo 3 f SMIP Residential: $0.00 ` SMTP Commercial: $26.25 TOTAL FEES: $1,426.94 **Refer to fee receipts for all fees paid for project NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE r. INSPEC110N TYPE 2Ain ENi1T1ALS GODEJ INSPECTION TYP IN 1616 Fixed System Fina! Fire Prevention 206 Final Mechanics! 1266 Pool Spa Final 208 Final Plumbing -200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy p��P 0 WORKERS' COMPENSATION DECLAF ATION:40 I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to sett -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ji I•have and will maintain workers' compensation insurance, as required by secl�ron•3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier_ _- r K 14 K G S sedixt need nor be =nplefed A rhe pemid is varied at one hLffxked dollars ($100) or less.) Polley Number: I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the L bor Code. I shall forthwith comply these provisions. Z alure t)at A ....w......-.. , •--� rl WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. uaff---4-(las•" u -/�- dot. zu za Contractor's Signature CONSTRUCTION LENDING AGENCY: [II hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Owner ID verified by drive. C3 Yes ❑ No - Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Division of Industrial Safety Permit Number: Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1, Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be riled with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? [I Yes ❑ No (Section 25533 of the California Health and Safety Code, with some ��exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely Lender's Name: hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Lender's Address: Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required Signature Date to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL 00 THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature Date 3057-46 (3M7) Health and Safety Code been fully compiled with? ❑Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes )] No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If -yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If 'yes', attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all slate laws and city ordinances regarding Hazardous Materials and Emissions. Signature Dale CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all slate laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature of Legal Owner(s) Dare GGA. 2 �-(1-�0' kga,Authonzed Appricant.,� '�� Dain ` CITY OF COSTA MESA BUILDING DIVISION 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 Fax (714) 7544856 • www_d.costa-mesa.ca.us �. FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BC07-0021.1 PERMIT TYPE: B_COMBO STATUS: ISSUED Sub Type: COM—ALT DATE ISSUED: 1012412007 ISSUED BY: SOK JOB ADDRESS: 3333 SAKS BRISTOUST CM ._ SuIteJU611: SAKS APN: 41249105 f. ; Zoning: ; Vicinity: DO LCE GABANNA WITH IWSAKS 5TH AVE '='' . > - P_ Hmary Occ': Const Type: I -FR Ji.;%i SQ.�FT:-''` 410 Valuation: $200,000.00 SCOPE OF WORK: 410 SF INTERIOR T.I:`FOR"DOLCE GABANNA" WITHIN THE SAKS'FIFT_ H AVENGE STORE, ELECTRICAL AND MECHANICAL WORK INCLUDED. OWNER: SOUTH COAST PLAZA CALWIN REALTY II INCAddress: PROPERTY TAX DEPARTMENT Unit: BIRMINGHAM, AL } Phone:City/State/Zip: .760 L.AKESHORE PARKWAY APPLICANT: ROH, KEVIN Address: 2495 CAMPUS DR 'Unit: Phone: 949-833-1930 CitylStatelzZip: IRVINE, CA CONTRACTOR: WESTWOOD CONTRACTORS CORPLicense No. 618438; Phone: 817-877-3800 Address: 951 W 7TH STUnit: Cell: 817-334-1279 ' CftylState:,•FORT WORTH,'TX, ZipC6de 76102 ARCHITECT: CALVIN COATSWORTHP License No.C14388.' r 'r PHONE,949-833-1930 ENGINEER: License No. - -- PHONE:, COMBINTATION PERMIT FEE'SUMMARY Building Plan Check: $252.49 Building Fees( $1,553.75 Electrical Fees3( ,� '' $35.60 Mechanical Fees:x $37,20- - Plumbing Fees: ` : ' $0.00 SMIP Residential: $0.00 SMIP Commercial: $42.00 TOTAL FEES: $1,921-.04 . —Refer to fee receipts for all fees paid for project NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE 0. INSPECitORTYPE DATE INTMALS COOER INSPECTION TYPE N 1818 Fixed System Final Fire Prevention 206 Final Mechanical D V 128 U 8 Pool Spa Final 208 Final Plumbing 200 Final Re -Root 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 - Final Demolition 250 Final Building/Occupancy e WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the erformance of the work for which this permit is issued. have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: pam ,_ `[ (This seri bn need note ow#eted d the perrn4 is valued arone hundred ddlefs (S 100) orless ) C Pvltcy Num e 1 6 7 7 4 4 �� ❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Lab ode, I shall forthwith comply with these provisions. �% OGt. 2 ZUJ7 WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is infullforce and effect. Claws.# !7 dGf- z.<. 2 O ConlraCor's $igrtaturo (_Qat¢��' CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction tending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Owner ID verified by dri4ae. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): .l DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code), ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Date Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? 0 Yes ❑ No (Section 25533 of the Califomia Health and Safety Code, with some e2exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely Lender's Name: hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Lender's Address: Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. Signature Date 4, If an RMPP is presently required, has Section 25534 of the California OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws,). ❑ I am exempt under sec. Business and Professions Code for this reason: signature 3057.46 {3107) Date Health and Safety Code been fully complied with? ❑Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? [--]Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes-, the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code), 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If 'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. S gnature of Legal Ownerls) l'„' A�ri�dlor Aulnonzed Applicant �— Date Dc..� 2Lill 41V7 CITY OF COSTA MESA BUILDING DIVISION i 77 FAIR DRIVE, COSTA MESA, CA 92626 - (714) 754-5273 - Fax (714) 754-4856 • www.ci.costa-mesa.ca. t. FOR INSPECTIONS CALL: (714) 754-5626 07-00236 FIRE SUPRESSION PERMIT Job Address: 3333 BRISTOL ST Status: ISSUED Suite: SAKS - Applied: 07/26/2007 Vicinity: LOUIS VUITTON WITHIN SAKS :.y Issued: 08/14/2007 Parcel Nunmber: 41249105 Zoning: Applicant: LOONEY,. SHEILA'' Address: .r Phone: 714-993-2822 f ` Zip: Owner: SOUTH COAST,PLAZA'CALWIN.REALTY-] I,INC,- •. } z ,` "� `', ? Address PROPERTY TAX DE" AR_TMENT: BIRMINGHAM; AL? _ Phone: 75&LAKESHORE PARKWAY Zip: _ , 35211-4400 l Contractor: ALERT FIRE.PROTECTION INC -, - _ i •%+' Address: 5200 E HUNTER'AV - SURE B - Phone: 714-993=2822 ANAHEIM, CA 't: Zip: 92807 License: 316324: SCOPE OF PERMIT FIRE SUPPRESSION PERMIT TO REWORK THE EXISTING, FIRE SPRINKLER SYSTEM (23 HEADS) FOR A 1,350 SF INTERIOR TI FOR"LOUIS VUITTON" WITHIN THE SAKS FIFTH AVENUE STORE, REFM BC07-00104. FEE SUMMARY Plan Check: $72.31 - r; r' " Calc Valuation: 54,700.40 Permit: $111.25 Claimed Valuation: $4,704.40 Other: $0.00 Total: $183.56 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: in order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE M. INSPECTION TYPE 1616 Fixed System Final Fire Prevention 1266 Pool Spa Final 200 Final Re -Root 201 Final BlocklRetaining Wall 202 Final Factory Fire Place 203 Final Sign 204 Final Demolition HATE iNiRIALS C40E / INSPECTION TYPE 206 Final Mechanical 208 Final Plumbing 210 Final Electrical 212 Final Fire Prevention 220 Final Planning Approval 222 Final Site 250 Final Building/Occupancy DATE INTmALS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure`for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. tI have and will maintain workers' compensation insurance, as required by ction 3700 of the Labor Code, for the performance of the work for which this pennit is iss:11 ers' compensation Insurance carrier and policy number are: Carrier: (This sectbn need not be cfompletJed d the pemtt is vaR� at are hundred dadars ($100) or less.) Policy Number: / �O 5,5 7 — ❑ I certify that in the performance of the work for which this permit is issued, i shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to workers' compensation provisions of Section 3700 of the Labor Code, I forth comply these provisions. tri � -Z � •u Applicant's Signature 61, Date WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and eH ct. Lic. # �� Class #"CZ � V7 n a tor's Signature Come CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property. am EXCLUSIVELY CONTRACTING WITH, LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature 3657-46 (3/07) Date Owner ID verified by driver's t" ❑ Yes [--]No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ t hereby certify that no excavation fire (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Date Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to File and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons. or 200 cubic feet of compressed gas at standard temperature and pressure). 2. floes or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant of present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and tiling with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). T If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If 'yes",. attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding hazardous Materials and Emissions. Signature CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Sig t of Legal mer{s Dat Andlor Authorized Applicant Date CITY OF COSTA MESA BUILDING 'DIVISION 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 Fax (714) 754-4856 • www.ci.costa-mesa.ca. FOR INSPECTIONS CALL: (7'14) 754-5626 07-00276,' FIRE SUPRESSION PERMIT Job Address: 3333 BRISTOL ST _ =- _ r T• Status: ISSUED Suite: SAKS Applied: 09/20/2007 Vicinity: ARMANI MENS WITHIN SAKS"-r'f a x " Issued: 10/11/2007 = M Parcel Nunmber: 41249905 �A Zontrlg Applicant: LOONEYLSHEILA pry Address: �bt'°. Phone: x 714-993-2822 Zip:t s..ap Owner: SOUTH COAST PL'AZA'CALWIIV.REALTY II INC , Address PROPERTY TAX DEPARTMENT,, •• % m�. '�'=- - H BIRMINGHAM; -AL 4 r :' ~ ' Phone: t 756,LAKESHORE PARKWAY' Zip: m,35211-4400, r 11t _-7 ,. i Contractor: AL RT FIRE'•PROTECTION INC Address: 5200 E.HUNTER'AV SUITE B __Phone:714-993=2822 k.1 f; •: ANAHEIM CA Zip: _92807 r. License: 316324„ SCOPE OF: PERMIT - FIRE SUPPRESSION PERMIT TO ADD 4'NEW AND RELOCATE 10 EXISTING FIRE'.SPRINKLER HEADS FOR A 232_SF INTERIOR T:I: FOR 'GORG10'ARMANI MENS"'STORE WITHIN THE SAKS:FIFTH AVENUE STORE. REF:#�BC07=00226 / M- '3-`', FEE SUMMARY _ Plan Check: $63.21 = :r-_ s; ", ` =- `"F ' Calc Valuation: $4,000.00 Permit: $97.25 =s Claimed Valuation: $4,000.00 Other. $0.00 Total: $160.46 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE N, INSPECTION TYPE 1616 Fixed System Final Fire Prevention 1266 Pool Spa Final 200 Final Re -Roof 201 Final Block/Retaining Wall 202 Final Factory Fire Place 203 Final Sign 204 Final Demolition DATE INTITIAL5 CODE A INSPECTION TYPE 206 Final Mechanical 208 Final Plumbing 210 Final Electrical 212 Final Fire Prevention 220 Final Planning Approval 222 Final Site 250 Final Building/Occupancy DATE INTMALS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the rformance of the.work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by ection 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are,�'' Carrier: I.(_>ia%t,C%l24 Ac:5., ; Gt (This season need not be completed slhe perms is valued atone hundred collars ($100) or less.) Policy Number: x.7,306006 8 7Sd 1r ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject Jo the workers' compensation provisions of Section 3700 of the Labor Code, allfo "th co ply with these provisions. Applicant's Signature Date WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in fulllforce and effe t. /7 / Lic. # 3 Class # G f0 1-07 actor's Signature Date CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature 3057-46(3107) Date Owner ID verified by driver's It, ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:. - ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Division of Industrial Safety Permit Number: Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if `yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If 'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date . CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection, S n re or Le Owners} Date Andlor Authonzed Applicant Date CITY OF COSTA MESA BUILDING DIVISION * 77 FAIR DRIVE, COSTA MESA, CA 92626 - (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us FOR INSPECTIONS GALL: (714) 754-5626 PERMIT NUMBER: BC07-00189 PERMIT TYPE: B. COMBO STATUS: ISSUED Sub Type: COM—ALT DATE ISSUED: 0811712007 -. ISSUED BY: SOK JOB ADDRESS: 3333 3000 BRISTOL ST' CM ', Suite/Unit:. 3000 APN: 41249102 ,Zoning:PDC, Vicinity: SPACE 3000 Primary 0= ;, Const Type: I -FR SO. FT` - 0 Valuation: $15,000.00 SCOPE OF WORK: NON-STRUCTUAL•,'INTERIOR DEMOLITION OF SPACE 3000 FOR FUTURE TENANT. OWNER: SOUTH COAST PLAZA' Address: 3315 FAIRVIEW AVE, Unit: MISC. Phone: City/State/Zip: _ COSTA MESA, CA APPLICANT: DAN LORIOT Address: Unit: Phone: 949-361-0111 CitylStatelzZip: CONTRACTOR: HURST AND SIEBERT License No. 622681 Phone: 949-361-0111 Address: 2377 SO EL CAMINO.REALUnit: SUITE 103 Cell: City/State: SAN CLEMENTE, CA ZipCode 92672 ARCHITECT: License No. PHONE: ENGINEER: License No. PHONE: COMBINTATION PERMIT FEE SUMMARY Building Plan Check: $163.31 Building Fees: $251.25.. Electrical Fees: $0.00 Mechanical Fees: $0.00 Plumbing Fees: $0.00 SMTP Residential: $0.00 - SMIP Commercial: $3.15 TOTAL FEES: $417.71 "Refer to fee receipts for all fees paid for project NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. LODE II INSPECTION TYPE DATE INTITIALS CODE N INSPECTION TYPE. DATE iNTMAL 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final _ 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final BlocklRetaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place _ 220 Final Planning Approval 203 Final Sign _ , _ 222 Final Site 204 Final Demolition 250 Final BuildinglOccupancy WORKERS' COMPENSATION DECLARATION: I hereby affirm under penally of perjury one of the following declarations: q 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued_ C� i:f,ave and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this Permit is issued. My workers' compensation Insurance carrier and policy number are: amer: _ —j c�tvD �(Thts Section need not be completed ! the permd isvaluedat one hundred dopa(s (S 1 POJ or less.) Policy Number: �FjB5l — 2-006 ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to ih�hWrth 'mpensation provisions of Section 3700 of t bar shaply with these provision . Applicant's Signature Date . - WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. 68. CCfass _. tractor's Signature � CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, f3usiness and Professions Code: Any city or county which requires a permit to Construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any appficant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole Compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale, If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that -he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. !Business and Professions Code for this reason: Signature 1ast46 (&V) Date Owner ID verified by drive, ise. [:]Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Cade). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Date Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gaftons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions• requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons. or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? [:]Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by Califomia Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If -yes", attach certificate of compliance from the appropriate air pollution control officer)._ CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this pegakuntil final inspection. tr� ertsy Date 1 Andlor Authorized Applicant t,,�, ate_ „ CITY OF COSTA MESA BUILDING DIVISION * 77 FAIR DRIVE, COSTA MESA, CA 92626 - (714) 754-5273 - Fax (714) 754-4856 - www,ci.costa-mesa.ca.us J FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BC07-00382 PERMIT TYPE: B_COMBO STATUS: ISSUED Sub Type: COM_ALT DATE ISSUED: 12110/2007 ISSUED BY: JOB'ADDRESS: 3333 SAKS BRISTOL' -6T -CM.;'";_- Suite/Unit: :SAKS APN: 41249105 Zoning: Vicinity: PRADA WITHIN SAKS FIFTH AVE , - y: µ4 Primary.;Occ:' Const Type: II -F `,' SQ._TT:a 492 Valuation: $120,000.00 SCOPE OF WORK: 492 S.F. INTERIOR ALTERATION FOR "PRADA" WITHIN SAKS FIFTH AVENUE. ELEC: 24 LIGHT FIXTURES, 2 OUTLETS, 5 SWITCHES;'MECH: 5 VOLUME DAMPERS, 1 REPAIR/ALT COOL/HEAT (13`DIFFUSERS) t, OWNER: SOUTH COAST PLAZA CALWIN REALTY II INCA_ddress , PROPERTY TAX DEPARTMENT Unit: BIRMINGHAM, AL Phone: yCity/State/Zip: 750 LAKESHORE PARKWAY APPLICANT: Address: Unit: Phone: CitylStatelzZip: CONTRACTOR: WESTWOOD CONTRACTORS CORP License No. 618438 Phone: 817-877-3800 Address: 951 W 7TH STUnit: Cell: 817-334-1279 -_; CitylState: FORT WORTH, TX' ZipCode 76102 ARCHITECT: CALVIN COATSVIIORTH License No.C14388 _ PHONE949-833-1930 ENGINEER: License No. PHONE: COMBINTATION PERMIT FEE SUMMARY: ' Building Plan Check: $179.69 Building Fees: $1,105.75 ' Electrical Fees: $$56.12 = - Mechanical Fees: $37,20" Plumbing Fees: SMTP Residential' - _ $0:00- SMIP Commercial; TOTAL FEES: $1,403.96 " Refer to fee receipts for all fees paid for project NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CoDE I. imspEcnoN TYPE 1616 Fixed System Final Fire Prevention 1266 Pool Spa Final 200 Final Re -Roof 201 Finat BlocklRetairning Wall 202 Final Factory Fire Place 203 Final Sign 204 Final Demolition DATE INTnMALS CODE/ i CTION TYPE 206 JOIFinal Mechanical 208 Final Plumbing 210 Final Electrical 212 Final Fire Prevention 220 Final Planning Approval 222 Final Site 250 • Final Building/Occupancy �t3INTITIAL i WORKERS' COMPENSATION DECLARATION: Owner 10 verified by drive, nsa. ❑ Yes ❑ No I hereby affirm under penalty of perjury one of the following declarations.:.,..Dmer's License No. Expires: ❑ 1 have and will maintain a certificate of consent to self -Ensure for wokers' Verification of Ownership by (type of document, i.e. - property tax bill or deed): compensation, as provided for by section 3700 of the Labor Code, for the Performance of the work for which this permit is issued. ❑ I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: permit is issued. My workers' compensation Insurance carrier and policy ❑ I hereby certify that no excavation five (5) or more feet in depth into which a number are, person is required to descend, will be made in connection with work authorized © by this permit, and that no building structure, scaffolding, falsew.ork, or demolition Carrier: or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp (This sectionn ne a petro is valued at one un r dol+ars ($roof a+ess.j Art2 Sec 341 Title 8, California Administrative Code). Policy Number: ❑ As owner -builder I will not employ anyone to do work which would ❑ I certify that in the performance of the work for which this permit is Issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the abor Code, 15 forth omp ith these p isions. 1-2 -W Apphran'signat r pale WA4tUILAWFUL G: FAILURE TO SEURWORKERS' COMPENSATION COVERAGE IS AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Dale Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS (Section 25505 of the California Health and Safety Code requires, with some PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND exceptions, that a Business Plan be filed with the Costa Mesa Fire ATTORNEY'S FEES. Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of LICENSED CONTRACTORS DECLARATION: 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas I hereby affirm that I am licensed under provisions of Chapter 9 (commencing at standard temperature and pressure). with Section 7000) of Division 3 of the Business and Professions Code, and 2. Does or will the applicant or present or future building occupant need to file my license is in full force and effect. ___--a registration form for acutely hazardous materials? ❑ Yes ❑ No Lic. # Class# (Section 25533 of the Califomia Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by r((� each business which at any one time has on hand a quantity of acutely Contractor's Sign u �- Date hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard CO RUCTION LENDIN AGENCY: temperature and pressure). ❑ I hereby affirm that there is a construction lending agency for the 3. Does or will the applicant or present or future building occupant need to performance of the wnrk for which this permit is issued. (Sec. 3097, Civil Code). prepare an RMPP (Risk Management and Prevention Pmnrnm fnr nriitaty Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold .within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of.sale.). ❑ I, as owner of the property, am EXCLU511VELY CONTRACTING WITH LLCENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). F_]I am exempt under sec. Business and Professions Code for this reason: Signature 3057-46 (37071 Date hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to re ister acute) hazardous materials with the Fi D rt t V y re epa men . 4, If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residentia) building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If 'yes', attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. • Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree of occupy or allow occupancy of any building au orized by ' permit i pection. S of Lea n Date r` I thonz pticanl Date CITY OF COSTA MESA r BUILDING DIVISION o 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 • www.cf.costa-mesa.ca.us FOR INSPECTIONS CALL: (714) 754-5626 F07-00352 FIRE SUPRESSION PERMIT Job Address: 3333 BRISTOL ST Status: ISSUED Suite: SAKS t Applied: 11/19/2007 Vicinity: Issued: 12/13/2007 Parcel Nunmber. 41249105 �Zoning: `-- Applicant: SHEILA -LOONEY ` Address: 5200 E HUNTER AV SUITE B' , Phone: 714-993-2822 ANAHEIM,'CA ` Zip: 92807 Owner: SOUTH COAST PLAZA.CALWIN'REALTY II INC l Address PROPERTY TAX DEPARTMENT - BIRMINGHAM, AL Phone: 750 LAKESHORE PARKWAY - Zip: - 35211-4400 Contractor: ALERT FIRE PROTECTION INC Address: 5200 E HUNTER AV SUITE B Phone: 714-993-2822 ANAHEIM,.CA-.1-!'. Zip: 92807: I- License: 316324- SCOPE OF PERMIT RELOCATE 5 OVERHEAD SPRINKLERS FOR "SAKS 5TH AVE" LOCATED AT MID LEVEL. REF.: B06-01738` `FEESUMMARY Plan Check: $35.10 Calc Valuation: $1,500.00 Permit: $54.00 — Claimed Valuation: $1,5o0.0o Other: $0.00 Total: $89.10 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE /. INSPECTION TYRE DATE INTFUML CODE A INSPECTION r1rK DATE INTMAL 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention - 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. qI have and will maintain workers' compensation insurance, as required by tio'n 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' co pensation Insurance carrier and policy number are: Carrier._ 1 (This section need not be campreted d the permit is valued at one hundred do#ars fS100) or less.) Policy e -c. t 5"3owp? 75d r7— ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subj to th workers' compensation provisions of Section 3700 of the Labor C I shtorthwith c 1ply with these provisions. o7 1 Appl canr!; Signature Date_ / WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST. AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. (—Contra ors Si ure— _ (Date -v_1 CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Dale OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve. demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($5000: ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature 305746 {3107) Date Owner ID verified by driver's licc_e. ❑ Yes ❑ No Driver's License No, Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Division of Industrial Safety Permit Number: Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to File and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4, If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑Yes 17-1 No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (if "yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Si t of Legal Ownerts) Dale ;da� 12 13--�d 7 v AnNor Aulhcnzed Apdirant— Elate j CITY OF COSTA MESA 1 O ' c� U �• BUILDING DIVISION • 77 FAIR DRIVE, COSTA MESA, CA 92626 - (714) 754-5273 • Fax (714) 754-4856 • www.ci. sta-mesa.ca.usFp8-00237 ` FOR INSPECTIONS CALL: (714) 754-5626 FIRE SUPRESSION PERMIT Jot Address: 3333 BRISTOL ST Status: ISSUED Suite: SAKS Applied: 09/26/2008 Vicinity: 2ND FLOOR SMALL PORTION IMPROVEMENT Issued: 10/072008 Parcel Nunmber: 41249105 Zoning: Applicant: PULIDO, DANNY Address: Phone:626-332-7066 Zip: Owner: SOUTH COAST PLAZA.CALWIN REALTY Il INC Address PROPERTY TAX DEPARTMENT BIRMINGHAM, AL . Phone: 750 LAKESHORE PARKWAY Zip: 35211-4400 Contractor: ALLREADY FIRE SPRINKLER Address: 818 N GRAND AVE Phone: 626-913-6720 COVINA, CA Zip: 91724 License: 358795 Plan Check: Permit: Other: Total: SCOPE OF PERMIT FIRE SPRINKLER PERMIT TO RELOCATE 34 SPRINKLER HEADS FOR A 33,954 SF INTERIOR TI FOR 'SAKS", THIRD FLOOR AND SMALL PORTION OF SECOND FLOOR. REF: BCOB-00167 FEE SUMMARY $6321 - Calc Valuation' $4 000 00 $97.25 $0.00 $160.46 Claimed Valuation: $4,000.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations, (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must oomply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. com #, ff rt i7bT.l; LaMIL &4P>=.! INSPECTION Int 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Popl Spa Final 208 Final Plumbing 200 Final Re -Roof 210 final Electrical 201 Final BlocIVRetaining Wall 2Q_ Final Fire Prevention 7OR' Cul - 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section. 3700 of the Labor Code, for the performance of the work for which this permit is issued. XXI have and will maintain workers' compensation insurance, as required by 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: 1" -Carrier: _ ; U Ka/E`e --- (Thm secdon need not be wm/pleettedd i Ute t eeppwr f is valued at am Rundred doftrs (5 100) of less.) ��1 -Policy Number: E/V C.�(J�O ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' corn ensation laws of California, and agree that if I should become subje o the rkers' compensation provisions of Section 3700 of the Ike ! shat! fo th co ply with these provisions. t- /D_ 7-0d' ,'Applicant's Signature Date WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force andeffect. Lic.- .' S Class # 1 r -7 —6 do Contractor's Signature pate CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lenders Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law dues not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors license taws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature 3057-46 (3!071 Date Owner ID verified by drive, � license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ i hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding. falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high, (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Cafe). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industria! Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Division of Industrial Safety Permit Number: Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits), 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (if yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all slate laws and -city ordinances regarding Hazardous Materials and Emissions. Signature Date . CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection, e of egal Own r s) Date Wew<v ul _ortzed Applicant ,,,� cote CITY OF COSTA MESA BUILDIMIG DIVISION F� 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 • www.ci,co ta-m=.ca_uJF08-0a1 63 ti FOR INSPECTIONS CALL: (714) 754-5626 FIRE SUPRESSION PERMIT .lob Address: 3333 BRISTOL ST Status: ISSUED Suite: SAKS Applied: 06/24/2008 Vicinity, THIRD FLOOR Issued: 07/09/2008 Parcel Nunmber: 41249105. Zoning: Applicant PULIDO, DANNY - Address: 818 N GRAND AVE Phone: 626-913-6720 COVINA, CA 1 Zip: 91724 Owner: SOUTH COAST PLAZA CALWIN REALTY 11 INC Address PROPERTY TAX DEPARTMENT BIRMINGHAM, AL . Phone: 750 IAKESHORE PARKWAY-- '' Zip: 35211-4400 Contractor: ALLREADY FIRE SPRINKLER Address: 818 N GRAND AVE. _ - Phone: -626-913-6720 COVINA, CA Zip: 91724 _ License: 358795 SCOPE OF PERMIT FIRE SUPPRESSION PERMIT TO RELOCATE 83 SPRINKLER HEADS FOR A 33,954 SF INTERIOR TENANT IMPROVEMENT FOR THIRD FLOOR AND SMALL PORTION OF SECOND FLOOR FOR "SAKS". REF#: BC08-00167.' ". 110 163 !15 t i ELD •`11241: DGZ Calc Valuation: $12,500.00 Claimed Valuation: S12,500:00'k NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. C4PE.1 LNAM02! M DATE INTMALs CODER INSP ONTYPE Pl1E 11111/1L5 1616 Fixiad System Final Fire Prevention ( 206 Final Mechanical 1266 Pow Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical •"' 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy FEE SUMMARY Plan Check: $145.11 Permit: $223.25 Other: $0.00 Total: $368.36 ". 110 163 !15 t i ELD •`11241: DGZ Calc Valuation: $12,500.00 Claimed Valuation: S12,500:00'k NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. C4PE.1 LNAM02! M DATE INTMALs CODER INSP ONTYPE Pl1E 11111/1L5 1616 Fixiad System Final Fire Prevention ( 206 Final Mechanical 1266 Pow Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical •"' 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. s I have and will maintain workers' compensation insurance, as required by kection 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy [number are: �D � Carrier: x� llax&typ�r Ae-e- (This seder+ rieed AM !/��.�/beaWWkfed Ari d* per+n9 is ,�ea_faf orw ffxk v *)Ws ($100) or less.) Policy. Number. �N22� 9sZ; _ ❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subje workers' compensation provisions of Section 3700 of the C e. I hall orthwith mply with these provisions. 7 -'F- p icant's Signature _ Dale WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. SL'ic..#' 7g5 Class -a� tractors Signature Date CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.)., ❑ 1, as -owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors license Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature Dale 3057-46 (3/07) Owner ID verified by driver acense. []Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation rime (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Date Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Dopartment. 4, If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safely Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If 'yes", .attach certificate `of compliance from the appropriate air pollution control officer). ' CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws -and city ordinances regarding Hazardous Materials and Emissions. Signature Date , CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating -to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. -r---9m lure pf Leg I Owner(s) Date .-7�•5, Antlror Aullwoz Applicant r Date `�.� tom_ , CITY OF COSTA MESA BUILDIMIS DIVISION } 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 www.d. sta-mesa-ca.uF08'04245 �. FOR INSPECTIONS CALL: (714) 754-5626 FIRE SUPRESSION PERMIT .fob Address: 3333 BRISTOL ST Status: ISSUED Suite: SAKS Applied: 10107J2OO8 Vicinity: THIRD FLOOR Issued: 1 011 512 00 8 Parcel Nunmber: 41250107. Zoning: PDC PDC Applicant: WIEMANN, JOHN,.' ; Address: 818 N GRAND AVE Phone: 626-332-7066 COVINA. CA Zip: 91724 , •, �JO j tri Owner: SOUTH COAST PLAZA Address 3315 FAIRVIEW RD Phone: COSTA MESA, CA Zip: 92626 Contractor: ALLREADY FIRE SPRINKLER Address: 818'N GRAND AVE Phone: 626-913-6720 COVINA,.CA Zip: 91724 License: 358795 SCOPE OF PERMIT FIRE SUPPRESION PERMIT TO RELOCATE 84 SPRINKLER HEADS FOR "PHASE Il" OF THIRD FLOOR INTERIO TI FOR 'SAKS FIFTH AVENUE". REF#: BC08-00167 FEE SUMMARY Plan Check: $163.31 Calc Valuation. $15,000.00 Permit: $251.25Claimed Valuation: Siuoo.00 Other: $0.00 - , ' . � � ' Total: $414.56 _ NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered Legal, such work must comply with all applicable codes, and all required insp@ctions and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit.. GORE /• INSPEC110N TYPE QAC M L CODER thisnc710N TYPE t IN 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Root 210 Final Electrical f 201 Final Block/Retaining Wall 212 Final Fire Prevention cl'Qre-_( 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Oemolition 250 Final Building/Occupancy WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: . ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are, r Carrier:. . — —a1dr�SCf) (This section neck{nW be000rnpileted I Um pemrf d is vahred at oft txffxk dolars (S100) a less.) L Policy Number: �c,4-64 6!!� q(D-2, ❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should becom su jact l0 t workers' compensation provisions of Section 3700 of the La de, f �ha� forthwilh comply with these provisions. Q Applicant's Signature Date WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lia S Class # tats -lam ContradorsSignature Date o CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code), Lender's Name: Lenders Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature Date 3057.46 (3M7) Owner_ ID verified by drive.., ecense. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e, - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirly-six (36) feel high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Division of Industrial Safety Permit Number: Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be flied with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one lime has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? []Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'fres", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (if 'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I cerlify that under penalty'of• perjury the information given above is correct. 1 agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that -the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. ign e f regal Owner(s) Date L 0-- 1 � Andlor Aulhonzed Applicant Date CITY OF COSTA MESA BUILDING DIVISION s ' a 77 FAIR DRIVE, COSTA MESA, CA 92626 - (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BC08-00459 PERMIT TYPE: B_COM130 STATUS: ISSUED Sub Type: COM—ALT DATE ISSUED: 10/15/2008 ISSUED BY: YH JOB ADDRESS: 3333 SAKS BRISTOLST CMSuite/Unit: ` SAKS APN: 41249105 - Zoning: Vicinity: SAKS 3RD FLOOR Primary Occ: M" Const Type: II -A SQ. FT: - 562 Valuation:. $125,000.00 SCOPE OF WORK: 562 SF INTERIOR TI•FOR VENDOR SHOP "DOLCE & GABBANA", LOCATED ON THE 3RD FLOOR WITHIN SAKS FIFTH AVE, WITH 38 FIXTURES; 2 OUTLETS, 5 SWITCHES AND 1 ALTER/REPAIR DUCTING. OWNER: SOUTH COAST PLAZA CAUMN REALTY II INCAddress: PROPERTY TAX DEPARTMENT Unit: BIRMINGHAM, AL ; Phone: CitylStatelZip: 750 LAKESHORE PARKWAY- a APPLICANT: MOUTES, MICHAEL t ,;~ Address; Un4 it: Phone: 818 581-5787 CitylStatelzZip: CONTRACTOR: POSSELL CONSTRUCTIOWCO., INC. " License No. 336576,• -• Phone: 818-785-1151 Address: 7059 VALJEAN AVE Unit: - Cell: _ City7St6te: VAN. NUYS, CA' ZipCode • 91406 ARCHITECT: License No. ENGINEER: License No. COMBINATION PERMIT FEE SUMMARY Building Plan Check: $184.24 Building Fees: = $1,133.75 Electrical Fees: $67.34 Mechanical Fees: $37.20 Plumbing Fees: SMIP Residential: SMIP Commercial: -$26,25 TOTAL FEES: $1,44$.?8 —Refer to fee receipts for all fees paid for project PHONE: PHONE: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration.of this permit. CODE 0 INSPECT19M M OAST INTRIAIS CODEjj INSPECTION TYPE r� r��7F IN711TIAL 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy Z ✓ WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. EV I have and will maintain workers' compensation insurance; as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: f7hAs section need not be completed.d the pemrd is valued at one hundred dollars (S100) or fess.) Policy Number: ._/_ S i CIo /p S 7A- ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if 1 should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I s _4altsforthwith compjyivith these provisions. Applicant's Mg -nature Date WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic. #_3 3 6 S 7t Class # Contractor's Signature Date CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws,). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature 3057-46 (31071 Owner ID verified by drive, - ocense. ❑ Yes ❑ No Driver's License No. Verification of Ownership by (type of document Expires: i.e. - property tax, bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:, ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Date Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4, If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied All ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? []Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7, If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If 'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: 1 certify that under penalty of perjurythe information given -above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF' ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature of gal Owners) Andfor Authorized Applicant Date Date CITY OF COSTA MESA BUILDING DIVISION i 77 FAIR DRIVE, COSTA MESA, CA 92626 - (714) 754-5273 - Fax (714) 754-4856 - www.ci.costa-mesa.ca.us FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BC08-00415 PERMIT TYPE: B_COMBO STATUS: ISSUED , 1. • -• Sub Type: COM—ALT DATE ISSUED: 10/15/2008 - ISSUED BY: YH JOB ADDRESS: 3333 SAKS BRISTOL ST CM Suite/Unit:, -SAKS APW 41249105 Zoning: Vicinity: INSIDE SAKS FIFTH AVENUE 3RD FL Primary Occ: M. Const Type: I -A } SCS. FT: 542 Vafuation: $444,000.00 SCOPE OF WORK: 542 SF INTERIOR TI FOR VENDOR SHOP "GUCCI READY TO WEAR" LOCATED ON THE 3RD FLOOR WITH IN SAKS FIFTH AVENUE WITH 115 LIGHT FIXTS, 5 OUTLETS, 7 SWITHCES, 2 COMMUNICATION DROPS, 12 MISC CONDUIT, 7 MIS CONDUCTORS, 1 ALTER/REPAIR DUCTING, OWNER: MOUTEs, MICHAEL ' . Address: Phone: 818 581-5787 City/State/Zip: APPLICANT: WERNIJ, BRANDON Address: Phone: 949-833-1930 CitylStatelzZip: u® CONTRACTOR: POSSELL CONSTRUCTION CO., INC. - License No Phone: 818-785,1151 Address: 7059 VALJEAN AVE Unit: Cell: City/State: VAN NUYS, CA ARCHITECT: CALVIN COATSWORTH License No.C14388 = ENGINEER: License No. COMBINATION PERMIT FEE SUMMARY Building Plan Check: $201.53 Building Fees: $1,240.15 Electrical Fees: $476.05 Mechanical Fees: $37.20 Plumbing Fees: $0.00 SMIP Residential: $0.00 SMIP Commercial: $30.24 TOTAL FEES: $1,985.17 "Refer to fee receipts for all fees paid for project Unit: Unit: 336576 ZipCode 91406 PHONE:949-833-1930 PHONE: a�6 NOTICE: The work Authorized by this permit shall comply with all applicable handicap access requirements under California. statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE t, lllsntTlON UK p INTMAL cope a INSPECTION1rPE QQ IN 1616 Fixed System Filial Fire Prevention 206 Final Mechanical I - � �O 1266 Pool Spa Final 208 Finaf Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site ., 204 Final Demolition 250 Final BuildinglOccupancy WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for ►workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. W I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: S' i ATF (This seabn need nor be mrnpleeedllhe permit is vah+ed as one hundred daeirs (Er00) or ress,) Policy Number: O I Q ❑ 1 certify that in the performance of the work for which this permit is issued. I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California. and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I s orth%#Ath comp th these provisions. Ln —! S — D8' Applicants Signature w Date WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000)• IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic. # 3 3 g: , 7L Class # Contractors Signature I (Yate CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sate (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not appjy to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors license Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Date 3057.46 (3107) Owner ID verified by drive.., acense. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed):' DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation fire (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, fatsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, Califomia Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Date Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4, If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65650.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if 'yes-, the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safely Code). 7. If a permit from the South Coast Air Ouality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No S. (If "yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under'penalty of perjury the information given above is correct. I agree to comply with all. state laws and city ordinances regarding Hazardous Materials,and Emissions. , Signature . Date CERTIFICATE OF COMPLIANCE ANb' AUTHORIZATION OF ENTRY: i certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state taws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit unlit final inspection. - �SignaSure of �tst �Andlor Authorized Apric-aril Date Cate CITY OF COSTA MESA BUILDIMO DIVISION } 77 FAIR DRIVE, COSTA MESA, CA 92626 - (714) 754-5273 - Fax(714)754-4856 - www.ci.costa-mesa.ca.us FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BCOB-00415 PERMIT TYPE: B_COMBO STATUS: FINALED Sub Type: COM—ALT DATE ISSUED: 10/1512008 '-ISSUEDBY: YH JOB ADDRESS: 3333 SAKS BRISTOL- CM b J ' ° SuitelUrn'it i 'SAKS '(i 41249105 : FS' . F'- Zoning: Vicinity: INSIDE SAKS FIFTH AVEN6E'3RD-FL ' PrimaryOcc .M Const Type: I -A SQ. _FT:,- , 542 :.Valuation: $144,000.00 ' SCOPE OF WORK: 542 SF INTERIOR TI FOR VENDOR SHOP "GUCCI READY TO WEAR!"LOCATED_ON THE 3RD FLOOR WITH IN SAKS FIFTH AVENUE W1TH,1115 L1GNT FIXTS, 5 OUTLETS, 7,SWITHCES, 2 COMMUNICATION DROPS, 12 MISC CONDUIT, 7 MIS CONDUCTORS, 1 ALTERIREP-AIRtDUCTING. 17 _OWNER: MOUTES, MICHAEL., ',:,. Address: .. -�' Unit: Phone: 8185811-578i, 7City/State/Zip: APPLICANT: WERNLi, BRANDON ,• ,,' .. Address: `Unit: : Phone: 949-833-1930 CitylStatelzZip ­" CONTRACTOR: POSSELC CONSTRUCTION CO., INC.- -- License No. 336576 ' Phone: 818-785-1151 Address: 7059 VALJEAN AVE Unit: Cell: j - CitylState VAN NUYS,,CA` r' ZipCode 91406 ARCHITECT; CALVIN COATSWORTH --. License No.C14388" _ PHONE:949-833-1930 ENGINEER: '•4,,= License No. PHONE: - COMBINATION_PER-MIT FEE SUMMARY: • ,f S : Building Plan Check: $201'53, Building Fees: Y` $1,240.15' Electrical Fees: $476.05y Mechanical Fees: " y $37.20 Plumbing Fees: s $0:4D .4, SMIP Residential: - . $0:00 i SMIP Commercial $30:24 TOTAL FEES: $2,016.83) "Refer to fee receipts for all fees paid for project NOTICE: The work authorized by this permit shall'. comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. QDE I. INSPECTION TYPE 1616 Fixed System Final Fire Prevention 1266 Pool Spa Final zoo Final Re -Roof 201 Final Brock/Retaining Wall 42 Final Factory Fire Place 203 Final Sign 204 Final Demolition CODER INSPECTION TYPE 206 Final Mechanical 208 Final Plumbing 210 Final Electrical 2f 2 Final Fire Prevention 220 Final Planning Approval 222 Final Site 250 Final Building/Occupancy WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ 1 have and will maintain workers' compensation insurance. as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: (This section need not be compleled d the permd is valued at one hundred dollars ($100) or fess.) Policy Number: ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisions. Applicant's Signature Dale WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic. # Class # Contractor's Signature Date CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARA N I hereby affirm that under pen%or EXEMPT FROM THE CONTRACTORS LICENSE reason (Sec. 7031.5, Business and Professions Co Anich requires a permit to construct, alter, improve, d olisre, prior to its issuance, also requires the applicanr e gned statement that he or she is licensed pursuas he Contractors License Law (Chapter 9 (commencing with Section Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon,.and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. if, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving• that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractors) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature 3057-46 (3707) Date Owner ID verified by driver .,cense. []Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Division of Industrial Safety Permit Number: Dale HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to fire and certify a Business Plan for emergency response to release or threatened release of a hazardous material? []Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be fumished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (if "yes', attach certificate of compliance from the appropriate air pollution control officer). = CERTIFICATE. OF COMPLIANCE: I certify that under penalty of perjury the information.given above .is correct. I agree.to comply with all state laws and city ordinances regarding,Hazardous Materials and Emissions. Signature IDale CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: ' 1 certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives .'Of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow Dccupaincy of any building authorized by this permit until final inspection. Signature of Legal Owner(s) And/or Authorized Applicant Date Date CITY OF COSTA MESA BUILDING DIVISION FO&00294 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 www.ci.costa-mesa.ca.us �. FOR INSPECTIONS CALL: (714) 754 5626 w � Job Address: Suite: Vicinity: Parcel Nunmber: Applicant: Address: Owner: Address Contractor: Address: Plan Check: Permit: Other: Total: FIRE SUPRESSION PERMIT 3333 BRISTOL ST _ SAKS GUCCI HANDBAGS WITHIN SAKS 41249105 "d, �. ,.,-Zoning:.-. JOHN WIEMANN F r r s Phone: 626-332-7066 Zip: SOUTH -COAST PLAZA CALWIN REALTY II INC PROPERTY TAX DEPARTMENT BIRMINGHAM;'AL Phone: 750 LAKESHORE PARKWAY Zip: 35211-4400 ALLREADY FIRE SPRINKLER 818 N.GRAND AVE Phone: 626-913-6720 COVINA, CA Zip: 91724. Status: ISSUED Applied: 12/30/2008 Issued: 0 111 512 0 0 9 License: ' 358795' k , SCOPE OF PERMIT RELOCATION OF 9 OVERHEAD SPRINKLER HEADS IN CONJUNCTION WITH THE 493SF INTERIOR 2ND FLOOR'STORE TI WITHIN SAKS FOR "GUCCI HANDBAG." REF: BC08-00416 FEE SUMMARY $29.15 Calc Valuation: $1,200.00 $44.85 Claimed Valuation: $1,200.00 $0.00 $74.00 3 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE 1• INSPECTION TYPE 1A NI TMAlS CODER INSPECTION TYPE DATE INTMALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 206 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final 61ocklRetaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occmancy WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following dectarations: ❑ 1 have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: WA o n VAwqht,� I.—{This sea on need not be completed d the pem-d is valued ai one hundred dollars (E100) or less,) Policy Number:j�nl7��j��7i ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the rkers' compensation laws of California, and agree that if I should beco ske, t to t e workers' compensation provisions of Section 3700 of the Lao I fbrthw ith comply with these provisions. tr"Y' 1 C _ -Applicant's Signature Gate - WARNING? FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Class # Contractor's Signature Date CONSTRUCTION CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature 3057-46 (3/07) Owner ID verified by driver's Iia ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341. Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Dale Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if 'yes the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (if "yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I.certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. 1 agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Sign lure ( Legal Owneris) Date -i " An or AuthonZed Applicant Dale 1- k 6-01-- �� ry Date CITY OF COSTA MESA o BUILDING DIVISION F 77 FAIR DRIVE, COSTA MESA, CA 92626 - (714) 754-5273 • Fax (714) 754-4856 - www.ci.costa-mesa.ca.us �.� FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: E07-00791 PERMIT TYPE EIEC STATUS: ISSUED DATE ISSUED: 09/11/2007 ISSUED BY: RMD JOB ADDRESS: 3333 SAKS BRISTOL ST CM_ Suite/Unit:" SAK Vicinity: INSIDE SAKS ; SCOPE OF WORK: ELECTRICAL PERMIT FOR A 495 S.F. INTERIOR TENANT IMPROVEMENT FOR VENDO HOP, GUCCI, WITHIN EXISTING STORE, "SAKS FIFTH AVENUE". WORK.TO INCLUDE: 9 LIGHT FIXTS, 4 OUTLETS,,.2 SWITCHES. REF#: B07-00724 OWNER: SOUTH COAST PLAZA CALWIN REALTY II INC Address: PROPERTY TAX DEPARTMENT Unit: BIRMINGHAM, AL PHONE: City/State/Zip: 750 LAKESHORE, PARKWAY APPLICANT: AYALA, RICHARDO Address: 137 N"L'ARCHMONT BL Unit:UNIT 567 PHONE: 562-929-6615 - CitylStatelzZip: LOS ANGELES, CA i CONTRACTOR: CALIMA ELECTRIC License No. 357034 Address: 137 N LARCHMONT BLUnit: UNIT 567 ' PHONE: 562-929-6615 City/State: LOS ANGELES, CA ZipCode: 90004 CELL: ELECTRICAL PERMIT FEES Electrical Plan Check Fee: $0.00 Electrical Permit Fee: $40.00 Reinspection Fee $0.00 _ TOTAL FEES .- $40.0.0 - NOTICE. The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. C0� INSPECTION TYPE DATE iNTMALS OPE I INSPECTION TYPE DATE �INTITIAL 1616 Fixed System Final Fire Prevention _- 206 Final Mechanical 1266 Pool Spa Final _ 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical t 4 7 201 Final BlocktRetaining Wall _ ._ 212 Final Fire Prevention 202 Final Factory Fire Place _ 220 Final Planning Approval 203 Final Sign _ 222 Final Site f� 204 Final Demolition _ 250 Final Building/Occupancy WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' Compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ 1 have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number ara:�� 1 46 �� Carrier: iii _ TAis se ( ,on need not he completed if the permR+s valued at a+e�hundred dollars (.8f OO) orless) 15614 icy-Namber: _ 2_9 0/ &CPQ ❑ I certify t1ri the performance of the work for which this permit is issued, I shall nobii�, ploy any person in any manner so as to become subject to the wo ers' compensation laws of California, and agree that if I shouid becomec�:to the workers' compensation provisions of Section 3700 of r--. . the La r ;.t.sftatl,.fortFlwith " rrtply,with these provision 07 Applicants S gnats Date----_. WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in f341 force and effeFt. Lic,.# J.qril4ctors Signature Date` 0'. __--1_ct— CONSTIR - nCIN LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec, 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of -proving that he or she did not build or improve for purpose of safe.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws,). ❑ I am exempt under `sec. Business and Professions Code for this reason: Signature Date 305746 (3107) Owner ID verified by drive, ise. ❑ Yes ❑ No Driver's License No, Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title B, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Division of Industrial Safety Permit Number: Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. -If "an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes 0 No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits), 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No B. (If "yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. 1 agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized this permit until final inspection. of Legal Owners) Date El/ ] t �Ahonzed Applicant Date CITY OF COSTA MESA (BUILDING DIVISION y 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 - www.ci.costa-mesa.ca.us FOR INSPECTIONS CALL: (7`14) 754-5626 PERMIT NUMBER: BC08-00443 PERMIT TYPE: B_COMBO STATUS: ISSUED _ Sub Type: COM -ALT DATE ISSUED: 1011512008 _ . -..;.. _ ISSUED BY: YH JOB ADDRESS: 3333 SAKS BRISTOL"•"ST CM`. F SlaitelUnt:,�' SAKS APN: 41249105 -.. Zoning: Final Fire Prevention Vicinity: SAKS FIFTH AVENUE,, Primary Occ: M Const Type: II -A. SQ: F.T: - 340 Valuation: $110,000.00 SCOPE OF WORK: INTERIOR Tl'FOR VENDOR SHOP "CHLOE" WITHIN SAKS FIFTH AVENUE WITH 25 FIXTURES, 3 OUTLETS, 3 SWITCHES, 1 ALTER/REPAIR DUCTING, NO PLUMB. OWNER: SOUTH COAST PLAZA CALWIN REALTY II INCAddress: - PROPERTY TAX DEPARTMENT Unit: BIRMINGHAM, AL r Phone: r City/State/Zip: 750 LAKESHORE PARKWAY, APPLICANT: MOUTES, MICHAEL Address: Unit: Phone: 818 581-5787 City/StatelzZip: CONTRACTOR: POSSELL CONSTRUCTION CO., INC. License No: 336576 Phone: 818-785-1151' Address: 7059 VALJEAN AVE Unit: Cell: :' - City/State:' VAN NUYS, CA ZipCode 91406. ARCHITECT: CARLILE COATSWORTH ARCHITECTS, INC License No.13665 PHONE: 949-833-1930 ENGINEER: License No. PHONE: COMBINATION PERMIT FEE SUMMARYf,.; _ Building Plan Check: $170.59 Building Fees: $1,049.75 Electrical Fees: $55.75 Mechanical Fees: $37:20." Plumbing Fees: $0.00 SMIP Residential: Moo SMIP Commercial: $23:10' TOTAL FEES: $1,336.39 "Refer to fee receipts for all fees paid for projetl NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord, No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE /. INSPECTION TYYPE AQ�T 1616 Fixed System Final Fire Prevention 1266 Pool Spa Final 200 Final Re -Root 201 Final Block/Retaining Wall 202 Final Factory Fire Place 203 Final Sign 204 Final Demolition INTMAL CODE iNSPECTION� 206 Final Mechanical 208 Final Plumbing 210 Final Electrical 212 Final Fire Prevention 220 Final Planning Approval 222 Final Site 250 Final Suilding10ccupancy r 4p �Zaj~ WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure'for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. [;�" I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: 747 (This section need not be compfeted tl the permit is valued atone hundred dollars (5100) or )ess.) Policy Number: ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I sh rthwith comply these provisions. v ' Applicant's Signature Date WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic. # Class # C ntractor's Signature Dale CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement, is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License taw does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature ' 3057-46 (3107) Dale Owner ID verified by drive - ucense. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Division of Industrial Safety Permit Number: Dale HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. if an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? []Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (if 'yes-, attach certificate of compliance from the appropriate air pollution control officer). : CERTIFICATE OF COMPLIANCE: I certify that under pertalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND'AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. 1 agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property ,for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. . -gnature IOwner(si f And/or Aulhonz _pphtant Date Date CITY OF COSTA MESA BUILDING DIVISION i 77 FAIR DRIVE, COSTA MESA, CA 92626 - (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us } FOR INSPECTIONS CALL: (714) 754 5626 "'MaRnm PERMIT NUMBER: BC09-00145 PERMIT TYPE: BCOMBO � S FINALED STATUS; . Sub Type: C6M_ALT DATE ISSUED: 08/07/2009 ISSUED BY: BJK JOB ADDRESS: 3333 SAKS BRISTOL ST CM- ' Suite/Unit: SAKS APN: 41249105 Zoning: Vicinity: PRADA, 2ND FLOOR OF SAKS FIFTH AVE`_ - Primary Occ: .M Const Type: I -A SQ: FT:`•. 1007 Valuation: $125,000.00 SCOPE OF WORK: 1,007 SF INTERIOR FOR A NEW VENDOR SHOP "PRADA" LOCATED ON THE SECOND FLOOR OF SAKS FIFTH AVENUE. ELEC: 112 LIGHT FIXTS; S OUTLETS, 6 SWITHCES, 2 COMMUNICATION DROPS AND MECHANICAL: i REPAIRlALT COOLIHEAT OWNER: SOUTH COAST PLAZA CALWIN REALTY II INCAddress: PROPERTY TAX DEPARTMENT Unit: BIRMINGHAM, AL Phone: City/State/Zip: 750 LAKESHORF PARKWAY APPLICANT: TURNER, GEORGE Address: 951 W 7TH ST Phone: 817-896-9791 City/State/zZip: FORTWORTH, TX CONTRACTOR: WESTWOOD CONTRACTORS CORP License No. 618438 Phone: 817-877-3800 Address: 951 W 7TH STUnit: Celt: 817-334-1279 City/State: FORT WORTH, TX ARCHITECT: CALVIN COATSWORTH License No.C14388 ENGINEER: License No. . COMBINATION_ PERMIT FEE SUMMARY - Building Plan Check: $184.24 Building Fees: $1,133.75 Electrical Fees: $130.26: Mechanical Fees: $37.20 Plumbing Fees: $0.00 ' SMIP Residential: $0.00 SMIP Commercial: $26:25 _ Bldg Std Admin Fund $5.00 TOTAL FEES: $1,611.54 -Refer to fee receipts for all fees paid for project Unit: : ZipCode 76102 PHONE:949-833-1930 PHONE: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-2$, § 1, 12-21-92) EXPIRATION. PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE /" INSPECTION TYPE DATE INTMALS CODE! INSPECTION TP DATE INTMAL 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing �y 200 Final Re -Roof 210 Final Electrical Zd / 201 Final BlocklRetaining Wail 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site r� 204 Final Demolition 250 Final Building/Occupancy r♦ r� WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: (This section need not be completed d the penng is valued atone hundred dollars (5700) w less.) Policy Number: ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisions. Applicant's Signature Date WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THF LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic. # Class # Contractor's Signature Date CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction tending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contraclor(s) license pursuant to the Contractors license Laws.), ❑ I am exempt under sec. Business and Professions Code for this reason: Signature Date 305746 (3107) Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: .1hereby certify that no excavation five (5) or more feet in depth into which a U s rewith work authorized d t no building structurescafiddingfalsework, or demolition ling will bere than thirty-six (3fi) feet high. (Chap. 3.2, Grp c �� Ca is Administrative Code). LJ As owner -buts not employ anyone to do work which would require a permit from th i n of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Division of Industrial Safety Permit Number: Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If "yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature of Legal Owner(s) Date Andlor Authonzed Applicant Date CITY OF COSTA MESA o a "'� BUILDING DIVISION > 77 FAIR DRIVE, COSTA MESA, CA 92626 - (714) 754-5273 - Fax (714) 754-4856 - www.ci.costa-mesa.ca.us * L FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BC09-00145 PERMIT TYPE: B COMBO STATUS: ISSUED Sub Type: COM -ALT DATE ISSUED: 0810712009 ISSUED BY: BJK JOB ADDRESS: 3333 SAKS BRISTOL ST CM Suite/Unit: SAKS APN: 41249105 Zoning: Vicinity: PRADA, 2ND FLOOR OF SAKS FIFTH AVE Primary Occ: M Const Type: I -A SO. FT: 1007 Valuation: $125,000.00 SCOPE OF WORK: 1,007 SF. INTERIOR FOR A NEW VENDOR SHOP "PRADA" LOCATED ON THE SECOND FLOOR OF SAKS FIFTH AVENUE. ELEC: 112 LIGHT FIXTS, 8 OUTLETS, 6 SWITHCES, 2 COMMUNICATION DROPS AND MECHANICAL: 1 REPAIR/ALT COOL/HEAT OWNER: SOUTH COAST PLAZA CALWIN REALTY ll INCAddress: PROPERTY TAX DEPARTMENT Unit: BIRMINGHAM, AL Phone: City/State/Zip: 750 LAKESHORE PARKWAY APPLICANT: TURNER; GEORGE Address: 951 W 7TH ST Unit: Phone: 817-896-9791 CitylStatelzZip: FORT WORTH, TX CONTRACTOR: WESTWOOD CONTRACTORS CORP License No. 618438 Phone: 817-877-3800 Address: 951 W 7TH STUnit: Cell: 817-334-1279 City/State: FORT WORTH, TX ARCHITECT: CALVIN COATSWORTH License No.C14388 ENGINEER: License No. COMBINATION PERMIT FEE SUMMARY Building Plan Check: $184.24 Building Fees: $1,133.75 Electrical Fees: $130.26 Mechanical Fees: $37.20 Plumbing Fees: $0.00 SMIP Residential: $0.00 SMIP Commercial: $26.25 Bldg Std Admin Fund $5.00 TOTAL FEES: $1,579.88 "Refer to fee receipts for all fees paid for project ZipCode 76102 PHONE:949-833-1930 PHONE: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes -and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE A• INSPECTION TYPE DATE 1616 Fixed System Final Fire Prevention 1266 Pool Spa Final 200 Final Re -Roof 201 Final BlocWRetaining Wall 202 Final Factory Fire Place 203 Final Sign 204 Final Demolition l"11AL CODE INSPECTION TYPE 206 Final Mechanical 208 Final Plumbing 210 Final Electrical 212 Final Fire Prevention 220 Final Planning Approval 222 Final Site 250 Final Buildingloccupancy DATE INTITIAL 10-q �,nri } oZo6 WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: f This section need not be completed d the pem* is vahred alone hundred dollars (S100) or less) Policy Number: AI certify that in the performance of the work for which this permit is 5sued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Calitomia, and agree that if I should become subject to the work mponsation provisions of Section 3700 of the Labor Code, I tui mi with these provisi /Zoo ,A7ING9�gnature !_DaLeY WARNING: FAILSECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. 7 .Class.# a Contract ture Dat4Ye CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature Date 305746 (3107) Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation rime (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec, 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above. unless such person has a permit to do such work from the division. Applicant's Signature Date Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? [:]Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Ouality Management District or from any other air pollution control district or agency? []Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8, (If 'yes". attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature o al er( Ole or, Auth on ze18 scant _ p tom' 4bCITY OF COSTA MESA BUILDING DIVISION > 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 - www.a.costa-mesa.ca.us FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BC08-00417 PERMIT TYPE: B_COMBO STATUS: ISSUED Sub Type: COM—ALT DATE ISSUED: 1 011 5120 08 ISSUED BY: YH JOB ADDRESS: 3333 SAKS BRISTOL ST CM' , SuitelUnit:- -SAKS APN: 41249105 Zoning-.-.-, , Vicinity: INSIDE SAKS FIPTH AVENUE,.3RD FL } - Primary Occ: M . Const Type: I -A SQ. FT: 1092 Valuation; $109,000.00 SCOPE OF WORK: 2,092 SF IN TI -FOR VENDOR SHOP "PIAZZA SEMPIONE";LOCATED ON THE 3RD FLOOR WITHIN SAKS FIFTH AVENUE WITH 19 LIGHT..FIXTS, 4 OUTLETS, 3 SWITHCES, 1 COMMUNICATION DROPS, 6 MISC CONDUIT, 5 MIS CONDUCTORS AND 1 ALTIrRIREPAIR•DUCTING. OWNER: SOUTH COAST PLAZA CA­LWIN REALTY Il INCAddre'ss: PROPERTY TAX DEPARTMENT • Unit: ' BIRMINGHAM, AL ` Phone: 1= City/State/Zip: 750 LAKESHORE PARKWAY r APPLICANT: MOUTES, MICHAEL Address: Unit: - Phone: 818 581-5787 C!, tatelzZip: CONTRACTOR: POSSELL CONSTRUCTION CO., INC.. _ License No. 336576 Phone: 818-785-1151 Address:, :7059 VALJEAN AVE Unit: Cell: CitylState: _ VAN- NUYS, CA ZipCode 91406 ARCHITECT: CALVIN COATSWORTH.. License No.C14388 PHONE: 949-833-1930 ENGINEER: License No. PHONE: COMBINATION PERMIT FEE SUMMARY Building Pian Check: $169.68 Building Fees: $1,044.15 Electrical Fees: $253.30— 253.30 Mechanical Fees: Mechanical $37.2.0 Plumbing Fees: $0.00 SMIP Residential: $0.00 _ SMIP Commercial: $22.89 - TOTAL FEES: $1,527.22 "Refer to foo receipts for all fees paid for project fug �.DU:1, : PINS . NOTICE: The worts authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) . ,c:20 EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will.result in the expiration of this permit. CODE 1. INSM11ON DATE INTITIALS CODE p INSPECTION TYPE 1� J�p� Q ' I nnn I 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Fool Spa Final 208 Final Plumbing � 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wali 212 Final Fire Prevention 1. 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy / F WORKERS' COMPENSATION DECLARATI 1 hereby affirm under penalty of perjury one of the following declarations:. ❑ I have and will maintain a certificate of consent to self-Insure'fo� workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: �5T14 t' (This section need nor be completed if the pemtf is valued at one hundred "ars (s 100) or fess.) Policy Number: Z, ?. & p C 16 3 %( ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California. and agree that if 1 should become subject to the workers' compens on provisions of Section 3700 of the Labor Code, 1 s fort[ ' h comply these provisions. Applicant's Signature Dale WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic. # 3 3 :ala 5—,Z ,� Class # / e./6—,/ T--gs Contractor's Signature Date CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code), Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption, Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale,). ❑ I, as Owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 704.4, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature 3057-46 (3107) Date do Owner ID verified by rise. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high, (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safely, as noted above. unless such person has a permit to do such work from the division. Applicant's Signature Division of Industrial Safety Permit Number: Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Wilt the applicant or present or future building occupant need to file and certify a Business Pian for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds. or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'fres", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of (his application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (if 'yes", attach ceriiftcate ofcompliance from the appropriate air -pollution control officer), • . 1 - CERTIFICATE' OF COMPLIANCE: I%certify that under penalty of, perjury the information given above is correct. I agree, to comply with all state laws and city ordinances regarding Hazardous Materials.and Emissions. Signature Dale . CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Sr late of Dale —/s —esAf And/or Authorized Applicant Date CITY OF COSTA MESA BUILDING DIVISION 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us FOR INSPECTIONS CALL: (714) 754-5626 19 PERMIT NUMBER: BC08-00416 PERMIT TYPE: B_COMBO STATUS: ISSUED` - , - , Sub Type: COM_ALT DATE ISSUED: 12/16/2008 ISSUED BY: RMD JOB ADDRESS: 3333 SAKS BRISTOLST yCM: ` ` . '' "�Suiii610nit.' -SAKS APN: 41249105 r _r,.%� zoning: Vicinity: GUCCI INSIDE SAKS FIFTH AVE 2ND,FLO6k' ' ~ '' "'rPgrriary,Occ:.-'M,: Const Type: I -A SQ: FT'_'' 682- ;Vaivatiori: $206,000.00 s.j7 SCOPE OF WORK: 682 SF �INTERIOR TI FORVENDOR SHOP "GUCCI HANDBAGS" WITH°lN SAKSlFIFTH AVENUE WITH 923 LIGHT FIXTS, 9 OUTLETS,90 SWITHCES; 2 COMMUNICATION DROPS, 1 SIGN CIRCUIT, 13 M_ISC CONDUIT, 9 MIS CONDUCTORS; MECH: 1 REPAIRIALT COOL/HEAT OWNER: SOUTH COAST PLAZA CALWIN REALTY -11 INCAddress:'. PROPERTYJAX DEPARTMENT Unit: BIRMINGHAM, AL Phone:r CitylStatelZip: 750 LAKESHORE PARKWAY APPLICANT: MOUTES,�MICHXEL' : ; - Address: r Unit: �.. Phone: 818-785-1151. CitylStatelzZlp 4 °� CONTRACTOR: POSSELL.CONSTRUCTION CO., INC.i-_-, License No. _336576 " Phone: 818-785-11511.1 Address:'.�7059,VALJEANIAVE'Unit: " { r i Cell; _ _ { ' City/State: VAN' NUYS, CA ' ZipCode 91406 ARCHITECT: CALVIN COATSWORTH" � .,F - License No.C14388PHONE949-833-1930 ENGINEER: -'`x" ', r. License No: "` ! _. ri PHONE: -; COMBINATION PER FEE SUMMARY" Building Pian Check: $251:95 Bding Fees: :$1 uil587.35' Electrical Fees: `' = 1::j544"' :: j544 19 Mechanical Fees:`3720-., f, t• Plumbing Fees: ;fid, '$o00-,,,`,', SMTP Residential: SMIP Commercial: $4326' - TOTAL FEES: $2,469.95 "'Refer to fee receipts for all fees paid for project NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval trust be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE 0, IN2E00NTYPE 1616 Fixed System Final Fire Prevention 1266 Pool Spa Final 200 Final Re -Roof 201 Final BlocklRetaining Wall 202 Final Factory Fire Place 203 Final Sign 204 Final Demolition DATENI TrULS CODER INSPECTION TYPE 206 Final Mechanical 208 Final Plumbing 210 Final Electrical 212 Final Fire Prevention 220 Final Planning Approval 222 Final Site 250 Final Building/Occupancy ME INTIMLs WORKERS' COMPENSATION DECLARATION: hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier:- S'T-IA�F_ (Thu section need not be curnpiel&d Athe permd is valued at one hundred dollars ($100) or less) �Policy.Number: 30 115.3 28- Z.bt.2 ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code h rthwith c ly with these provisions. A cant's Signature Date - WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic, #_._a;Rg. wT %,6 Class # /2,/6—Zany '-Contractor's Sig re Date CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civif Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that i am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon; and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that -he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property; am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature 'Date 3057.46 (3107) Owner ID verified by driver ..,cense. []Yes ❑ No - Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Division of Industrial Safety Permit Number: _ Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to fire and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the Califomia Health and Safety Cade, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the Califomia Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If 'Yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of pequry the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signatur f Legal Owner(sI Date ,LZ—/6— And/or Au on Zed pphranDale, . CITY OF COSTA MESA o.0;TA "'p, BUILDING DIVISION 77 FAIR DRIVE, COSTA MESA, CA 92626 - (714) 754-5273 - Fax (714) 754-4856 - www.ci.costa-mesa.ca.us FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BC10-00278 PERMIT TYPE: B_COMBO STATUS: ISSUED Sub Type: COM—ALT DATE ISSUED: 07/26/2010 ISSUED BY: RMD JOB ADDRESS: 3333 SAKS BRISTOL ST CM Suite/Unit: SAKS APN: 41249105 Zoning: Vicinity: INSIDE SAKS FIFTH AVE Primary Occ: Const Type: 11-A SQ. FT: 718 Valuation: $40,000.00 SCOPE OF WORK: 718 SF INTERIOR Tl TO CONSTRUCT A NEW VENDOR SHOP FOR "REED KARAKOFF", LOCATED INSIDE "SAKS FIFTH AVE" WITH 12 LIGHT FIXTS, 11 OUTLETS. OWNER: SOUTH COAST PLATA CALWIN REALTY II INCAddress: PROPERTY TAX DEPARTMENT Unit: BIRMINGHAM, Ai_ Phone: City/State/Zip: 750 LAKESHORE PARKWAY APPLICANT: BENSON, RANDY Phone: 817-312-1552 Address: CitylState/zZip: CONTRACTOR: WESTWOOD CONTRACTORS CORP License No. 618438 Phone: 817-877-3800 Address: 951 W 7TH STUnit: Cell: 817-334-1279 City/State: FORT WORTH, TX ARCHITECT: CARLILE COATSWORTH ARCHITECTS License No.C13822 ENGINEER: License No. COMBINATION PERMIT FEE SUMMARY Building Plan Check: $88.28 Building Fees: $543.25 Electrical Fees: $48.80 Mechanical Fees: $0.00 Plumbing Fees: $0.00 SMIP Residential: $0.00 SMIP Commercial: $8.40 Bldg Std Admin Fund $2.00 TOTAL FEES: $690.73 Unit: ZipCode 76102 PHONE:949-833-1930 PHONE: 'Refer to fee receipts for all fees pald for project HOURS FOR CONSTRUCTION ACTIVITY: EFFECTIVE 3/18/2010 - PER CMMC Sec. 13-279 Monday thru Friday - 7:00 am thru 7:00 pm. Saturdays- 9:00 am thru 6:00 pm. Prohibited all hours - Sundays and the following Federal holidays: New Years Day, Memorial Day, Indeeendence Day, Labor Day, Thanksgiving Day and Christmas Day NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia Statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE t. INSPECTION TYPE 1616 Fixed System Final Fire Prevention 1266 Pool Spa Final 200 Final Re -Roof 201 Final Block/Retaining Wall 202 Final Factory Fire Place 203 Final Sign 204 Final Demolition DATE INTITIAL CODED INSPECTIOR TYPE 206 Final Mechanical 208 Final Ptumbing 210 Final Electrical 212 Final Fire Prevention 220 Final Planning Approval 222 Final Site 250 Final Building/Occupancy DATE INTMAL WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: D i- eamR> t (1l1 ✓t To S �i G — fin` i� twr need not be completed d the pemut is valued atone hundred dWars ($100) or fess,) Poffiicy Number: ❑ I certify that in the performance of the work for which this permit is issued. I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become ubject to the workers' compensation provisions of Section 3700 of the r Code, [ forthwith with these provisions. A�rjtanr'4 Signature { LZat,e.�.� WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHAL4 SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS bECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. �ojtractors•Sltlnawre"" .. - I]ate'•�'a'._ CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Coqe: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THi_ WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature Date 3057.46 (3107) Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e.. property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Division of Industrial Safety Permit Number: Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If 'yes , attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. nature of r1s} AndlorAuttmnzed'Apptrcant:�,� -- - M -� Date fir— 16 DaL...� ,IMM CITY OF COSTA MESA BUILDING DIVISION h77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax(714)754-4856 v".ci.costa-mesa.ca.us s+w FOR INSPECTIONS CALL: (714) 754-5626 . PERMIT NUMBER: BC07-00002 PERMIT TYPE: B_COMBO STATUS: ISSUED Sub Type: COM ALT DATE ISSUED: 06/12/2007 ISSUED BY: RMD JOB ADDRESS: 3333 SAKS BRISTOLST CM Suite/Unite., SAKS Vicinity: JO MALONE WITHIN.SAI<S Const Type: I -FR SQrFT_„ __ - "'312 Valuation:..$75,000.00. g ` +fir • �.�%.A'-+ _ .' SCOPE OF WORK: 312SF INTERIORJSTORE TI FOR "JO MALONE" WITHIN SAKS'5TH.'AVENUE AT_,SOUTH COAST PLAZA. ELEC & MECH WORK ASSOCIATED 1NITW7HIS Tl. OWNER: 'SOUTH COAST PLAZA CA WIN REALTY II INC.-,.; . „ Address: PROPERTY TAX DEPARTMENT, Unit:BIRMINGHAM, AL i PHONE: ; ; , _ r `; :>;- .. - '•C itylStatelZip:;" '750 LAKESHORI= PARKWAY ' r - r. APPLICANT: PROFFITT,JM ttA"i Address: Unit: PHONE: 817-896-9881City/StatelzZip: ' k , CONTRACTOR: TEXAS WESTWOOD.CONTRACTORS INC -'License No. 618438 T Address: 777 MAIN STUnit:f'STE 950~ PHONE: 817=877-3800" ' CitylState: FORT WORTH TX ' Zlpbocl&_76102 CELL: 817-334 1279 ARCHITECT: CALVIN .COATSWORTH,;z, is License No.C14388'__ : % PHONE:949-833-1930 ENGINEER- _ License No._::PHONE:•' '•+.?'• . 1. `��• - :.f^F' '� . ) .' I COM13INTATION PERMIT FEE=`SUMMARY_n ,1�"``' , _} Building Pian Check: Building Fees: $818;751 , 'w Electrical Fees: Mechanical Fees: Plumbing Fees: SMTP Residential:0 SMIP Commercial: $15:75„ TOTAL FEES: $1,070:55"'"• —Refer to fee receipts for all fees paid for project NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. cooE /• INSPiecnoxINTITIALS GQpE/ INsaEcnoH � , , f �� INnnAL 1616 Fixed System Final Fire Prevention "206 Final Me ,oal�[i�_'w�/rn 1266 . Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final BlocklRetaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/OccupancyN L of Ylb Li WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the tt,. ..tg declarations:' ❑ I have and will maintain a certificate of consent to self -Insure for_workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work'for;which,this permit is issued. ❑ I have and will maintain workers' compensation insurance, .as,required by, section 3700 of the Labor Code, for the performance of the work for'which this permit is issued. My workers' compensation Insurance carrier and policy number are: r a� l Carried 'S J __ (This section eed n b completo d flee permit is valued atone hundred dollars {$ 100) w less.) Policy Number: ❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the abor Code, I shallf ith co p wit se provisions. F1 Appl(cani's Signature_ _ ate WA ING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS LAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full t ce and ef( Class #. C - rContractor's Signa LDate� J C TRLICTION LENDING A ENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of.proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, -am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The: contractors license Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature 3057-46 (3107) Date Owner ID verified by drive. El Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsew'ork, or demolition *r -dismantling thereof, will be more than thirty-six (36) feet high, (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title a, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Date Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Cade requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department, 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes j] No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If `yes", the facility must meet the requirement of Sections 25534 and 42303 of the Califomia Health and Safety Code). 7. if a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No a. (If 'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF.'COMPLIANCE: I certify, that. under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature egal wnerl Date -Andlor Authonzed Appli n_t Date [ CITY OF COSTA MESA BUILDING- DIVISION * 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 • www,ci,costa-mesa.ca.LA FOR INSPECTIONS CALL: (714)154-5626 F07.00264 FIRE SUPRESSION PERMIT Job Address: 3333 BRISTOL ST Status: ISSUED Suite: SAKS Applied: 09/0512007 Vicinity: JO MALONE IN SAKS 5TH AVE Issued: 09/05/2007 Parcel Nunmber: 41249105 Zoning. Applicant: LOONEY; SHEILA-."; Address: 5200 E HUNTER AV = - SUITE B Phone: -!714-993-2822 ANAHEIM, CA Zip: : 92807 Owner: SOUTH COAST PLAZA-CALWIN REALTY II INC Address PROPERTY TAX bEPARTMENT BIRMINGHAM, AL, Phone: 750 LAKESHORE PARKWAY Zip: 35211-4400 Contractor: ALERT FIRE PROTECTION INC Address: 5200 E HUNTER AV _ SUITE B Phone: 714-993-2822 ANAHEIM, CA I Zip: 92807 License: 316324 t • F SCOPE OF PERMIT ADDITION OF 1 NEW SPRINKLER HEAD AND CHANGE 3 EXISTING HEADS TO CONCEALED HEADS IN CONJUNCTION WITH THE STORE TI FOR "JO MALONE" WITHIN SAK 5TH AVENUE. REF: BC07-00002 FEE SUMMARY Plan Check: $37.08 "1, Calc Valuation: $1,600.00 Permit: $57.05 Claimed Valuation: $1,600.00 Other: $0.00 .' Total: $94.13 NOTICE: The work authorized by this pefmit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 160 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained: Failure to obtain inspections and final approval will result in the expiration of this permit. CODE /• INSPECTIONTYPE l),Ai�F ENTMAL5 CODE I IMCTION TYRE gig INTMAL 1616 Fixed System Final Fire Prevention __ 206 Final Mechanical 1266 Pool Spa Final _ 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final 9tock/Retaining Wall w _ 212 Final Fire Prevention 119 -7-127 619 202 Final Factory Fire Place _ 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy WORKERS' COMPENSAT)ON DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers Compensation, as provided for by section 3700 of the Labor Code, for th p�Ilmh' nce of the work for which this permit is issued. ave and will maintain workers' compensation insurance, as required by n 3700 of the abor Code, for the performance of the work for which this permit is issued.rkers' comp Insurance carrier and policy number are: Carrier: _ (This section need not be completed 0 me ppeeefm_4 is va ed al; hundred dWars (S 100) w fess.) Policy Number: �0_ S/"J, ❑ i certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California. and agree that if I should become subjec to th workers' compensation provisions of Section 3700 of the Labor I Fh forthwith omply with these provisions._ 9 -0 % Applicant's Signature Date WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full 16, force and effe t. /� Lic. # " Class. ## /W Conuador's Signature to CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his -or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. - Business and Professions Code for this reason: Signature 3057-46 (3107) Owner JD verified by drive. mse. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): e . DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high, (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division, Applicant's Signature Date Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or M)J the applicant or present or future building occupant need to rile a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Hearth and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If 'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by is permit until final inspection. gn re ofLe#1 Owners)Dat D Andlw Authorized Applican$UF" Date CITY OF COSTA MESA BUILDING DIVISION 4 * 77 FAIR DRIVE, COSTA MESA, CA 92626 - (714) 754-5273 - Fax (714) 754-4856 - www.ci.costa-mesa.ca. s '• FOR INSPECTIONS CALL: (714) 754-5626 F07-00266 FIRE SUPRESSION PERMIT Job Address: 3333 BRISTOL STStatus: ISSUED Suite: SAKS Applied: 09/05/2007 Vicinity CHANEL WITHIN SAKS 5TH AVE Issued: 09/05/2007 FEE SUMMARY Plan Check: $37.0$ ' ' Calc Valuation: $1,600.00 Permit: $57.05 - _ Claimed Valuation: $1,600.00 Other: $0.00 Total: $94.13 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE -OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE :. INSPECTION TYPE oAi INTMALS CODE # INSPECTION M OAT INmuL5 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1286 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final BlocklRetaining Wall 212 Final Fire Prevention t t -7-yl � 202 Final Factory Fire Place —� 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy Parcel Nunmber: 41249105 .'Zoning: Applicant: LOONEY','SHEILA'""''.- Address: 5200 E HUNTER AV SUITE B Phone: 714-993-2822 ANAHEIM, CA Zip: 92807 , Owner: SOUTH COAST PLAZA CALWIN REALTY I{ INC Address PROPERTY TAX'bEPARTMENT BIRMINGHAM, AL Phone: 750 LAKESHORE PARKWAY Zip: 35211-4400 Contractor: ALERT FIRE PROTECTION INC Address: 5200 E -HUNTER AV SUITE B Phone: 714-993-2822, ANAHEIM, CA ' ' Zip: 92807 , License: 316324 " SCOPE OF PERMIT CHANGE -OUT OF 4 EXISTING HEADS TO CONCEALED HEADS IN'CONJUNCTION WITH THE STORE TI FOR "CHANEL" WITHIN SAK 5TH AVENUE. REF: BC07-00086 FEE SUMMARY Plan Check: $37.0$ ' ' Calc Valuation: $1,600.00 Permit: $57.05 - _ Claimed Valuation: $1,600.00 Other: $0.00 Total: $94.13 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE -OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE :. INSPECTION TYPE oAi INTMALS CODE # INSPECTION M OAT INmuL5 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1286 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final BlocklRetaining Wall 212 Final Fire Prevention t t -7-yl � 202 Final Factory Fire Place —� 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy WORKERS'COMPENSATION DECLARATION. Owner ID verified by drive, ,rse. ❑ Yes ❑ No I hereby affirm under penalty of perjury one of the following declarations: Driver's License No. Expires: ❑ I have and will maintain a certificate of consent to self -Insure for workers' Verification of Ownership by (type of document, i.e. - property tax bill or deed): Compensation, as provided for by. section 3700 of the Labor Code, far the , p ormance of the work for which this permit is issued. 5have and will maintain workers' compensation insurance, as required by 3700 of the Labor Cade, for the performance of the work for which this DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION; permit is issued. M rkrs' corn ensation Insurance carrier and policy ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a number are: person is required to descend, will be made in connection with work authorized - by this permit, and that no building structure, scaffolding, falsework, or demolition Carrier: "` or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2 Art 2, �c 3413;tle8,CalifomiaAdministrative Code). (TW sectjwneednabecormp(eteddthepemT4is ruedar ndreddafars(sYoo)ortoss -} Policy � � ��. r_ Number: _ ' .� - ❑ As owner -builder, I will not employ anyone to do work which would ❑ I certify that in the performance of the work tor*which this permit ism`. require a permit from the Division of Industrial Safety, as noted above. unless issued. I shall not employ any person in any manner so as to become subfect" _such person has a permit to do such work from the division. to the workers' compensation laws of California, and agree that iftlrshould_'�** become subj t the rkers' compensation provisions of ectiorr.3706 of. the Labor C e shall hwith ly with these provisions. a. ­. v Applicant's Signature Date ,Q i Division of Industrial Safety Permit Number: Applicant's Signature Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: WARNING: FAILURE TO SECURE WORKERS' COMPENSATION CO SE+d 1. Will the applicant or resent or future building occupant need to file and PP p g p IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMI certify a Business Plan for emergency response to release or threatened PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS# release of a hazardous materiaf? ❑ Yes ❑ No ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that i am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and eff ct. Lic. # Class # C/Y� ontraaor's Signatur@ Dale CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold. within one year of completion, the owner -builder will have the burden of proving -that he or she did not build or improve for purpose of sale.). ❑ I, as owner•of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044,. Business and Professions Code: The contractors License Law does not appfy to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature e 3057xG 13/07) (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present of future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Wilt any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes , ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (if 'yes*, attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COty PLIANCE' I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions, - Sgnalure Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. �wney`W ate 1 /)f ! - zJ i s' AndrprAuthonzedApplZanl Dara CITY OF COSTA MESA t BUILDING DIVISION h77 FAIR DRIVE, COSTA MESA, CA 92626 - (714) 754-5273 • Fax (714) 754-4856 www.cl.costa-mesa-ca-us FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BC07-00086 PERMIT TYPE: B_COMBO STATUS: ISSUED Sub Type: COM -ALT DATE ISSUED: 07/2612007 -- _ J' :ISSUED BY: BJK JOB ADDRESS: 3333SAKS BRISTOL``ST`CM' J`� yM"'i r,. Suke/U'I t'j_,_SAKS APN: 41249105 r? r - Zoning: ZipCode 76102 _- Vicinity: CHANEL WITHIN SAK&I'`- Const Type: II -F SQ.; FT.,' 490 "" = Valuation: $75,000.00 ARCHITECT: CALVIN COATSWORTH„::`:';: - SCOPE OF WORK: 490 SFINTERIOR T_I FOR VENDOR STORE "CHANEL" INSIDE THLEXiSTING.SAKS STORE INCLUDE NEW >. t NON -LOAD BEARING WALLS,_ CEILING; FINISHES, CASH WRAP, ELECTRICAL AND MECHANICAL. OWNER: SOUTH COAST PLAZA CALWIN REALTY'll INCAddiess:� t PROPERTY TAX DEPARTMENT BIRMINGHAM, AL_ - Phone: 4 CitylState/Zip: 750 LAKESHORE PARKWAY APPLICANT: JIM PROFFITT "`Address:';;' ;. "i •r Unit: Phone: 817-896-9881 _ CitylStatelzZip: ' ' WORK TO Unit: CONTRACTOR: TEXAS-WESTWOCD CONTRACTORS INC — Licens 618438 Phone: 817-877-38001 ';: i;-:::.. ,Address:. _77TMAIN STUn' STE 950 Cell:817-334-1279=; i -'a, : ` , °s ' City/State:­ FORT WO ZipCode 76102 ,,.-. _} $55.03 Mechanical Fees: Plumbing Fees: ARCHITECT: CALVIN COATSWORTH„::`:';: - License N `M . ,., PHONE:949-833-1930 ENGINEER w Licens ;_, �� PHONE: COMBINTATION PERMIT FEE SUMMARY' Final Re -Root Building Plan Check: 't"' $133:05 Final Factory Fire Place Building Fees:~;T' $818.75 204 Electrical -Fees: ,,.-. _} $55.03 Mechanical Fees: Plumbing Fees: ,, "$37:20" _ - $0'.00 SMIP Residential _ . $0.00_ SMIP Commercial: $15:75 , I U I AL_ FEES: $9 ,059.7$ "Refer to fee receipts for all fees paid for project NOTICE: The work authorized by this permit shall comply with all applicable handicap access requiremen/undal,is statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must cplicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval wiliration of this permit. CODE #• INSPECTION TYPE DATE INTITIALS CODE 1 INSPECTION TYPE INTMALSO 1616 Fixed System Final Fire Prevention 206 Final Mechani 1266 Pool Spa Final 208 Final Plumbing 4"L4' 200 Final Re -Root 201 Final BlocklRetaining Wall 202 Final Factory Fire Place 203 Final Sign 204 Final Demolition 210 Final Electrical 212 Final Fire Prevention 220 Final Planning Approval 222 Final Site 250 Final Building/Occupancy � � r C/o rar- I WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury ane of owing declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Laboi Code, for the 3@rformance of the work for which this permit is issued. 6r I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number ar Carrier: e' _ 39_ J, (This section need pl r1 f/6l a pemW is valued soft one/hundred daUa ( 100) less.) Policy Number: �.1. 8 U L-6 f 1— O ❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the L or Code, I shall forthwi com it th se provisions. Applicant's Signature V Da WARNI : FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic. # Class # 7 Contractor's SignaweW U I Date CON RUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency, for the performance of the work for which this permit is issued. (Sec. 3097 iI ode). r Owner ID verified by dr' nse. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Division of Industrial Safety Permit Number: Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to .� prepare an RMPP (Risk Management and Prevention Program for acutely Lender's Name: �•p;r _ rp �. hazardous materials)? ❑ Yes ❑ No S tion 25534 of the California Health and SafetyCode provides that the Lender's Address: _ �� '4— '' Costa Mesa Fire Department may require the preparation, certification and filihoWth the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. signature If an RMPP is presently required, has Section 25534 of the California OWNER -BUILDER DECLARATIONS: h "1. �; Health and Safety Code been fully complied with? [3 Yes j] No I hereby affirm that under penalty of perjury that I am EXEM , M THEua 5. Does or will the applicant or present or future building occupant require for CONTRACTORS LICENSE LAW for the following reason ( �� 51 the work which is the subject of this application a permit for such construction Business and Professions Code: Any city or county which requires a perm or modification from the South Coast Air Quality Management District or from construct, alter, improve, demolish, or repair any structure, prior to its y other air pollution control district or agency? ❑ Yes ❑ No issuance, also requires the applicant for such permit to file a signed statement ( that he or she is licensed pursuant to the provisions of the Contractors $octan 65850.2 of the California Government Code requires that the requested License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the information be furnished on applications for non-residential building permits). Business and Professions Code) or that he or she is exempt therefrom and 6. Will any part of the facility to be constructed under this permit be within the basis for the alleged exemption. Any violation of Section 7031.5 by any 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No applicant for a permit subjects the applicant to a civil penalty of not more than (If 'yes the facility must meet the requirement of Sections 25534 and 42303 five hundred dollars ($500).): of the California Health and Safety Code). ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden,of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Coniractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature 3057-46 (37{17) Date 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No, 8. (If 'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct, i agree to comply with all state laws, and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and cilq ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature gal Own r(s r Date 1 � C.J• . Andlor Authorized Ap k = t Dat CITY OF COSTA MESA BUILDING DIVISION } 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 www.ci.costa-mesa.ca.us FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BC07-00085 PERMIT TYPE: B_COMBO STATUS: ISj� Sub Type: COM ALT DATE ISSUED: 97 JOB ADDRESS: 3333 SAKS BRISTOLxST CM ,� ! # , Sulte1Uniit,� SAKS Q�R APN: 41249105 " "F `, Zonlrig :alY . '> J a� i x ` Vicinity: INSIDE SAKS, JOHN HAYS`';Pro Const Type: II -F SQ FT 346' � V $75,000.00 SCOPE OF WORK: 346 SF_INTERIOR-;T 1' -`FOR VENDOR STORE "SK -II (JOHN HAYS)�3lNSIDE THE,EXISTING SAKS STORE. WORK TO INCLUDE NEW NOWLOAD BEARING ii 0ALLS, CEILING, FINISHES, CASH WRAP; ELECTRICAL^AND MECHANICAL. OWNER: SOUTH COAST PLAZA CALWIN'REALTY'II INCAddress PROPER 1 T J AX DEPARTMENT Unit: BIRMINGHAM, AL Phone: I City/StatelZip: 750 LAKESHORE PARKWAY APPLICANT: JIM PROFFkTT ` `•----,-Address:,.,,, ,.Unit: Phone: 817-896-9881 Cityistatel CONTRACTOR: TEXAS WESTW" OD CONTRACTORS INC ,..."w. -, License No. 618438:. Phone: 817-877-3800;, Address: 777•MAIN.STUnit:r STE 950 Cell: 817-334-1279.-y' CitylState.'' FORT WORTH, TX ZipC_ ode 76102 ARCHITECT: CALVIN COATSWORTH " License No.C14388 c'h ,f iPHONE:949-833-1930 ENGINEER: a';f i1" I License'No: F ,� PHONE: fir;" L, COMBINTATION PER FEE SUMMARY' Building Plan Check:' "' ` `$133:05 ?• :' �' Building Fees: ..,. - � � , Electrical Fees: ., L$55.0p' Mechanical Fees: $37 _ __ .` k` ,�w ^ :; , -,fir � :20; Plumbing Fees: =rte_ $0.00 SMIP Residential: $0:00_ .r. SMIP Commercial: $1'5:75` TOTAL FEES: $1,059.78 "Refer to fee receipts for all fees paid for project NOTICE:. The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval Wil result in the expiration of this permit. CODE 0. INSPECTION TYPE pig IN TIAL CODE / INSPECTION TYPE DTE INTITIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical yQ2/t d {t� % .0 NIM 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Root 210 Final Electrical' 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final BuildinglOooupancy 7 l WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the fo owing declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. AI have and will maintain workers' compensation insurance, as required by ion 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number ar Carrier: a4 00 p!T + ] (This seam need not be [anp)ef �A,th+e peermit is valued atone hundred dollars 00) or ! .) Policy Number: iii 46 7/, q � ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of th Labor Code, I sh rt h ' h o pl with these provisions. Applicant's Signa Dai WING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic. # Class # b All onlraWor's Signatur Dale CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (S500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvemgnt is sold within one year of completion, the owner -builder will have the burden of proving that he or she, did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The -contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature 3057-46 (3707) Owner ID verified by driv ft. ❑ Yes ❑ No Driver's License No, Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Date Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be tiled with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to File a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or wilt the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be fumished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'fres", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No. 8. (if `yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature of Legal Owner(sl //ate 9(O Andlor Authorized Applicant00 Dale CITY OF COSTA MESA BUILDING DMSION }• 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 www.ci.costa-mesa. us FOR INSPECTIONS CALL: (714) 754-5626 F07-00265 FIRE SUPRESSION PERMIT IJ rl C\ -'L,, .lob Address: 3333 BRISTOL ST Suite: SAKS Vicinity: SK -II (JOHN HAYS) WITHIN SAKS 5TH AVE Parcel Nunmber: 41249105 Zoning: Applicant: LOONEY, SHEILA Address: 5200 E HUNTER AV" SUITE B Phone: 714-993-2822 ANAHEIM, CA Zip: 92807 . Owner: SOUTH COAST PLAZA CALWIN REALTY 11 INC Address PROPERTY TAX DEPARTMENT BIRMINGHAM, AL Phone: 750 i.AKESHORE PARKWAY ,_ Zip: 35211-4400 Contractor: ALERT FIRE PROTECTION INC Address: 5200 E HUNTER AV - SUITE B Phone: 714-993_-2822 ,ANAHEIM, CA Zip: 92807 -. License: 316324 Status: ISSUED Applied: 09/05/2007 Issued: 09/05/2007 SCOPE OF PERMIT 4 EXISTING HEADS TO BE CHANGED TO CONCEALED HEADS IN CONJUNCTION WITH THE STORE TI FOR "SK -II (JOHN HAYS)" WITHIN SAK 5TH AVENUE. REF: BC07-00085 FEE SUMMARY Plan Check: $37.08 Calc Valuation: $1,600.00 Permit: $57.05 Claimed Valuation: 51,600.00 Other: $0.00 Total: $94.13 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION. PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE 0 iNSPEcngH,Trae DATE INMA . CODE INAPEcnoN lYPe DATE WMA 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Root 210 Final Electrical 201 Final BlocklRetaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final BuildirrgrOccupancy WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: . ❑ 1 have and will maintain a certificate of consent to self-tnsure for workers' compensation, as provided for by section 3700 of the Labor Code, for the p ormance of the work for which this permit is issued. R I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code. for the performance of the work for which this permit is issued. M rke 'tom ensation Insurance tamer and policy number are: Carrier: (TI, s-11 All n00 be [amp/feted d the ppermd is luedat/ h dakolfars ($TOO) or less) Policy Number:�" T ❑ l certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if l should become subject to thg' workersAcompensation provisions of Section 3700 of the Labarjode, sh fortf comply wit ese provisions. Applicant's Signature Date SLI j HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to fife and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from (he South Coast Air quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? O Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? © Yes ❑ No 8. (If 'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE'OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct, t agree to comply with all state laws and city ordinances regarding Hazardous,Materials and Emissions. Owner ID verified by drivE ,rise. ❑ Yes i] No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, fatsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2. Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Division of Industrial Safety Permit Number: Date WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is innfull fo ce and effe Lic. # 3 ^1 Class Contractor's Signature ate CONSTRUCTION LENDING AGENCY: 0 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm (hat under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the affeged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): Q t, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature 3057.46 t3Jn7t Date Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final' inspection. re 01,1.O 5 n wnedZ And/or Authorized Applicant Date CITY OF COSTA MESA r! f f , , BUILDING DIVISION F 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 - www.ci.costa-mesa.ca.us FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BC08-00426 PERMIT TYPE: B COMBO STATUS: ISSUED Sub Type: COM—ALT DATE ISSUED: 10/21/2008 ISSUED BY: ' RMD JOB ADDRESS: 3333 SAKS BRISTOL ST CM ' Suite/Unit: . SAKS APN: 41249105 Zoning: _ Vicinity: 3RD FLOOR OF SAKS Primary Occ: M Const Type: II -A SQ. FT: 322 Valuation: $85,000.00 SCOPE OF WORK: INTERIOR TI FOR A VENDOR SHOP WITHIN SAKS FIFTH AVENUE SPACE "ROBERTO CAVALLI READY TO WEAR", 3RD FLOOR WITH 31 FIXTURES, 1 OUTLET, 4 SWITCHES, 1 COMM. DROP, 5 MtSC CONDUIT & 8 CONDUCTORS. NO MECH. OR PLUMB. OWNER: SOUTH COAST PLAZA CALWIN REALTY II INCAddress: PROPERTY TAX DEPARTMENT Unit: BIRMINGHAM, AL Phone: City/State/Zip: 750 LAKESHORE PARKWAY APPLICANT: MOUTES, MICHAEL Address: Y Phone: 818-581-5787 City/StatelzZip: CONTRACTOR: POSSELL CONSTRUCTION CO., INC. License No. 336576 Phone: 818-785-1151 Address: 7059 VALJEAN AVE Unit: Cell: City/State: VAN NUYS, CA ARCHITECT: ENGINEER: License No. License No. COMBINATION PERMIT FEE SUMMARY Building Plan Check: $144.42 Building Fees: $888,75 Electrical Fees: $2.96.63 Mechanical Fees: $0.00 . Plumbing Fees: $0.00 SMIP Residential: $0.00 SMIP Commercial: $17,85 TOTAL FEES; $7,347.65 "Refer to fee receipts for all fees paid for project Unit: ZipCode 91406 PHONE: f. PHONE: .•- NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No, 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. 54.4€!, l+13 gOONrrar PM INTMAL OW INSFEcTION TWE DATE I9 1616 Fixed System Final Fire Prevention 206 Final Mechanical 12 _$-off_ _ IR �! 1266 Pool Spa Final 206 Final Plumbing - 200 Final Re -Roof 210 Final Electrical 201 Final BIockJRetaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy #�� WORKERS' COMPENSATION DECLARATION: hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ' ,W'I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: 'Carrier: y jAME I (This section need not be completed f rhe perms is valued of one hundred doAars (S 100) Of leu.) Policy Number: _� 9 a' O C 1 C -124' ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California. and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor de, 1 t rt mply wi hese provisions. p, Applirnnt rgn a Dale WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7006) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lie. # .3 -L Class # /a - zi —pce- T Contractors signature ' , Date CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5. Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).); ❑ I, as owner of the property, Or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own• employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature Date 3057.46 (3107) Owner ID verified by drive t se. ❑ Yes ❑ No r Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or,deed); DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty -sic (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division, Applicant's Signature Division of Industrial Safety Permit Number; Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department, 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If "yes". the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If yes", attach certificate ofcompliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: i certify that under penalty of -perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not (o'OCCupy or allow occupancy of any building authorized by this permit until final inspection. S gnatur eget Owner[s1 Dale And/or Aut zed Applicant Date LINWOOD ENGINEERING ASSOCIATES, P.A. consulting engineers 600 Anton Blvd, 11th Floor Costa Mesa, California 92626 TEL: (714) 371-4060 FAX: (714) 371-4001 To: Randy Buck, City of Costa Mesa B>C: 59 S,qKs 33sty I Date: December 17, 2008 LEA No: 08044 Fax No: NIA # Pages: I Re: Dolee & Gabbana RTW, Saks at South Coast Plaza Located on 3333 Bristol St. From: Adam C. Forni, P.E. Dear Sir or Madam, Regarding the electrical plans for Dolce & Gabbana., Ready -to -Wear. Linwood Engineering offers the following clarifications: We approve the use of circuits 7 and 29 on Panel "3A" for the lighting loads. This is a change from our sheet E-3, which depicts loads fed from circuit 10 and 12 on Panel "3B1 '. We trust that this meets your immediate needs. If you have any questions, feel free to call us at 714.371.4060. Yours Tru y, _ Adam C. Forni, P.E. Linwood Engineering Associates, I'A (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT Job Address: 3333 BRISTOL ST Status: ISSUED Suite No SAKS Applied: 04/30/2003 Vicinity: Issued: 04/30/2003 Parcel Nunmber: 41249105 Applicant: TED RUSSELLE ISSUED BY: Address: 41224 AVENIDA LA CRESTA Phone: (909)698-9103 MURRI ETA CA - Zip: 92362 Owner: SOUTH COAST PLAZA %CALWIN REALTY 11 INC, 'Address %PROPERTY TAX DEPARTMENT BIRMINGHAM, AL Phone: 750 LAKESHORE PARKWAY Zip: 35211-4400 Contractor: AMBER ELECTRIC Address: 41224 AVENIDA lA CRESTA MURRIETA CA -Phone: (909)69 8-9103 Zip: -92362 License: 414693 SCOPE OF PERMIT 540 S.F. INTERIOR REPAIR DAMAGE TO -EXISTING FIRST FLOOR MEN'S AND WOMEN'S RESTROOMS (LOCATED IN EMPLOYEE'S BREAK ROOM) CAUSED BY FLOOD. CONFIGURATE RESTROOM TO MEET A.D.A. REQUIREMENTS. "SAKS FIFTH AVENUE" ELECTRICAL TO INCLUDE: RELOCATE 9 LIGHT FIXTURES, 5 OUTLETS, AND 3 SWITCHES. SUBJECT TO FIELD INSPECTION. REF.: B03-00561 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21.92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446-46(SM) FEE SUMMARY Quantity Quantity ISSUE FEE $23.54 Temp Dist System / Lighting $0.00 .0 Temp service test $0.00 Busway 1100 ft $0.00 0 Res. a/c package $0.00 Standing Section $0.00 0 New Res (1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0 New Res (3+units) $0.00 0 Transformers up to 1 kva/kw $0.00 0 Pool / Spa $0.00 0 ................up to 10 kva/kw $0.00 0 Lighting Fixts $9.90 , 91 . .................up to 50 kva/kw $0,00 0 Recept Outlets $5.50 5 ............up to 100 kva/kw $0.00 0 Switches $3.30 3 ..................over 100 kva/kw $0.00 0 Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0 Res Appl $0.00 0 Low Volt Wiring System / Ckt $0.00 .0 Service to 200a $0.00 0' Misc. Conduit $0:00 0 Service to 1000a $0.00 0 Misc. Conductor $0.00 0 Service over 1000a $0.00 0 'Circus ( gen or ride) $0.00 0 Motors to 1hp $0.00 0 Circus (mech ride or lights) $0.00 0 Motors to 10hp $0.00 0 Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 0 Fireworks Stand $0.00 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21.92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446-46(SM) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the tabor Code, for the performance of the wwork for which this permit is issued. I,have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued, My wcorn nsalion Insuran carrier and policy number are: Carrier 2, 2 Policy Number: (This section need not be completed it t permit is valued atone hundred dollars ($100) or less.) Q I certify that In the performa of the work for this permit Is issued, I shall not employ any person In any manner so as to become subject to the workers' compensation laws of C ' omla, and agree t hould become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those p ions. Applicant Signature: Date: �! L WARNING: FAILU O SE RE WORKERS' PE TION COVERAGE IS UNLAWFUL AND SHALL SUaJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CfVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($1 00.0130), IN ADDITION TO TH COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3705 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am 11 a sed n ar pr visio of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Firssions Code, and my license Is In full force and effect. Lic. p �+ Class p %C- 11 Contractors Signature: Date:2_n_ e9e 1C l L 0 2,__, CONSTRUCTION LENDING AGENCY - C] ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is Issued. (Sec. 3097, Civil Code). Lender's Name: Lenders Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to Its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her awn employees, provided that such improvements are not Intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or dead): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec, 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by ovary business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ............_............................--._....._......................................... ....................................................................................... .................... - ................................................................................. 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 o1 the California Health and Safety Cade, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic foot of compressed gas at standard temperature and pressure). _................. _...................... --...._...................... ..... ..............._._.............. _........................ _........................... —............................ ..---............................................ -............................ ..._................. 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Coda provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. .. ........ .......................................................................... ................................................................................................................................ 1.1.......,11,...........-............................................... .....-................................................ a If an RMPP is presently required, has Section 25534 of the California Health and Safety Code boon fully complied with? ❑ Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject o1 this a plication aggeo rmit for such construction or mditicat€on from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes u No (Section 65850.2 of the Califomia Government Code requires that the requested information be furnished on applications for non-residential building permits). ... ............................................................................ ....................................................................................... ............................................................................... ...._.............................................................................................. Ye 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ s ❑ No (I1 -yes-, the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). _ ............................................_._....................................................... __....................._................... ...................... ..-................. Y_.. --- ... _................................ _........................ _............................... _ 7 it a permit from the South Coast Air Quality Management District or other air pollution control district or agency Is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? O Yes ❑ No ---- ..............._ _...................._..............................__................... _.................... -.................... —... ...................... ..__....................... _._................................... _............................. .............................. 8 (If yes', attach certificate of compliance from the appropriate air pollution control officer) - CERTIFICATE OF COMPLIANCE: ! certify that under penalty of perjury the Information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Slgnature: Data: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I cartity under penalty of perjury that I have read this application and state that the inlormallon given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costs Mesa to enter upon the above-described pro for inspect€/ rposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Si O1 Legal Owner(s), L_Date d/Or Authorized Applicant 1J [/•, I C Date CODE It. INSPECTION TYPE t7dLE INTrrinLs COOS • INSPECTION TYPE 12hi€INTITIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical �Lu 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Silo 204 Final Demolition 250 Final Building/Occupancy .--•4 (714) 754-5273 • Fax (714) 754-4856 • www.Ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 BUILDING PERMIT Job Address: 3333 BRISTOL ST Suite: SAKS Vicinity: SAKS FIFTH AVENUE (FIRST FLOOR RESTROOMS Status: ISSUED Applied: 04/07/2003 Issued: 04/18/2003 Parcel Number: 41249105 Zoning: Applicant: MOUTES, MIKE ISSUED BY: Address: Phone: 818-785-1151 Zip: Owner: SOUTH COAST PLAZA %CALWIN REALTY 11 INC Address %PROPERTY TAX DEPARTMENT BIRMINGHAM, AL Phone: 750 LAKESHORE PARKWAY Zip: 35211-4400 Contractor: POSSELL CONSTRUCTION CO., INC. Address: 7059 VALJEAN AVE Phone: (818) 785-1151 VAN NUYS, CA Zip: 91406 Licenser 336576 Arch : CCA - Eng: Address: 2458 DUPONT DR Address: Phone:- 949-833-1930 Phone: IRVINE, CA Zip: 92612 License: C14388 License: SCOPE OF PERMIT 540 S.F. INTERIOR REPAIR DAMAGE TO EXISTING FIRST.FLOOR MEN'S AND WOMEN'S RESTROOMS (LOCATED IN EMPLOYEE'S BREAK ROOM) CAUSED BY FLOOD. CONFIGURATE RESTROOM TO MEET A.D.A.- REQUIREMENTS. "SAKS FIFTH AVENUE" Plan Check: $138.74 Permit: $853.75 SMIP Res: $0.00 SMIP Com: $16.80 Other: $0.00 Inspection: $0.00 Total: $1,009.29 SETBACKS MAIN STRUCTURE Front 0-0 ACCESSORY Front 0- 0 PARKING Existing: 0 FEE SUMMARY " PLANNING"& ZONING Rear 0-0 Left .0-0 Rear 0-0 Left 0-0 Required: 0 Proposed: 0 Calc Valuation: $80,000.00 -Claim Valuation: $80,000.00 Right 0-0 Right 0-0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754.5626 ?446.46 (6/00) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance Of the 1 work for which this permit Is Issued. t I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. _ My workers' compensation -Insurance carrier and poli number erne: 9/ Carrier: t� I IT }U ►'yl� Policy Number: / W 75 (This section need not be completed if the permit is valued at one hundred dollars ($ f00) or less.} ❑ 1 certify that in the performance of the work for whichthispermit is iss d, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree�re Id become ject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these prov' ' L.�Applicant Signature:Date: / —1? eJ WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,1100), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business roff s ions Code, and my license is In full force and effect. Lia. # 4 t9 Class # Contractor's Signature: Date: m CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance o1 the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penatfy of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city Or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than two hundred dollars ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for safe (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or Improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement Is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Dale: Owner ID verified by drivers license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, AN 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone 10 do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity o1 hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ................. .................... -•---................................................................................................................................ -.......................................................... ....................................................................... ,............................................. 2 Does twill the applicant or present or future building occupant need to file a registration fort for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume o1 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure), ............................................................................ ,................................................... ........................................................................................................................................... ..................................... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. _.......................................................................__........................--....................... -................... .-............... _-.......................... ........-_........................ ............................................. ............................. -- ............... -. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No ......................... ......•............................................................................................................................................................................................................................................................... ........................................................................... 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this a plication a ermil for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes No (Section 65850.2 of the California Goverment Code requires that the requested Information be furnished on applications for non-residential building permits). ...................•---------...................................................................................................................................,.-............................................................................................. 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? [:]Yes ❑ No (if yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ......................................................................................................................................-.-......................._._--------•---------..........................- - -.................................. ..................... ................................ _ . 7 li a permit from the South Coast Air Quality. Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by Califomia Health and Safety Code Section 42303 been made? ❑ Yes ❑ No _..................._........................................................................_....................-_....................----.............-•---......................_...................................- ---... -............................... ..._...................... ............................... _... 8 (If 'yes', attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the Information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection, natur a al Owner Date Z '� �/c? -a3- And/Or Authorized Applicant Date ) CODE 1. INSPECTION TYPE IKTITIbLS CODE INSPECTION TYPINTITIA 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Placa 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy s Z7 b 3 (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 PLUMBING PERMIT Job Address: 3333 BRISTOL ST Suite No SAKS Vicinity: Parcel Nunmber: 41249105 Applicant: JOHNSON'S DISCOUNT PLUMBING Address: 12262 GEORGIAN ST Phone: (714)799-1907 GARDEN GROVE, CA Zip: 92814 , Owner: SOUTH COAST PLAZA %CALWIN REALTY II INC Address %PROPERTY TAX DEPARTMENT BIRMINGHAM, AL Phone: 750 LAKESHORE PARKWAY Zip: 35211-4400 Contractor: JOHNSON'S DISCOUNT PLUMBING Address: 12262 GEORGIAN ST Arch / Eng Address: Phone: (714)799-1907 GARDEN GROVE, CA Zip: 92814 License: 724339 Phone: Zip: License: ISSUED BY: Status: ISSUED Applied: 05/05/2003 Issued: 05/05/2003 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-26, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 2446-46 (6=) SCOPE OF PERMIT REF B03-00561 SAKS . 2 FLOOR DRAINS, 1 SEWER CONNECTION, 1 SERVICE MOP, 21 URINAL, 3 WASH BASINS, 4 TOILETS, AND 1 H2O HEATER. FEE SUMMARY AMT QTY AMT QTY AMT QTY ISSUE FEE' $23.50 Laundry Tub 1 Washer $0.00 0 Sump Pump $0.00 0 Backflow irrigation $0.00 0 Landscape Irrigation $0.00 0 Swimming Pool $0.00 0 Backflow Preventer $0.00 0 P -Trap $0.00 0 Trap Primer $0.00 0 Bathtub $0.00 0 Pressure Regulator $0.00 0 Urinal $9.80 1 Clarifier System $0.00 0 Process Piping (per 10 ft) $0.00 0 Vacuum Brkr Bkflow(1-4) $0.00 0 Connect (Ice,Soda,etc) $0.00 0 Receptors $0.00 0 Vacuum Brkr Bkflow(5+) $0.00 0 Dental Units $0.00 0, Septic Tank $0.00 0 ,, Wash Basin $29.40 3 Dishwasher $0.00, 0 Sewer Cap for Demo $0.00 0 Wash Basin Set $0.00 0 Drain, Floor $19.60 2 Sewer Connect $24.65 1 Waste and Vent System $0.00 0 Drain, Rainwater $0.00 0 Sewer Private Line $0.00 0 Water Closet (Toilet) $39.20 4 Drain, Roof $0.00 0 . Shower $0.00 0 Water Heater / vent $12.30 1 Drinking Fountain $0.00 0 Sink, bar $0.00 0 Water Piping (Inst or Rep.) $0.00 0 Expansion Tank $0.00 0 Sink, commercial $0.00 0 Water Re -pipe $0.00 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-26, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 2446-46 (6=) DECLARATiONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work Ior which this permit is issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit fs Issued. r compensation Insurance carrier and policy number are: _ Carrier: olicy or: anion need not be completed it the permit is valued of one hundred dollars ($ f 00) or cess.) ❑ I certify that in the performance of the work for which this permit is issued. I shall not employ any person in any manner so as to became subject to the workers' c tion laws of CalifoEnla, and a that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Coda, I shall forthwith ply with ase v' ns. / plicant Signal Date: J ARNI URE TO SECURE WORKERS' COM T10N COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOY TO CRIMI TIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE (5100,000), IN ADDITION TO THE T OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 37 LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: '1.1y affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of of the Business and Professions Code, and my license is in full farce and . Lic. # Glass # tura: A CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commending with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant 10 a civil penalty of not more then five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If. however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ i, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contracfor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Data: Owner iD verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): _ DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation live (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, lalsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and carlity a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of $00 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _...................�.......................... ................................. .............___......................... _................._._............_._............. ._.................. ..._............................................. ...,................................ ........ ......—_............... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with same exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _ ........................... __....._. - - ..................... .........__................... -............... ._.................................................................. ----......................... _..................... _..................... _ . 3 Does or will the applicant or present or future building occupant need to prepare an RMPA (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No Section 25534 of the California Health and Safety Code provides that the Cosla Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ....... is-'p-`r...------'1-y.'r.e............................................................................................H-e-...........'*n"..S-a-..............................'nt'l.,I'I'y...................................... ----....._.................................._......................................................... 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code bean fully complied with? ❑Yes ❑ No 5 Does or will the applicant or present or future building occupant require far fhe work which is the subject of this a plication a�e rmif for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes Lj No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ................................................................................................................................................,.........................................................................- ............................... 7 If a permit from the South Coast Air Quality. Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures proscribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No .................................. ................................................. .................................................................................................................................................................................................................................. --..................................... 8 (If fres", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct, i agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Slgnature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with ail state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Si net ner s Data A dl icant CODE t. INSPECTION UPEItiIID..9L i CODE i INSPECTION TYPE Qat INTITAJ� 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 5,11-o 200 Final Ra-Roof 210 Final Electrical 201 Final Block/Hetaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 2D4 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4855 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT .lob Address: 3333 BRISTOL ST Status: ISSUED Suite No SAILS Applied: 09/21/2001 Vicinity: SAKS' ELECTRICAL ROOM Issued: 09/21/2001 Parcel Nunmber: Applicant: 41249105 BOOMGAARDEN, DAVID ISSUED BY: Address: 222 N SEPULVEDA BL - = STE 2000 ! ��%%� l -'Phone: 310-335-2035 ELS UNDO CA ;%- �� Zip: 90245 Owner: /SOUTH COAST PLAZA' °1oCALWIN REALTY Ii. INC Address ,200 PARK•AV Phone: NEW YORK NY Zip: 10166-0005 , Contractor: ' ROSENDIN ELECTRIC INC Address: 222 N SEPULVEDA BL STE 2000 'Phone: 310-335-2035 EL SEGUNDO, CA Zip: 90245 , License: 142881 SCOPE OF PERMIT i CHANGE OUT MAIN ELECTRICAL SERVICE SWITCHBOARD,,2500 AMP, 480 VOLT, 3 PHASE 4 WIRE ONE UNDERGROUND PULL SCTION, ONE METER & MAIN SECTION ONE DISTRIBUTION SECTION. 1 SERVICE OVER 1000A NO OTHER WORK WITH THIS PERMIT. FEE SUMMARY,// :. Quantity Quantity ISSUE FEE $23.50 Temp Dist System / Lighting $0.00 0 Temp service test $0.00 Busway 1100 R $0.00 0 Res. a/c package $0.00 ,:: , Standing Section $0.00 0 New Res (1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0 New Res (3+units) $0.00 0 Transformers up to 1 kvalkw $0.00 0 Pool l Spa $0.00 0 ................up to 10,kva/kw $0.00 ' ' 0 Lighting Fixts` '. ✓ $0.0.01 - " 0s-, ...:.............up to 50 kvalkw '' $0.00 0 Recept Outlets $0.00 0 .................up to 100 kva/kw $0.00 - 0 Switches. ', $0.00,.: 0 ..................over 100 kvalkw . $0.00, 0 Non Res App] $0.00 ,' \0�, , Low Voltage Equipment $0.06 0 Res Appl $0.00 0 Low Volt Wiring System 1 Ckt $0.00 0 Service to 200a $0.00 , 0 Misc. Conduit $0.00 0; Service to 1000a $0.00 ; 0 Misc. Conductor $0.00 % 0 Service over 1000a ; $124.30 • r A Circus ( gen or ride), $0.00 Motors to 1 hp $0.00 01 Circus (meth ride or lights) $0.00 0 Motors to 10hp $0.00 0 Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 �.. 0 Fireworks Stand $0.00 0 Motors to 1 00h $0.00 0 _ Other Electrical Fee $0.00 Motors over 100hp $0.00 0 Communication drops $0.00 0 Investigation Fee $0.00 Sub panel to 200a $0.00 0 Plan Check Fee $0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $0.00 0 Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $147.60 Intermed Pole $0.00 0 COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable Codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446.46 (8140) DECLARATiOMS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the rk for which this permit Is issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. My workers' compensation Insurance carder and policy number are: Carder: Policy Number: (This section need not be completed d the permit is valued at one hundred dollars ($f 00) or less.) ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Califor la, and agree that it I should become sub ct to the workers' compensation provisions of Sectio 3700 of the Labor Code, I shall forthwith comply with these provisio Applicant Signature. Date: WARNING: FAILURE TO SECU KER MPENSATION GEIS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMIN L PENAL IES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE CAST OF MPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is In full force and effect. Lic. # Class # Contractors Signature: Date: 2 CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction tending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lenders Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a perms. subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or Improvement Is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose .01 sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, I.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 WIII the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes 0 No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity o1 hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .....................................................................................................................................................................................................................................................................................-�........................................ 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ............................................................................................................................................................................................................................................................................................................................................................. 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire apartment of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ........................................................................•--,........................................................................................................--------------......................................................... .....................I......................................................,.,,................. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? [:]Yes C1 No ................................................................................................•-----................................... ................................................ .................................................................................... ........................................... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this �!ppllcation aermit for such construction or modification from the South Coast Air QUelity Management District or from any other air pollution control district or agency? LJ Yes a No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ......................................................................................................................................................................................................................................................................................................................................................... 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). .................................................................................................................................................................................................................................................................. ............................ ..................... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No i-',- ..-...............................c'e,..............................................eir,.............................'r-o"I.......'69'......................................................................................----------------...................................------------.............................. 8 (ff "yes', attach certificate of comp)€ante from the appropriate air, pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state taws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. r S' ature Of Legal Owners) Date And! r Ut ori pi's nt ate CODE_0 INSPECTION TYPE DATE 1NMIALS CODEC INSPEUONTYPE DATE € $ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy J CITY OF COSTA MESA f _ BUILDING DIVISION DEVELOPMENT SERVICES DEPARTMENT. PERMIT NUMBER PERMIT 00-00395 (714) 764-5273 Fax (714) 754-4856 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT .lob Address: 3333 BRISTOL ST Status: ISSUED Suite No SAKS Applied: 05/01/2000 Vicinity: SAKS Issued: 05/01/2000 Parcel Nunmber: 41249105 Applicant: SMITH, KEVIN ISSUED BY: Address: 4701 VON KARMON AV#100 ,Phone: (949)724-1569 NEWPORT BEACH, CA' Zip: 92660 Owner: .SOUTH COAST PLAZA %CALWIN REALTY 11 INC Address, 200 PARK AV Phone: NEW YORK"NY Zip: 10166-0005 Contractor: SASCO ELECTRIC Address: 4701 VON KARMON AV#100 Phone:- (949) 724-1569 'NEWPORT BEACH, CA"Zip: 92660 License: 125897 SCOPE OF PERMIT REF B00-00392, SAKS, 40 LIGHTS, 7 OUTLETS AND 2 SWITCHES. FEE SUMMARY Quantity _ ,,', 11 . Quantity ISSUE FEE $23.50 J_ ti ' Temp Dist System I Lighting $0.00 0 Temp service test $0.00 _ Busway 1104 ft $0.00 0 Res. a/c package $0.00 Standing Sectiori $0.00 0 New Res (1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0 New Res (3+units) $0.00 0 Transformers up to 1 kvalkw $0.00 0 Pool I Spa $0.00 0:.....up to 10 kvalkw $0.00 0 Lighting Fixts $34.60 40 _ . .................up to 50 kvalkw $0.00 0 Recepi Outlets $7.70 7 :...........up to 100 kvalkw $0.00 0 Switches $2.20 2 ; ............ :..... over 100 kvalkw $0.00 0 Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0 Res Appl $0.00 0 Low Volt Wiring System 1 Ckt $0.00 0 Service to 200a $0.00 0 Misc. Conduit $0.00 0 Service to 1000a $0.00 0 Misc. Conductor $0.00 0 Service over 1000a $0.00 0 Circus ( gen or ride) $0.00 0 Motors to 1 hp $0.00 0 Circus (meth ride or lights) $0.00 0 Motors to 10hp $0.00 0 Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 0 Fireworks Stand $0.00 0 Motors to 1 00h $0.00 0 Other Electrical Fee $0.00 Motors over 1 00h $0.00 0 Communication drops $0.00 0 Investigation Fee $0.00 Sub panel to 200a $0.00 0 Piari Check Fee $0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $0.00 0 Temp Pwr Pale $0.00 0 TOTAL CALCULATED FEES $68.00 Intermed Pole $0.00 0 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations, (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: -This permit shall automatically expire and become void if work is not -commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. j FOR INSPECTIONS CALL: (714) 754-5626 f DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My wo �J 'Mtion Insurance carrier and policy number are: Carrier: f . L/ _ Policy Number: (This section need not4competed it the permit fs valued at one hundred dollars {$Y00} or less.}❑ 1 certify that in tmance of the work for which this ermit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation lafornia, and a that if I s Lid come subject to the workers' compensation provisions of Sectio 700 of the Labor Cade, I shall forthwith nS./�pplicant Signa_ a Date:WARNI RE TQ SQRKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EM CRkMINAL PENALTIES AND CIVIL FINNS UP TO ONE HUNDRED THOUSAND DOLL.ARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: 1 her tic ed e r visions of Chapter 9 (comm ncing with Section 7000) of Division usin and Professions Code, and my license is in full or_e and effect. fi � Class Contractors Sign ure: Date: — a0 CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Data: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, atter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ L, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth Into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need t0 file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or wilt the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Il Yes IT No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (it 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (If 'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: 1 certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above -de ribed property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signatur alOwner(s) Date r An Or uthorized Applicant Date CQPJ 0 INSPECTIONTYPE OA lid CODE INSPECDONTYPE DAN IISnTIAL� 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Root 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy 2446-46 CITY OF COSTA MESA .—. BUILDING DIVISION } DEVELOPMENT SERVICES DEPARTMENT. .PERMIT (714)754-5273 • Fax(714)754-4856 BUILDING PERMIT .lob Address: 3333 BRISTOL ST Suite: SAKS Vicinity: SECOND FLOOR AREA F 7P£R T NUMBER 600-00392 77 FAIR DRIVE, COSTA MESA, CA 92626 Status: ISSUED Applied: 03/26/2000 Issued: 04/27/2000 Parcel Number: 41249105 Zoning: ISSUED BY: Applicant: DOUG FRANZ Address: Phone: (949)833-1930 Zip: Owner: SOUTH COAST PLAZA %CALWIN REALTY II INC Address 200, PARK AV Phone: NEW YORK NY- Zip: 10166-0005 Contractor: D E I CONSTRUCTION Address: 6155 E INDIAN SCHOOL RD #200 Phone:' (480)990-0991 SCOTTSDALE,AZ Zip: 85261' License: 582869 Arch : CC ARCHITECTS _- - Eng: Address: 2458 DUPONT DR Address: F Phone: (949)833-1930 Phone: IRVINE,'CA Zip: 92626 License: License: SCOPE OF PERMIT 684 SF TI ON THE FIRST FLOOR OF SAKS FIFTH AVENUE. FEE SUMMARY Plan Check: $201.53 - Calc Valuation: $144,000.00 Permit: $1,240.15 r ," Claim Valuation: $144,000.00 SMTP Res: •$0.00 SMIP Com: $30.24 Other: $0.00 inspection: $0.00 Total: $1,471.92 PLANNING & ZONING SETBACKS MAIN STRUCTURE Front 0-0 Rear 0-0 Left 0-0 Right 0-0 ACCESSORY Front 0-0 Rear 0-0 Left 0-0 Right 0-0 PARKING Existing: 0 Required: 0 Proposed: 0 ' NOTES: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not -commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit_ FOR INSPECTIONS CALL: (714) 754-5626 DECLARATIONS --A WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. y workers' compensation Insurance carrier and policy number are: . Carrier: Policy Number: (This section need not be completed if the permit is valued at one hundred dollars ($100) or less.) ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that i1 I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisions. --r Applicant Signature: Date: _Qk WARNING: FAILURE TO SECURE WORKERS' COMPEN IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES D CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLlARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under revisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is In full force and effect. Lic. # �S � �� _ _T Class # Contractor's Signature:. Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Cade). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his Or her own emptoyees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractors) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Bate: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License Na- Expires: Verification of Ownership by (type of document, i.e. - property tax bili or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title B, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _ 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. -- ...------------------------...--------------------------- _ _ -------------------------- _ -------------- --------------------------------------- -----------.,...,...--- 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? []Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application armit for such construction or modification gge from the South Coast Air Ouatity Management District or from any other air pollution control district or agency? 0 Yes L1 No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). - —---------------- -- _ - -- -- — - - --_ —------- - ------ -- - — _ m 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'fres", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code), 7 If a permit from the South Coast Air Ouality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (If "res", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. 1 agree to comply with all state taws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for Inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit unlit final inspection, Signature Of Legal Owner(s) Date And/Or Afho9d A t Date CODE M• INSPECTION TYPE prjN INTMALS C00E! INSPECTION TYpINTRIA 1616 Fixed System Final Fire Prevention 206 Final Mechanicai 1266 Pool Spa Final 206 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy 2446-46 (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesaeL.MTRICAL PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Suite No SAKS Vicinity: Parcel Nunmber: 41249105 Applicant: RICARDO AYALA Address: 137 N LARCHMONT BL UNIT 567 Phone: 562-929-6615 LOS ANGELES, CA Zip 90004 Owner: SOUTH COAST PLAZA %CALWIN REALTY II INC Address %PROPERTY TAX DEPARTMENT BIRMINGHAM, AL Phone: 750 LAKESHORE PARKWAY Zi 352114400 - Contractor: CALIMA ELECTRIC Address: 137 N LARCHMONT BL UNIT 567. Phone:, 562-929-6615 LOS ANGELES, CA Zip: ' 90004 License: 357034 Status: ISSUED Applied: 03/02/2007 Issued: 03/02!2007 ISSUED BY: '00; SCOPE OF PERMIT INTERIOR 70,332 STORE Tl FOR "SAKS FIFTH AVENUE" WORK TO INCLUDE NEW FINISHES, FLOORING, CEILING, ETC. ELECTRICAL AND MECHANICAL PLANS TO BE DEFERRED SUBMITTAL. RESTROOMS NOT INCLUDED WITH THIS Ti. REF.: 806-01738 ELECTRICAL' INCLUDES: 2328 LIGHT FIXTURES, 196 OUTLETS, 35 SWITCHES AND 1 SUB PANEL TO 200 AMPS, 4127107: SUPPLEMENTAL PERMIT TO ADD: 3 LOW VOLT WIRING SYSTEM/CKT (206 SPEAKERS, 50 CAMERAS, 10 CONTROL WIRING FOR VAV BOXES; 80 COMMUNICATION DROPS (PHONEIDATA) NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ont. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void it work is not commenced within 580 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446-46 (6/00) U ' FEE SUMMARY - - - Quantity _ _ ' Quantity ISSUE FEE $23.50 Temp Dist System ! Lighting $0.00 0 Temp service test $0.00 Busway 1100 ft $0.00 0 Res. a/c package $0.00 Standing Section- $0.00 0 New Res 01 2 units) $0.00 0 Misc Electrical Equipment $0.00 0 New Res (3+units) ', $0.00 0 Transformers up to 1 kva/kw $0.00 "'0" Pool / Spa $0.00 0- { ' ...... up to 10 kva/kw $0.00 0 Lighting Fixts 706.84 2328 ,:-' :., up to 50 kvalkw $0.00 0 Recept Outlets -,,$150.48 196 .............:...up to_100 kvafkw $0.00 0 Switches $32.95 4 -, 35-.. , ........over 100 kva/kw_ $0.00 0 Non Res Appl $0.00 0 Low Voltage Equipment r ' ' $4.00 0 ' Res App $0.00 0 Low.Volt Wiring System I Ckt- ,$75.00 3 Service to 200a f$0.00 ' - _ 0 _ Misc. Conduit $0.00 , 0 Service to 1000a $0.00 0 Misc. Conductor $0.00-, 0 Service over 1000a _$0.00_/ ,; 0 Circus, ( gen or ride) $0.00 • '00 0 Motors to 1 hp $0:00 ,' -0 Circus (meth ride or lights), ', -',$0 0 r Motors to 10hp $0.00 •. 0, Christmas Tree Stand ,' $0.0,0'' 0 Motors to 50hp $0.00 0/ Fireworks Stand ". $0.00- - 0 Motors to 1 00h $0.00 0 Other Electrical Fee ,$7.50 Motors over 100hp $0.00' 0 Communication drops $63.80 -80- Investigation Fee. $0.00 Sub panel to 200a $30.50 - i Plan Check Fee ' $0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $0.00 0 _ NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ont. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void it work is not commenced within 580 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446-46 (6/00) U DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. � 7 I have and will maintain workers' compensation insurance, as required by section 3700 of the labor Code, for the performanog of the work for which this permit Is issued. My workers' compensation Insurance carrier and policy number are: Carrier. •�{�n I t }5 , PolicyNumber-. mber. O1U2'57__ - n Z _ (this sectiow need not be completed 1t the permit is valued at one hundred dollars ($100) or less.) ❑ 1 certify that in the performance of the work for which this permit is Issued. I shall not employ any person In any manner so as to become subject to the workers' compensation laws o tomia, and agree that I1 I should became subject to the workers' compensation provisions of Section 3700 of the labor Code, I shall forthwith comply with these o lo S. App[ ani Signature: WARNING: FAILURE TO SE RKER5' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100, ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am lice ed under provlslgns of Chapter 9 (Commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect Lic.,#_3 t7 G Class a C�y Conliactors'Signature: (Date: -7-00 -_-- CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction (ending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lenders Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that t am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a cMI penalty of not more than five hundred dollars (55oaJ.J: ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL 00 THE WORK, and the structure is not Intended or offered for sale (Sec. 7D44, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). • ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sac. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of properly who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors license Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet In depth into which a person Is required to descend, will be made In connection with work authorized try this permit, and that no building structure, scaffolding, ialsework, or demolition or dismantling thereof, will be more than Ihirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec, 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present Or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic loot of compressed gas at standard temperature and pressure). .................................................................................................................................................................................................................................................................._.............................. ............................................................................ 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic lost of compressed gas at standard temperature and pressure). — .............. _ ............... ......._.._........ .......---....................__................. —............... _.—................................. _._... ----......................................... _._........................ ._.......................... 3 Does or will the appplicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? [I❑ Yes ;Vo (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. .......................................................................................................................................................................................... 4 If an RMPP is presentiy roquired, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No ..................................................................................................................................... _........................................................................................................................... D ... 5 oes or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification.. from the South Coast Air Quality Management District or from any other air pollution control district or agency? E Yes U No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ......... ............ ........................ ...................... ................................... -........................................................... 1111................ ..............1111 ...............................................,.. 6 WIII any pert of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). _................_... .......... ....._............... ---.............................—................ —_.................. -_................. __........................................---................................__................... _-_ ............ _._1.1............. 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No --._..� . �..-•---•-•---.................................... p----•-••aRProP ..� _1111-------�...............—..................................................................._..�._.-...........-..�......_..............�..... B it s , attach certificate of compliance from the nate air Ilotion Control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the Information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Slgnature: Date: CERTIFICATE OF CO%iiAlD AUTHORIZATION OF ENTRY: I certify under penalty of perjury that 1 have read this application and state that the information given is correct. I agree to Cotete laws and city ordinances relating to building construction, and authorize representatives of the Clty of Costa Mesa to enter upon the above-described proption purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. S e e 01 Legal Owner(s) Date A d/Or'AuthorizedjApplicant Date CODE R. INSPECTION _J PE 2AR INMA4ai CODE i INSPECTION TYPE J jNTITALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 2D0 Final Re -Roof 210 Final Electrical 1 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.8LHLDING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Status: ISSUED Suite: SAKS Applied: 05/24/2007 Vicinity: Issued: 06/27/2007 Primary Occ: M DisplaylSale Merchandise Type of Construction: II -F Parcel Number: 41249105 Zoning: Applicant: PROFFITT, JIM Address: Phone: 817-869.9881 ISSUED B . Zip: Owner: SOUTH COAST PLAZA CALWIN REALTY II INC Address PROPERTY,TAX DEPARTMENT BIRMINGHAM, AL Phone, 750 LAKESHORE PARKWAY Zip: 35211-4400 ` Contractor: .TEXAS WESTWOOD CONTRACTORS INC Address:. 777 MAIN ST STE 950 • ,:. Phone: 817-877-3800 FORT WORTH, TX Zip: 76102 License: 618438 F Arch : -CALVIN COATSWORTH Eng: Address: 2458 DUPONT DR r Address: Phone: 949-833-1930 Phone: IRVINE, CA `t Zip: 92612 License: C14388 License: SCOPE OF PERMIT 495 S.F. INTERIOR TENANT IMPROVEMENT FOR VENDOR SHOP, GUCCI, WITHIN EXISTING STORE, "SAKS FIFTH AVENUE" __ ... FEE.SUMMARY--._. Plan Check:` $104.69 - _ ;Calc Valuation: $50,000.00 Permit: $644.25 Claim Valuation: $50,000.00 SMIP Res: $0.00 SMTP Com: $10.50 Other: $0.00 Inspection: $0.00 Total: $759.44 " PLANNING & ZONING ;; 2. SETBACKS - ETBACKSMAINSTRUCTURE ,- MAIN STRUCTUREFront,,.'- 0- 0 Rear ;.'0- 0 �, Left. 0-0,_ Right 0- /;; ACCESSORY Front 0-'0 S CRear E 0-0 _ Left 0- 0 Right ".0- 0 PARKING ` "Exisifn4: 0 Required:- 0 Proposed:' 0 - NOTICE: - NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended:or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspectlons and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446.46 (6=) DECLARATiONS WORKERS' COMPENSATION DECLARATION: 'r I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compen sa ion Insurance carrier and policy numb r are: (/lJ 1 0/3 21 -30 CCamme�i` 9 ( IPolicy Number: (Thig-sectioC,gbad not be completed if the permit is valued at one hundred dollars ($100) or less.) ❑ I certity that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' Cc 11 law of California, and agree that if I should coma subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these "is ns. AJ Applicant Signature: =ata: % WARNING: FAILURE TO SEC E WORKERS' COMPENSATIO RAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIV FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($too, ),IN ADDITION TO THE COST PENSATION, DAMAGES AS PROVIDED FOR IN SEC -PON 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am IIc used nder prov ns of Chapter 9 (commencing with Section 7000) of Division 3 of.ihe Business�nd Professions Code, and my license is in full force and effectrLic_k LClass It Contractor's.' Signatui Rate: � G�—A 7-0:7 CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code), Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation o1 Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500)J: ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a Contractors) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property fax bili or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be ''.ore than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title S, California Administrative Code). ❑ As owner -builder, I will not employ anyone 10 do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Dale: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure), ..................................................................................................................................................................................................................................................................................................................................................................... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ........................ .......... ................ ....................................................................................... ....................................................... ....................................................................................................................................................................................... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ....................................................................................................................................................................................................................................... ............................... 4 li an RMPP is presently required, hes Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No ..................................................................................................................................1-..................................... .................................... ... ............................................................................................................................................... 6 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ennit for such construction or modification from the South Coast Air Ouallty Management District or from any other air pollution control district or agency? Yes I No (Section 65650.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ....................................................................................................................p. ei.........b'e'.w"ith"in"-,..........."ie"'......................................................ie,s...................................................................................................................................... 6 Wi11 any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes ❑ No (if "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ....... .. ................................................................................................................................................................................................................................................................................................................................................................................. 7 If a permit from the South Coast Air Cluality Management District or other air pollution control district or agency is required for the workwhich is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No .io..............a-p.....o. p-..........eir..p---------...................................................................................................................................................................................................................... 6 (If 'fres", attach CertltlCafe of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certity under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. nature e I r(s) Date 7-D7 i !ndlOr.A h i d A cant f` -'Date INSPECTION TYPE 2M INTITIALS CODE - INSPECTION TYPE DAN 19IITIA4 1616 J Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 206 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy f0 I M (714) 754-5273 • Fax (714) 754-4856 • www.cl.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 BUILDING PERMIT Job Address: 3333 BRISTOL ST Suite: SAKS Vicinity: SAKS 5TH AVE (LOWER LEVEL) Primary Occ: M Display/Sale Merchandise Type of Construction: I -FR Parcel Number: 41249105 Zoning: Applicant: RICK VANDERHOVEN FEE SUMMARY Address: 8819 NIGHTINGALE AV Calc Valuation: $3,000.00 Permit: - Phone: 714-404-1924 SMIP Res: FOUNTAIN VALLEY, CA Zip: 92708,•' Owner: SOUTH COAST PLAZA %CALWIN REALTY II INC` Address ' %PROPERTY TAX DEPARTMENT " ' . $83.25 BIRMINGHAM, AL Phone: 750 LAKESHORE'PARKWAY Zip: 35211-4400 , Contractor: R A V CONSTRUCTION & DEVELOPMENT COMPANY Address, 8819 NIGHTINGALE AV - Phone: 714-404-1924 `.' FOUNTAIN VALLEY, CA SETBACKS��/,� Zip: 92708 - License: 637429 Status: ISSUED Applied: 04!1812005 Issued: 07!1212005 ISSUED BY: Arch Eng: Address: Address:' Phone: Phone: Zip: �' License: License: SCOPE OF PERMIT', LEGALIZE THE INSTALLATION OF A DEISEL ENGINE GENERATOR AT "SAKS 5TH AVENUE." NOTES: NOTICE., The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work Is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result In the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 2446.46 (6!00) FEE SUMMARY Pian Check: $54.11 Calc Valuation: $3,000.00 Permit: $83.25 - Claim Valuation: $3,000.00 SMIP Res: $0.00 SMIP Com: $0.63 ' Other: ' . $83.25 Inspection: $0.00, Total: $221.24 PLANNING & ZONING SETBACKS��/,� MAIN STRUCTURE. Front` 0-.0 'Rear`` 0= 0 �� ,�. Left 0-0 Right ,Q- Q' ACCESSORY Front , .0-0 `� �� • Rear 0-0 Left 0-0 Right 0- 0' �- PARKING Existing:'-- 0 _ Required: 0 Proposed: 0 NOTES: NOTICE., The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work Is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result In the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 2446.46 (6!00) DECLARAVONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. ❑ 1 have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Coda, for the performance of the work for which this permit Is Issued. My workers' compensation Insurance carrier and policy number are: Carrier: _ Policy Number: i s section need not be completed if the permit Is valued at one hundred dollars (3100) or less.) rt- cerilfy that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and roe that if I should become subject to the workers' compensation provisions of Section 3700 of the LOW Code, I shall forthwith comply with those�v/iJsions, n AppficantSignatt7ra:_Jsc�—------------ :,Date: °/ W�AAN1Np. FAILURE"TO SECURE WORKERS' OOMPENSATION COVERAGE IS UNLAWFUL AND SW a SUBJECT AN £MPbO FR To'cmmNAL PENALTIES AND GV1L FINES UP TO ONE HUNDRED TF� DOLL4RE ($100,000€, IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am Iicens d Fye €o Chapter 9 (commencing with Section 7000) of Division 3.atthe� sine nd Professions Code, and my license is in full force,,',a.�n'd'Bffect.,Llc..IV ' � C Class p Cf mi air ctors SlgnaturIi e —r.. . CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lenders Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: TO I hereby affl�n the rVanajty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the fallowing reason (Sec. 7031.5, Business and Professions Code: Any u'ffy-$F"amwhich.ra lr�,gg�It to Construct, alter, Improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit to file a signed statement that he 4r she- i�ilE nsed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business ard-Prcrbn QrksF(;ode) or that he she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects vw t to a 610 �4, �f not i?fflre than five hundred dollars ($500).): ❑ I, as owner of the p pe�rty mp ' th wages as their sole compensation, WILL DO THE WORK, and the slruclure Is not Intended or offered for sale (Sec. 7044, Business and Professions Coft The ConiraC10r5 License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. 11, however, the building or Improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who Contracts for such project with a contractor(s) license pursuant to the Contractors license Laws.). ❑ I am exempt under sec. _ Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet In depth into which a person Is required to descend, will be made In connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, l will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and comity a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does Cr will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ NO (Section 25533 of the Califomia Health and Safety Code, with some oxce tions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _.._.,..... ----........_................................ ............-................. _.._._................... ........................... ............................................................................... ............................ ......._._......... ..._............. _ 3 Does or will theaappplicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the Califomia Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and tiling with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully compiled with? ❑ Yes ❑ No ....—_._ ........ __._................. —. .... ............ -- -_ .. ...................._.......................................... � .._w— .. 5 Does Or will the applicant or present or future building occupant require for the work which Is the subject of this a plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes f No (Section 85850.2 of the California Goverment Code requires that the requested information be furnished on applications for non-residential building pormi ts). _ h"is .........._.......,w"Ith"in, B-0—of ............._..._—..._............,......................._...................................................IN.................�...................._�............... 6 w€1E any pan of the teal!€ty to lye Constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes ❑ No (11''yes', the facility must meet the requirement of Sections 25534 and 42303 o1 the California Health and Satety Code). ---—...............................__ _............._............................ _........................_—_.............................. _.. 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency Is required for the work which is the subject of this application, have all of the disclosures prescribed by Calllomla Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (It W, attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above Is correct. I agree to Comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given Is correct. I agree to comply with all state I cos and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-descri props for Irtspl@ction rposes. I agree not to Occupy or allow occupancy of any building authorized by this permit until final inspection. Signmure 01 Legal Owner(s) r �Date C And/Or Authorized Applicant Date CODE c INSPEMN TYPE 263 CODE# INSPECTIQNIYPE 2M fiQl�§ 1616 Fixed System Final Fire prevention 206 Final Mechanical 1266 Pool Spa Final 206 Final Plumbing 200 Final Re -Root 210 Final Electrical 201 Final BlocklRetaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy, 7 t� (714) 754-5273 • Fax(714)754-4856 • www.cl.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT .lob Address: 3333 BRISTOL ST Suite No SAKS Vicinity: SAKS Parcel Nunmber: 41249105 Applied: Applicant: VANDERHOVEN, RICK 07/12/2005 Address: 8819 NIGHTINGALE AV, :- SCOPE OFiPERMIT _ '� Phone: 714-404-1924 LEGALIZE THE INSTALLATIONIOF'A FOUNTAIN VALLEY, CA - Zip 92708 REF: B05-00634 1 MOTOR TO 50 HP (30KW GENERATOR) , Owner: SOUTH.COAST PLAZA%CALWIN REALTY 11 INC_" Address, TAX DEPARTMENT BIRMINGHAM; AL Phone: 750"LAKESHORE PARKWAY Zip: 35211-4400 ` Quantity Quantity; /r ISSUE FEE Contractor:" " R A-V CONSTRUCTION & DEVELOPMENT COMPANY Address. 8819 NIGHTINGALE AV 0-" Temp service test ., $0.00 Phone: 714-404-1924 Busway /100 ft VALLEY; CA Zip: - - Res.`alc package ; ,FOUNTAIN 92708 ,Standing Section $0.00 License: 637429 •� New Res,(1-2 units) $0.00 0 Status: ISSUED Applied: 07/11/2005 Issued: 07/12/2005 NOTICE: The work aulhorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446.46 (6=) SCOPE OFiPERMIT _ LEGALIZE THE INSTALLATIONIOF'A DEISEL ENGINE GENERATOR AT -,SAKS 5TH AVENUE." REF: B05-00634 1 MOTOR TO 50 HP (30KW GENERATOR) , FEE SUMMARY / ` Quantity Quantity; /r ISSUE FEE $23.50 Temp Dist System'l Lighting $0.00 0-" Temp service test ., $0.00 Busway /100 ft $0.00 ;0,',' Res.`alc package ; $0.00 ,Standing Section $0.00 ,; 0 •� New Res,(1-2 units) $0.00 0 y ;: =7�: Misc Electrical Equipment $0.00 New Res,(3+units) $0.00 0 Transformers up to 1 kvalkw $0.00 ,-', 0 Pool l Spa '$0.00 0 ....up to 10 kvalkw $0.001''/' 0 , Lighting Fixts , , $0.00 t _ ' = 0'" =_. up to 50 kva/kw $24.60' 1 ' Recept Outlets ' �. ��$D.00�_' , v 0 :....up to 100 kvalkw ",$0.00 0 Switches /�// $0.00 ,_ 0 %. ..................over 100 kvalkw x10.00 i , 0 Nan Res Appl �� Fees Appl �; $0.`00 $0.00 ? .��;0� 0 '- Low Voltage Equipment Low Volt Wiring Systerri'l Ckt $0.00 $0.00., '�0 , ' "0", , - -" Service to 200a 0 _ Misc,,Conduit - $0:00 r /0, Service to 1000a y� ,$0:00 ,' 0 �� Misc. Conductor �, i'$0.00 , "o Service over 1000a $0.00 ~ j ' , 0" i • .� . Circus ( gen or ride)' , ` $0.00 0 Motors to 1hp $0.00', , " 0 Circus (meth ride or lights) _$0-00,/1 0 Motors to 10hp $6.06'. �. 0 Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 0 --\-'Fireworks Stand _-'$0.00 0 Motors to 100hp $0.00 - 0. _ - Other Electrical Fee" ' ' $0.00 Motors over 1 00h $0.00 0 Communication drops $0.00 0 Investigation Fee $48.10 Sub panel to 200a $0.00 0 Plan Check Fee $0.00 NOTICE: The work aulhorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446.46 (6=) PA DECLARAMNS WORKERS' COMPENSATION DECLARATION: 1 hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. ❑ 1 have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit Is Issued. My workers' Compensation Insurance carrier and policy number are: Carrier: Policy Number: (This section need not be completed if the permit is valued at one hundred dollars ($100) or less.) #•certify that in the performance of the work lot which this permit Is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and ogre tial If f should b come subject to the workers' compensation provisions of Section 3700 of the La Code, I shall forthwith comply with these pr sio f ^� rA.pplicant'SIg a Date -` r r G WARNING"FAILURE TO SECURE WO RS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EIAPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED -7F6USAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisi f Chapter 9 (commencing with Section 7000) of Division 3 of the•$usiness a d Professions , and my license is In full force•and"effect. Lic. # ��r%L��_ ^,f �Cl�ass-# �= _I;ontMcto` Signatare::r_ ii In_P_� �" Dere:-Yr1= 1 Z� O675------- CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW toy the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to Its Issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (Commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civi��alaity of not more than five hundred dollars ($500).): ❑ I, as owner of the property4or my employees with wages as their sole Compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code:,Tho Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or hers it thro his or her own,employeas provided that such Improvements are not Intended or offered for sale. If, however, the building or improvement is sold within one year o eiltj4;,j la owner-bui;hl have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am IVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does riot apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws>)o ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Data: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet In depth Into which a person is required to descend, will be made In connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec, 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or Future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _.......................... 1111....... 1 111 .....__ ..........._...............iii i................_.......-- - ............. _ .... .�........ _--.._..... _........................ __................. 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ..................... _ _ _........._ ._........................._............................................ _.............. ---.... _........................................ ..... _..--- ....... _....... ......................................................... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ....................-•---.._......—....................................................................._._....__................_....—.........-..........-..._......................................................................-^---•-••------••---•-----•---...................................................-1111... 4 If an RMPP Is presently required, has Section 25534 of the California Health and Safety Coda been fully complied with? ❑Yes ❑ No _................. —.__. _ 1111.. ........_�,. -.—_..........................................._..........._....................................—......._............................ .. ......... ...................... 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this a plication appermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? EJB Yes L] No (Section 85850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ....... ......._....... ..... _._................ ............................................................ .........---•---........................................ ....................................................... ....................... .....1111.....................................11.11................ 6 Will any part of the facility to be constructed under this permit be within 1000 foot from the outer boundaries of a school? ❑ Yes C1 No (11 *yes-, the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). _.-........._..-.. .................................. ................................... _ .._.._.......... ..--.................... ---............ _.._ .... --• 7 If a permit from the South Coast Air Quality. Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes E] No 8 (If 'yes', attach certificate of compliance from the appropriate air pollution control officeq. CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to Comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above -do scri property for Inaluke'tf ection p uses. I agree not tO occupy or allow occupancy of any building authorized by this permit until final Inspection. Legal Owner(s) 7ZDa'ao� ___._•�^^•--"--1111.-.- - -• AndlOr Authorized'Applicant Date �- CODE I INSPECTION TYPE Quit IN7RIALg CODE 1 INSPECTION TYPE 2M INTITIIA 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Ra -Roof 210 Fina! Electrical 201 Final BlocklRetaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Rnal Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy ,lob Address: 3333 BRISTOL ST Status: ISSUED Suite: SAKS Applied: 10112/2006 Vicinity: SAKS Issued: 02115/2007 Primary Occ: M Display/Sale Merchandise Type of Construction: I -FR Parcel Number: 41249105 Zoning: -P,d& Applicant: Address: Phone: ISSUED BY: Owner: SOUTH COAST -PLAZA %CALWIN REALTY II.INC Address %PRO PERTYTAX.DEP.ARTMENT l . BIRMINGHAM, AL �, Phone: 754 LAK SHORE PARKWAi\ Zip;-- 35211=4400 Contractor:. TEXAS WESTWOOD.CONTRACTORS INC Address: `i777 MAIN ST SUITE 9501X =�` Phone: 817-877-3800 FORT WORTH, 7X ,i Zip: 7fi102 `- License: 618438 \� \ ✓ \\`•� Arch CCA Eng: Address: `2458 DUPONT DR Address: Phone: 949-833-1930 Phone: IRVINE,CA` Zip: 92612 -:License: , C14388 License: i SCOPE OF PERMIT 03/22/07 REVISED: ADDING A MEN'S RESTROOM ON 1 ST LEVEL AND CONVERT 2ND FLOOR.RESTROOM TO A.WOMEN'S RESTROOM. INTERIOR 70;332 STORE TI FOR "SAKS FIFTH AVENUE" WORK TO INCLUDE NEW FINISHES, FLOORING, CEILING, ETC, ELECTRICAL AND MECHANICAL PLANS_ TO BE DEFERRED SUBMITTAL, RESTROOMS NOT -INCLUDED WITH;THIS TI. "FEE SUMMARY Plan Check: $2,690.80 \ f"' Calc Valuation: $4,000,000.00' Permit: $16,558.75 - h r' /.!ir,,_ Claim Valuation: {;, $4,000,040.00 SMIP Res; $0.00 SMIP Com: $840.00 Other: $0.00 ;Inspectiam, $0.00 Total: $20,089.55 ' PLANNING & ZONING✓'i` SETBACKS MAIN STRUCTURE Front - 0- 0� � Rear 0-0� Left, 0-0 Righi;. �D D� \ ACCES50RY�v�," Front 0; 0 -Rear,. 0-0 , Left 0-10 -Right O�O PARKING �. Existing: 0 ~, Required:- -'0:, = Proposed:_ NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No, 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work Is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446-46 (6100) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. JE 1' hve and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. y_workers' compensation Insurance carrier and policy number are: L C Y r- �- o11cy.Number: C� 20 (This section need not be comp! led if the permit is valued stone hundred dollars ($100) or less.) ❑ t certify that in the performance of the work for which this permit is Issued, I shall not employ any person In any manner so as to become subject to the workers' compensation laws of California, and agree that If I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these sI at e: r - �D�ta: T -_� • �a �0 7 _ ], WARMING FAM RE TO'SECU WORKERS' OOMPEN$ATION COVE G UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CMIL FINES UP TO ONE: HUNDRED THOUSAND DO LARE ($t 00, ADDITION TO THE ODST OF COM ON, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that! am,licensed under provislons o Chapter 9 (commencing with Section 7000) of Division 3 of the Busine and Professions Code, and my license is In full &Da:t sstiff �'.t actof$ Slgnature: e.-7-5 CONSTRUCTION LENDINGENCY: [3I hereby affirm that Cher is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lenders Name: _ Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions o1 the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business end Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars MOO).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or Improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). • ❑ 1, as owner of the property, am EXCLUSIVELY CONTRAC77NG WITH LICENSED CONTRACTORS to consfrucf the project (Set. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: _ Date: Owner ID verified by driver's ficense. ❑ Yes ❑ No Criver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet In depth Into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, SCaffplding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at stangard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater then a weight of 500 pounds, or a volume of 55 gallons, or 240 cubic feet of compressed gas at standard temperature and pressure). 3 Ooes or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No .............. ................... -.............................. ..—...._....__........__...,............................. _--•••--•---.............................. ..._..............................................................._......._.................................. - - — - - 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application a ffrmit for such Construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? [3 Yes LJ No (Section 65850.2 of the California Government Code requires that the requested Information be fumished on applications for non-residential building permits). _...................._..............-_ . his p within 1—._.....--•---................................-...-fa', ..-........ac. 4_.._..— _......---....-- •6 Will any part of the fadllty to be constructed under this permit be within 1000 feet from the outer txwndaries Of fl schod7 ❑Yes ❑ No (If 'yes". the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 if a permit from the South Coast Air Quality Management District or other air pollution Control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ........................ --...... ................................. •-------•--­................---._.................----......................................................................,........_........................._............................ ... ....... ..- 8 (It Tres", attach certificate of compliance from the appropriate air pollution Control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: _ _ Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the Information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature Of Lega ar(s) Dale W0111 arized applicant *fa x,: , �`-_I y. , Date CODE #. INSPECTION TYPE IKMALS CODE INSPECTIDN TYPE RM INMA 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Well 212 Final Fire Prevention 202 Final Factory Flre Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Bulidingl0ccupancy r� (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca-us PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Suite No SAKS Vicinity: Parcel Nunmber: 41249105 Applicant: MIKE MITCHELL 4 ISSUED BY: Address: 12781 WESTERN AV UNIT U i Phone:, 714-835-5325 GARDEN GROVE; CA: '-'� Zip: ; 92841 '_ A � �. ,., � , ; /l, rte•. Owner: SOUTH COAST PLAZA'%CALWIN REALTY II INC - Address' , %PROPERTY, TAX DEPARTMENT 7 •BIRMINGHAM,ACPhone: ' 7501AKESHORE':PARKWAY Zip: 35211-4400 /Contractor:-, DYKE;RLUMBING AND HEATING INC, Address:,', 12781'.WESTERN AV UNIT Phone: -714-835-5325 GARDEN GROVE„CA Zip: '92841 Status: ISSUED Applied: 03/21/2007 Issued: 0312112007 v f _ License.. 414210 , :a ., ,fir , y �- f fT. "., _ _- �i�� � _ �• i \, SCOPE OF PERMIT t INTERIOR 70,332 STORE TI FOR "SAKS FIFTH AVENUE" WORK TO INCLUDE NEW FINISHES,) FLOORING, CEILING; ETC. ELECTRICAL AND MECHANICAL PLANS TO BE.DEFERRED SUBMITTAL.i., RESTROOMS NOT INCLUDED WITH THIS TI:.REF-:306-01738 _ PLUMBING INCLUDES: 2 URWALS,,5--WASH BASINS; AND 2•WATER CLOSETS, t COMMENTS 1 SPECIAL -CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia statutes and'related regulations. (Ord; No. 92;28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is,s spended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446.46 (6/00) .„ FEE SUMMARY I t ISSUE FEE �+ AMT $23.50 QTY _. r' AMTA�QTY.-_- ` ' ' f -r�$O.OQ�JO'� i Sump Pump ,AMT ! ,QTY $0.00 �: 0 Backfiow irrigation $0.00 0 --L•aundry1ubd>Washer•� Landscape -Irrigation z .. j, 1 $0.00 /0�-- -' Swimming Pool ,; $0.00 0 Backflow Prevent& ti ' . $0.00 0 P -Trap $0:00 0 Trap Primer f '' $0.00 0 Bathtub $0.00 0 Pressure Regulator I$6.00% 0 _Urinalf :. , $19.60;, 2 Clarifier System , ' $0.00 0' _ Process Piping (per 10 ft) y t _$0.00, 0 Vacuum Brkr Bkflow(1--4),_, ,$0;00• 0 Connect (lce;Sod6,etc) $0.00 04 Receptors $0.00 _F-0 Vacuum Brkr'8k€Iow(5+) $0.00., 0 Dental Units, . - $0.00 0 5 Septic Tank .•d, : ` ,.,;: �., asin, �,,f ` f $0.00 0 Wash Basin,," $49:00` 5 Dishwasher. $0.00 0 , Sewer Cap;fo;r Demo $0.00 0 Wash Basin Set $0:00 0 Drain, Floor,,, $0.00 ,\ 0 Sewer Connect: $OAO ,_ 0 Waste arid'Vent System" "$0.00 0 Drain, Rainwater 50.00, 0 Sew i Private Line %� $0.00 ''0 Water Closet (Toilet) $19-60 2 Drain, Raof.��: A ✓ $0.00;",� Q �,; ,�..>?� Shower ,, ,.yz , �1 $0.00: =0 i 7^6 ,'W ter; Heater Ivent' �'�`,. $0.00 0 Drinking Fountain, $0:00 `��0';, Sink, bar ,, . "$0.00 0 _ -Water Piping (Inst or Rep:)V$0.00 0 Expansion Tank '� !$0:00 , 0� ,` Sink, coinmercia! x $0.00 0 I,;: Water Re=pipe,$0.00 �/ 0 Gas Earthquake Valve, ` ,50.00 ~ 0� ' �' _� Sink; Floor -'i `' $Of00 �0 ' %Water Service/ ' i' $0"00 0 Gas (1-4 outlets) V ` $0.00 0 _Sink,.kitchen' �,, �� $0.00 O j Water -Softener/ �, $0.00 0 �� Gas (Over4 outlets)�% : ` $0:00 0_ Gas Repipe ,` "$0.00' ,0- , Sink, servioelmop�__ ,-,� -.Spa (private} $0:00-„ $0.0----=0-� OTHER/ % 0 ,� \ -VIOLATION' ! $0.00 $0.00 Gas Service $0:00,_1 ,0 0'.-J� /, J Spa (public) _ - $0.00_,,0_\~ , P.LAN CHECK` ` $0.00 Interceptors (Grease, Oil) $0.00z-' e0 ;` 1r- , ' �w"' s REINSPECTION $0.00 0 Interceptors (Sand Auto ) $0.00•- TO TAIL CALCULATED FEES: $111.70 COMMENTS 1 SPECIAL -CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia statutes and'related regulations. (Ord; No. 92;28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is,s spended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446.46 (6/00) DECLARATIONS WORKERS' COMPENSATION DECLAUTION: I hereby affirm under penalty Of perjury one of the following declarations: V❑ ave and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issueq. --I have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. __—My workers' compensation Insurance Carrier and poli number are: �(7hl ss action need not be completed If the permit Is valued ar one hundred dollars {$100) or less.) ❑ I certify that in the performance o1 the work for which this permit is issued, I shall not employ any person in any manner s0 as to become subject to the workers' compensation laws of California, and agree that It 1 should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, i shall forthwith comply with these provisions. -Applicant Signature:'Date:. - -WARNING: F� TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CrVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE (S100 o00), W ADDITION 70 THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed u dal provisions of Chapter 9 (comm with Section 7000) of Divisionof the Business and P I lons Code, and my license is in full (#orce'and effect. Classado `Contractor's Signature::" CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit to Nle a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty Of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself Or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ' ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of properly who builds or improves thereon, and who contracts for such project with a contraclor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Data: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bili or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding. Wsawork, or demolition or dismantling thereof, will be more than lhirly-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 6, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division o1 Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present Or future building occupant need to file and Certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _..............................................._...........................................................................................................................------...................................._............................................................. ......................,...................... ................................................ 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑Yes ❑ NO (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feel of compressed gas at standard temperature and pressure). - ...................................... __............................................................. ................................................................................. ............................................. ..............•...........,..............................................................................................------•. 3 Does or will theappplicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes 11NO (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ...........It.............................................................................................................................._...................................-••-------....................................................ile, .............. ........."a ....................................................................................... 4 If a.. RMPP is presently required, has Section 25534 01 the Calilomia Health and Safety Code been fully complied with? ❑Yes ❑ No 5 Does or will the applicant or present Or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency/? Yes 1 No (Section 65850.2 of the California Covornment Code requires that the requested information be furnished on applications for non-residential building permits). ----------------------------..............................................._._................... .............................._.......................................................... B Will any part Of tho facility to be constructed under this permit be within 1000 feet from the ouler boundaries of a school? ❑Yes ❑ No (if "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). _..........................._...............................................................-...----.--------------..........._........................_._......-----•--•-------._................................_...—.................................--.-- ................... — .................. 7 If a permit from the South Coast Air Ouality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ........... 8 (if "yes", attach certificate o1 Compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. elure ner(s) Date CODE 0 jN§PECTIONTYPE DAM IC{TMALS CODE INSPECTION TYPE j&M INMAL$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Hoof 210 Final Electrical 201 Final Block/Retaining Wall • 212 Final Fire Prevention 202 Final Factory Fire Place - 220 Final Planning Approval 203 Ffnaf Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.cosla-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Suite: SAKS Vicinity: SAKS FIFTH AVENUE Parcel Nunmber. 41249105 zoning: Applicant: LOONEY, MARK Address: 5200E HUNTER AV SUITE B Phone: 714-993-2822 ANAHEIM,-CAZip: 92807 Owner SOUTH COAST PLAZA CALWIN REALTY II INC- _ Address'%PROPERTY TAX DEPARTMENT BIRMINGHAM, AL Phone: - 750 LAKESHORE PARKWAY Zip: 35211-4400 Contractor: ALERT FIRE -PROTECTION INC Address: 5200 E HUNTER AV Status: ISSUED Applied: 03101/2007 Issued: 03121/2007 ISSUED BY: cy,�L SUITE B , ,� Phone: 714-993-2822 , ANAHEIM, CA Zip: 92807 License: 316324 _ SCOPE OF PERMIT INTERIOR 70,332 STORE TI FOR "SAKS FIFTH AVENUE" WORK TO INCLUDE NEW FINISHES, -FLOORING, CEILING ETC. RESTROOMS NOT INCLUDED WITH THIS TI. REF: B06-01738 PROJECT TO BE DONE IN 3 PHASES: PHASE 1: RELOCATE 45 SPRINKLER HEADS AND ADD 4 NEW HEADS FOR A TOTAL OF 49 HEADS. FEE SUMMARY Plan Check: $353.11 Calc Valuation: $40,000.00 Permit: $543.25 Claimed Valuation: $40,000.00 Other: $0.00 -- - - Total: $896.36 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 2"5-48 (8100) DECLARATiONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance o1 the work for which this permit Is Issued. I have and will maintain workers' compensation Insurance, as required by section 3700 of the labor Code, for the performance of the work for which this permit is issued. My workers' pensallon Insurance carrier and policy number are: ' 7 % Carrier, _-S`i� C_f)ktAD Policy Number•. 15 / o — 60 (This section need not be completed N the rmll is valued at one hundred dollars ($100) or fess.) ❑ I cartify that in the performance of the work for which this permit Is issued, I shall net employ any person In any manner so as to become subject to the workers' compensation laws of California, and ae that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisio Applicant Signature: Date: 3r �) - WARMNG: FAILURE TO SECURE WORKERS' COMPENSATION E IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED AN THOUSD DOLLARE ($100,000), 1N ADDITION TO THE COST OF ENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effact..Oc. S a 11y,�Class'1f L - (- Contractors signature: (Date: 3 - - U CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued, (Sec. 3097, Civil Code). Landers Name: Lenders Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business end Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to Its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation o1 Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License law does not appy to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). . ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person Is required to descend, will be made In connection with work authorized by this permit, and that no building structure• scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 6, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the Calilomia Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure), 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight o1 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ..... __— _ _ ..m......................._ _ -..-........ _........ —_................. 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of thisa pilcation a6rmit for such construction or modification from the South Coast Air Quality Management District or from any other air pollutlon control district or agency? byes jJ No (Section 65850.2 of the Califomia Govomment Cade requires that the requested Information be furnished on applications for non-residential building permits). ..... _.._.... ........ ........................... .............................................................__......................._......................................................................................................_....- ..�........ _ ......_. 6 Wtfl any part of the facility 10 be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes ❑ No (if yes', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ........_.._......_...._..._..- ----------.............................6'a".................-----....................................'ro'...................................................1*"d.....................------............s r*...--ul'r..... f'o"r t'h"...................................I'h" ..............'e"t ......t'h-l-.... 7 If s hermit from the South Coast Air OualitV Management District or other air poliuticn control district or agency Is required for the work which Is the subject of this application, have all 01 the disclosures prescribed by Califomla Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (If 'yes', attach Certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the Information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to anter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Sig ra,@tkm0IOwner(s) Date AndlOr Authorized Applica Date CODE f. INSPECTION TYPE V DATE INTMA GODS INSPECTION TYPE gAIE INTITIA 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy Job Address: 3333 BRISTOL ST DATE: 2� �— Status: ISSUED Suite: SAKS Applied: 03/01/2007 Vicinity: SAKS FIFTH AVENUE Issued: 03!21!2007 Parcel Nunmber: 41249105 Zoning: ISSUED BY: Applicant:. LOONEY, MARK Address: 5200 E HUNTER AV SUITE B Phone: 714-993-2822 ANAHEIM, CA Zip: 92807 Owner: SOUTH COAST PLAZA CALWIN REALTY li INC Address %PROPERTY TAX DEPARTMENT BIRMINGHAM, AL Phone: 750 LAKESHORE PARKWAY Zip: 35211-4400 Contractor: ALERT FIRE PROTECTION INC Address: 5200 E HUNTER AV SUITE B Phone: 714-993-2822 ANAHEIM, CA Zip: 92807 License: 316324 SCOPE OF PERMIT INTERIOR 70,332 STORE TI FOR "SAKS FIFTH AVENUE" WORK TO INCLUDE NEW FINISHES, FLOORING, CEILING, ETC. RESTROOMS NOT INCLUDED WITH THIS TI, REF: B06-01738 PROJECT TO BE DONE IN 3 PHASES: PHASE 1: RELOCATE 45 SPRINKLER.HEADS AND ADD 4 NEW HEADS FOR A TOTAL OF 49 HEADS. PHASE 2: RELOCATE/REPLACE 26 OVERHEAD SPRINKLERS. FEE SUMMARY Plan Check: $353.11 Calc Valuation: $40,000.00 Permit: $543.25 ,, Claimed Valuation: $40,000.00 Other: $0.00 Total: $896.36 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: to order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2""0 (ep) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of 0onsent to self -Insure for workers' compensation, as provided for by section 3700 o1 the Labor Code, for the performance of the work for which this permit Is issued. _[]—I have and will maintain workers' compenperformance satlon Insurance, as required by section 3700 of the Labor Code, for the perfoance of the work for which this permit Is issued. .W.workers' c mpe sation Insurange carrier and polity number are: l /S '� �a r O Carrfer.. rPo'I€ Number' _(.This -section need not be completed lf the permit is talued at one hundred dollars ($100) or less.) � ❑ 1 certify that In the performance of the work for which this permit Is issued, I shall not employ any person In any manner so as to become subject to the workers' compensation laws of California, and roe that I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provision Appitcant•Stgnature: at m !f p WA 9NG:,FAU1 RE -TO SECURE WORKERS' COMPENSATION COVE IS UNLAWFUL AND SHALL SUBJECT AN EM -TO CR!MINAL PENALTIES AND CIVIL FINES UPTO ONE HUNDRED THOUSAND DOLLARE ($10D,DDo), IN ADDITION TO THE COST OF COM SATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I herby affimm that I am licens d er SI fter(c m i with Section 7000) of Division 3 of the Business and Professions Code, and my license Is in full forts and effect. Uf` c�N` Cress p f!i." �O _3�9Dtracfo_?sSig attire: - ' s Date: ` ", -lo CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3087, Civil Code), Lender's Name: Lender's Address: Signature: _ Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7831.5, Business and Professions Code: Any city or county which requires a permit to construct, alter. Improve, demolish, or repair any structure, prior to Its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of DMsion 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption, Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself Or herself or through his or her Own employees, provided that such improvements are not Intended or offered for sale. If, however, the building Or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). • ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors Ucanse Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: _ Date: Owner ID verified by driver's license. ❑ Yes ❑ No Drivoes License No. Expires: Verification of Ownership by (type of documoht, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, st:affolding, falsework, or demWtlon or dismantling thereof, will be --ore than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 6, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I Will the applicant or present or future building occupant need to file and certlty a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration farm for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater then a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic fest of compressed gas at standard temperaturo and pressure). 3 Does or will the a plicani or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ lo (Section 25534 of the California Health And Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Npartment of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. _....._._._.................... ................ _............ ._• — -..._............................................................ 4 If an RMPP Is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No —._ _...�._...._....-- – -- __ _ — _ ...............�—. ----.................................... ....... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of thisa EPe pllcation armit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? 8 Yes LJ No (Section 65850.2 of the California Govemment Code requires that the requested Information be fumished on applications for non-residonfiat building permits). _........................................_...............................................................,.............................._—.............................................................. _...................... __....._.__... fi Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (it yes-, the facility must meet the requirement of Sections 25534 and 42383 of the California Health and Safety Code). _._._.._ _. _................_ ........... _ ..... _........ ._._.._....................._......................._ ..._._.._............... _ 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency Is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (it yes attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certity that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the Information glven is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for Inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. SI tura Le —D a �7 AndIQ uthorize Appi[cant, . IlDate ~- CODE 1 INSPECTION TYPE 1pfirm6L,g CODE t INSPECTION TYPE �AIE Jt 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final BlocklRetaining Wall 212 Final Fire Prevention��_ 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Buildingloccupancy (714) 754-5273 • Fax(714)754-4856 • www.cl.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 MECHANICAL PERMIT ,lob Address: 3333 BRISTOL ST Suite No SAKS Vicinity: SAKS FIFTH AVENUE Parcel Number. 41249105 Applicant: GARRY, ROBERT Address: 10880 WALKER.ST J " Phone: 714-484-9600 FEE SUMMARY CYPRESS,'.CA` Zip: 90630-50111 Quantity Owner: -SOUTH COAST PLAZA'%CALWIN REALTY II INC - Address: %PROPERTY TAX DEPARTMENT $23.50 BIRMINGHAM AL - Phone: 0 ' 750 LAKESHORE:PARKWAY Zip: 35211-4400 0-Repair/ 0Y' Repair 1 All'Refrigeration Unit 50.00 ' Contractor. TALENVAIR" $0.00. 0 _ System $0:00 Status: ISSUED Applied: 0312212007 Issued: 03/22/2007 ISSUED BY; fo Address: 10880WALKER ST - Phone: 714-484-9600 CYPRESS, CA Zip: 90630-5011 - license: 702568' i SCOPE OF PERMIT 03/22/07 REVISED: ADDING A MEN'S RESTROOM ON 1 ST LEVEL AND CONVERT 2ND;FLOOR RESTROOM TO A WOMEN'S RESTROOM, INTERIOR 70,332 STORE Tl FOR "SAKS FIFTH AVENUE". REF.: B06.01738. MECHANICAL INCLUDES: Plan Check Fee $0.00 Reinspection Fee" $0.00 TOTACCALCULATED FEES 5413.10 COMMENTS t SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work Is not commenced within 180 days, or If work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes and all required Inspections and final approval must be obtained. Failure to obtain inspectlons and final approval will result in the expiration of.this permit. FOR INSPECTIONS CALL: (714) 754-5626 e 2448-48 (SM) FEE SUMMARY Quantity 'r Quantity ISSUE FEE $23.50 Repai(tAlt Absorbtion Unit $0.00 0 Inst FAU <100 k BTU • $0.00 0-Repair/ 0Y' Repair 1 All'Refrigeration Unit 50.00 ' 0' Inst FAU >100 k BTU $0.00. 0 _ System $0:00 0 Repair/Alt Cooling/Heat $219.20 16 Evaporative Cooler $0.00 0 Inst 1 Rep. Recess Wall Htr S0.00 0 Commerciat Incinerator 50:00 i0 Refrig Sys <100 k BTU $0.00 0 Domestic Incinerator WOO 0, Refrig Sys >100 k BTU $0.00 0 Compressors /Absorption Systems Gas Piping$0.00 0 Up to 3 hp/ 100 k BTU $0.00 0 Factory Fireplace $0.00 0-.,3 •' To 15 hp 1500 k BTU $0.00 0 ; Hood w/Mech Exhaust $0.00 0 ;< 15 To 30 hp 11,000 k BTU $0.00 0;, VAV Box $170.40 16 30 T650 hp 1 1,750 k BTU ' $0.00 0 Vent Fan 1 Single Duct $0.00 0 Over 50 hp'/ Over 1;750_BTU, ,,-„ $0.00 .0 Appliance $0.00 0 Boilers Fire Dampers $0.00 0 . Up to 3 hp , ��' $0.00' 0 Smoke Dampers $0.00.;, 0 , 3 To 15.hp 'l",,/ i /,$0.00 "50.00 0 Inst or Relocate Appl Vent $0.00' � O `'y , 15 to 30 hp 0 Air Handlers < 10000cfm . %$0 00 0 •�� �� '' - _.� 30 to 50 hp `'%' / X,_ j i . '' $0.00 0 Air Handlers > 10000cfm. $0.00 0_ - Oyer 50 hp -� ��` ,, �. ;, $0.00 0 Floor Furnace $0.00 0 Other Mechanical Fee Floor or Suspend Heater \ $0.00 `, 0 -, Investigation Fee 1 r �; $0.00 Plan Check Fee $0.00 Reinspection Fee" $0.00 TOTACCALCULATED FEES 5413.10 COMMENTS t SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work Is not commenced within 180 days, or If work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes and all required Inspections and final approval must be obtained. Failure to obtain inspectlons and final approval will result in the expiration of.this permit. FOR INSPECTIONS CALL: (714) 754-5626 e 2448-48 (SM) 101 WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ i have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the ork for which this permit is issued, -1'have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit Is Issued M works' m nsatlon I ranee carrier and Ii num � lare: � 4 �7 �r Garrier.y, � MYDe�t �� . ti-[�+5. Policy&Number: 0144 � 1 I r I '2?Wtses ctlon need not be completed if the p rmN is valued at one hundred dollars ($100) or less. J ❑ I certify that in the once of the work Lor which IV. permit Is Issued, I shall not employ any person in any manner so as to become subject to the workers' compensation I alifomia, and agree If I s uld become subject to the workers' compensation provisions of Section 3700 of the tabor Code, I shall forthwith comply wi ase p visio S. i -7 Applicant Signature: Dater --7 I /�L l WARNING: FAILURE TO SECURE WORKERS' CAMPENSAT COVERApE IS UNLAWFUL AND SHALL SUBJECT AN F P 'ER TO GRIMINAL PE TIES ANt) CiVlt RNES UP TD ONE HUNDRED THOUSAND DOLLARE ($100.000), IN ADDr110N TO THE CO CF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that.l_am licensed under��ppravjSl4 of apfer 9 ( mencing with Section 7000) of Division of.the Business and Prof scions Code, and my license is in full 'fbrca.and effect. Lic-M- ©ot- ass'ft"L, Contractor's Signature: �--� CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction landing agency for the performance of the work for which this permit Is issued. (Sec. 3097, Civil Code), Lender's Name: Lenders Address: Signature: Data: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to Its Issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Sectlon 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or Improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ' ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, Le, - property lax bill or deod): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Adminislrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .... ................. ...�.............................. ................. .... ............. ..............._---- ......-- -----.._.__......._....................... ............. _- ................... - 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic foot of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. - - -- -- W...... ................_..._ . ._......—..._...................�._..............._.._._......._ 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yos ❑ No _.__ ....................----.... __ _............. ............................------•--............... .......................................... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application a ermlt for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ---.................................__...._........... —_..... -•---..........................- 8 Will any part of the facility to be Constructed under this permit be within 1000 feet from the outer boundaries of a Schad? ❑ Yes ❑ No (it yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Solely Code). ...............................-------••--•--..............-........._. ,_,..,___..—....---•----............_....................................... _. _......._..........._......._..................................................................... 7 if a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disdosures prescribed by Califomia Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (If yes", attach certificate of compliance from the appropriate air poeution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I cartify under penalty of perjury that I have read this application and state that the information given is correct, I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature Of LegJI Owner(s) ate _. — 1ZZ 0 tPel&r Authorized Applicant... _.. � 16 CODE to INSPECTIONTYPE QAM ISL$ ScQM INSPECTION TYPE QATfa �f Jj 1616 Fixed System Final Fire Prevention 206 Final Mechanical ]L L�L?�`!►_ 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final BlockfRetaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final BuitdinglOccupancy t (714) 754-5273 • Fax (714) 754-4856 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL. ST Suite: SAKS Vicinity: SAKS ROOF Parcel Number: 41249105 Applicant: SAMMY ZEPEDA Address: 987 NORTH BATAVIA BUILDING PERMIT Zoning: Phone: (714)744-6964 ORANGE, CA Zip: 92867 Owner: SOUTH COAST PLAZA %CALWIN REALTY II INC Address 200 PARK AV NEW YORK NY Contractor: CENTIMARK CORP Address: 987 NORTH BATAVIA ORANGE,CA Zip: 92867 Arch : Address: Phone: Zip: 10166-0005 Phone: (714)744-6964 License: 497859 Eng: Address: ISSUED BY: Status: ISSUED Applied: 06/28/2000 Issued: 06/28/2000 0 Total: $791.19 SETBACKS MAIN STRUCTURE Front 0-0 Rear 0-0 ACCESSORY Front 0-0 Rear 0-0 PARKING Existing: 0 Required: 0 NOTES: PLANNING & ZONING Left 0-0 Left 0-0 Proposed: 0 Go 11��'J SG -c r�o►-� S c.� F(o� i rvs�� C r v�-S Right 0-0 Right 0-0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 Phone: Phone: Zip: License: License: SCOPE OF PERMIT REROOF - TIO, INSTALL RETRO FIT BOARD 112" MECHANICALLY FASTENED AND NEW EPDM RUBBER ROOF UL #R13220N. SUBJECT TO FIELD INSPECTION. FEE SUMMARY Plan Check: $0.00 Calc Valuation: $68,763.00 Permit: $776.75 Claim Valuation: $68,763.00 SMIP Res: $0.00 SMIP Cam: $14.44 Other: $0.00 Inspection: $0.00 Total: $791.19 SETBACKS MAIN STRUCTURE Front 0-0 Rear 0-0 ACCESSORY Front 0-0 Rear 0-0 PARKING Existing: 0 Required: 0 NOTES: PLANNING & ZONING Left 0-0 Left 0-0 Proposed: 0 Go 11��'J SG -c r�o►-� S c.� F(o� i rvs�� C r v�-S Right 0-0 Right 0-0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 Q. iDECiARATIONS tlkRKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is Issued. 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Cade, lot the performance of the work for which this permit is issued. My workers' compensation Insurance carder and policy number are: Carder: Policy Number: (This section need not be completed if the permit is valued at one hundred dollars ($100) or lass.) ❑ 1 certify that in the performance of the work for which this permit is Issued, I shall not employ any person in any manner so as to become subject to the workers' compensation taws of mia, and agree that It I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisl s. Applicant Signature:Z",21 Date: -zey d WARNING: FAILURE TO SECUR RKERS' coMIPENsATI& C66aGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed nder provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is In full force and effect. Lic. # Class # Contractors Signature: Data: 67 CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there Is a construction lending agency for the performance o1 the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lenders Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or Improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or dead): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet In depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling (hereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8. California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed wlih the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for aculely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Cade, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater then a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department, 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this application armit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ �e Yes L.f No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications lar non-rosidentlal building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes', the facility must moat the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 It a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (It 'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of porjury the Information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given Is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final Inspection. SignagalOwner(s) Date z� AndfOC u h zed Appiicant r Date COPE /, INSPEMON TYPE Q�i'E LhIITLAL$ CODE I^PECTIONTYPE 26ig INTMALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 2D0 Final Re -Roof Nei 7co 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy 2446-a6 - CITY OF COSTA MESA { BUILDING DIVISION ROOF COVERING CERTIFICATION Property Address ���3 5 ,e% s o I r Owner k_ iT'4 Aole_y") Contractor _ vU �•� �2 p9 F State Contractor License Number Classification G 3 I hereby certify that I have installed, or caused to be installed, a minimum Class C roof covering at the above address in conformance with Chapter 32, and Section 1704 of the latest adopted edition of the Uniform Building Code, as amended in Section 5-17 Title 5 Costa Mesa Municipal Code, and the installation instructions of the manufacturer. ❑ I further certify that I am the owner of the property. (Owner -Builder permittee only). ❑ I further certify that I am: ❑ Owner of sole proprietorship company ❑ Full partner of the company ❑ Limited partner of the company D:r- Officer of the corporation I certify that as an authorized officer or agent of the company or corporation, I am empowered to make this certification, which shall be binding on all successors or assigns of the company or corporation. I shall deliver a copy of this Certification to the above listed owner, after submittal of form to the Building Division for acceptance. Received by Building Division By: Initial Date 099D-46 MW 9197 White • Building Div.; Canary • Contractor; Pink • Owner J4 Company or to Name Address Printed or Typed Name r � , o, r _ t - r Existing: 0 --- (714) 754-5273 - Fax(714)764-4856 CITY OF COSTA MESA BUILDING DIVISION DEVELOPMENT SERVICES DEPARTMENT Required: 0 PERMFrroposed: 0 .lob Address: 3333 BRISTOL ST Suite No Vicinity: BRIDGE/GARDEN TERRACE Parcel Nunmber: 41250106 Applicant: GEORGE KOFORD Address: r Owner: SEARS, ROEBUCK & CO Addiess ' D1768TAX,B2-116A PLUMBING PERMIT Phone: 310-532-8870 Zip: PERMIT NUMBER POO -00071 77 FAIR DRIVE, COSTA MESA, CA 92626 Status: ISSUED Applied: 02/02/2000 Issued: 02/02/2000 ISSUED BY: S TOTAL CALCULATED FEES: $46.45 COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 HOFFMAN ESTATES, IL Phone: 3333 BEVERLY RD Zip: 60179 Contractor: DEEL MECHANICAL CORPORATION Address: 13726 HARVARD PL Phone:. (310)532-8870 - GARDENA, CA Zip: 90249 License: 352015 Arch ! Eng Address: Phone: Zip: SCOPE OF PERMIT ADD TO ISSUED PERMIT P99-00723 FOR "BRIDGE/GARDEN TERRACE", 3TRENCH DRAINS AND 1 TRAP PRIMER, Rg:699-01437. FEE SUMMARY AMT QTY AMT QTY AMT QTY ISSUE FEE $725 Laundry Tub 1 Washer $0.00 0 Sump Pump $0.00 0 Backflow irrigation $0.00 0 Landscape Irrigation $0.00 0 Swimming Pool $0.00 0 Backflow Preventer $0.00 0 P -Trap $0.00 0 Trap Primer $9.80 1 Bathtub $0.00 0 Pressure Regulator $0.00 0 Urinal $0.00 0 Clarifier System $0.00 0 Process Piping (per 10 ft) $0.00 0 Vacuum Brkr Bkflow(1-4) $0.00 0 Connect (Ice,Soda,etc) $0,00 0 Receptors $0.00 0 Vacuum Brkr Bkflow(5+) $0.00 0 Dental Units $0.00 0 Septic Tank $0.00",_ 0 Wash Basin $0.00 0 Dishwasher $0.00 0 Sewer Cap for Demo $0.00,"" 0 Wash Basin Set $0.00 0 Drain, Floor $0.00 0 Sewer Connect $0.00; • 0 Waste and Vent System $0.00 0 Drain, Rainwater $0.00 0 Sewer Private Line $0.00 0 Water Closet (Toilet) $0.00 0 Drain, Roof $29.40 3 Shower $0.00 0 Water Heater I vent $0.00 0 Drinking Fountain $0.00 0 Sink, Oar $0.00 0 Water Piping (Inst or Rep.) $0.00 0 Expansion Tenk $0.00 0 Sink, commercial $0.00, 0 Water Re -pipe $0.00 0 Gas Earthquake Valve $0.00 0 Sink, Floor $0.00 0 Water Service $0.00 0 Gas (1-4 outlets) $0.00 0 Sink, kitchen $0.00 0 Water Softener $0.00 0 Gas (Over 4 outlets) $0.00 0 Sink, service/mop $0.00 0 OTHER $0.00 Gas Repipe $0.00 0 Spa (private) $0.00 0 VIOLATION $0.00 Gas Service $0.00 0 Spa (public) $0.00 0 PLAN CHECK $0.00 Interceptors (Grease, Oil) $0.00 0 REINSPECTION $0.00 0 Interceptors (Sand Auto ) $0.00 0 TOTAL CALCULATED FEES: $46.45 COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 M1 DECLARATiONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performanceIthe rk for which this permit is issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: _ Carrier: %r6f-klUkxi t(-r9i"' IL A--cu:-AyJ4—L1'- [�• Policy Number: (This section need not be completed if the permit is valued at one hundred dollars (S f ) or less.) ❑ I certify that in the1pene of the ork for h' h this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation lawa, and the if hould become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these Applicant Signature: / Date: a ®� WARNING: FAILURE TO SEG E WO ERS' ENBATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,0001, IN DITI T E COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am lic d under provisions of Chapter 9 (commencing with Secti 000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic. # 7 2X9 ('l Class a Contractor's Signatur:21�4/ Date: CONSTRUCTION LENDING A ENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for safe (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractors) license pursuant to the Contractors License Laws.), ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No, Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth Into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication agermil for such construction or modification from the Soulh Coast Air Quality Management District or from any other air pollution control district or agency? U Yes Ld No (Section 65850.2 of the Califomia Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any pan of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency Is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (If 'yes", attach certificate of compliance from the appropriate air pollution control officer), CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the Information given above is Correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Data: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above -describe proparly for inspe an purpos gree not to occupy or allow occupancy of any building authorized by this permit until final inspection. i Ofa Owners) 2 Date An r Authorized Applicant Date CODE 0, TYP PAA ftl 4§ CODE ItSE€GIlON 2PE IrnMaL 1616 Fixed System final Fire Prevention 206 Final Mechanical l 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final BuildinglOccupancy 244646 I N 1.,\.JMNy.�1cf CITY OF COSTik'MESA Development Services, Division of Building and Safety L CERTIFICATE OF- OCCUPANCY This certificate is issued pursuant to the requirements of the Uniform Building Code, Section 308 adopted by the City of Costa Mesa certifies that at the.time of its issuance the building structure herein below described was inspected and approved for occupancy as follows: ;. Building Address 3333 Bristol St. Ste 2810 Bldg. Permit Number R05 -0125E Use Commercial - — -- Group B Type of Construction V -N -1 P(iyeXLrdfiUse Zone South_ Coast Plaza Tenant The Naturalizer Owner of Building Address 315 Fairview Rd. . Costa Mesa CA 92626 BUILDING OFFICIAL-Klanh,Q. Nguyen, C.B.O. Ed Petros, Chief of Inspection Date ;1 REQUIRED TO BE POSTED IN A CONSPICOUS PLACE CI 'Y OF COSTA ML -)A Development Services, Division of Building and Safety CERTIFICATE OF OCCUPANCY This certificate is issued pursuant to the requirements'of the 2007 California Building Code, Section 110 adopted by the City of Costa Mesa certifies that at the time of its issuance the building structure herein below described was inspected and approved for occupancy as follows: Building Address 3333 2810.. Bristol St..: _ Bldg.. Permit Number BC1 1-0015 5 Use Commercial.. . Group M Type of Construction II—B Fire.Zone Use Zone Owner of Building South _Coast Plaza T Tenant Charles David Address 3315 Fairview.,Rd., Costa Mesa CA 42626 ,v s By BUILDING OFFICIAL -Keith Clarke, C.B.O. j Date REQUIRED TO BE POSTED IN A CONSPICUOUS PLACE �L CI_Y OF COSTA M_ -SA Development Services, Division of Building and Safety CERTIFICAT;EOF-OCCUPANCY This certificate is issued pursuant to the requirements.of the Uniform'Building Code, Section 308 adopted by the City of Costa Mesa certifies that at the time of rts tssuance.the building structure tierern below described was inspected and approved for occupancy as follows.Vl/ Building Address 1;4 2 �`� Retail- 1,468,)) Intei-j Use 3333 Brifit.0Atreet Space 2810 - Icig Per`�mit Number B00-01654 r/Ten ant-Imnr6vement1-,1: Group M Owner of Building Address jl" f1l ? ? Type of Construction•n_Z:%FR Fire Zone 6 Use Zone 56uih_Coaet Plaza ) �t s SeRrestYo�:._ Tenant i'" " - ' ` H�titralizer 3315`, Fairview jRd, Costa Mesa CA 926261!' :cif BUILDING OFFICIAL -Rick' Brown;;�C.B 0. .Date��r f February 15 , 2001 REQUIRED TO BE POSTED INA CONSPICOUS PLACE 14 - I_ CITY OF COSTA MESA, BUILDMtii WETY DIVISION ' POST IN CONSPICUOUS -PLACE ON THE JOB NOTICE Somduis ansperttan oM Workday In advance. To SCh adWC tnspaC�oras, c4tl (714) 764.58$8. Provide the t0 Wwno infarfnatlpn; 1) ParmA number. 2) Jab addraass, 3) Inspamn Item number, 4) Qay and date you need the tnapecoun. PRRMITS SXPIU 180 DAYS (S MONTHS) FROM 1"U1 OR LAST IKOP901"ON am" a« vas Zee 4 Wa B£=*0 10-LL-H3J pmt♦ t;TRUCTURAL flue bag P=A SPA � 4 FOQW 94 PW� LOcadara 8 Slab 96 Steel Reinbmnent $ Svz tral Flux 100 eactrical OW421 1 z Raaf Sh 102 Paigh Plumb 3 Pm= n Ted 14 T -Bar COEwStimoirel 104 Appmal to Cow • Gob 16 E4M Shear Parwl - 106 Else candadt uxw Nm 1S Frank 3 FWWg 106 Gas Npa4J round Teat 70 22 L S Song insulation 110 Bockwash Lines, P -Trop, Undo round V N 112 Appmvtl to Deck Y6 Plaster ftm Cost 116 Pod Plumbirg System • Final 30 Pro -Grout 116 Pao] E196*W - Final 33 diSON Accau 122 Fencing & Acom AWOYW 124 Appmval for Plastering ELECTRICAL J1 125 PowSo System - Final 31 Elac CandA. UndeMround 44 46 50 R014EIN • Wh Elec T$s Ceitn EkC Poway Final t619 1]rorhd HydidOveitad ' f p • DI 1612 Ory Chea+ical PLUMSDIG i MECNAKFAL 1611 pry an*e 52 Soil incl • Fixed System —115-01 1W 54 64 64 Wates 502e 2E23 RmO MectaanO Can f7141 7,54-M forthe followlr q: oft a "ft se - F Fnplmm 200 FvW Re.fiogf 72 Go Tee! 201 FirW SloddRetaining Wad 90 Gee tripe Tm • Find 203 Final Sp� 92 Water Servkm - Final 204 Final Demolition 206 final Machankat de ra'4901" 206 Fatal Plumb 2101 Final Electrical Cell 1027,.7400 for tM lloltowt : tn:tredor film Fmal Fin Prsusnwn -► . p1 H 0 f � Q 6�SG - 11) »I•i]If fa the foitorrin : t1m tiea.crm 2141 Final Transportation Svs, can 11 764.971 for the Dm IrNP�1gr ,1s Q R p rw 216 1 Final Engin - Approval ` Can 14) 7b/-5307 for the followf : Cw i,ue.ctor 216 Firta1CWISO &00 Cad V141 7s4.6245 for the f0nowt : oft Moaar AE CIO dko —(I!/ 2DI Final Plan ' Can (714) 756MR for the 101towlnq: DueApeft ,� 222 Final Site 250 Final sWft a vi -o -a ;,79IfW .,.� am" a« vas Zee 4 Wa B£=*0 10-LL-H3J r-r-r�rr� CITY 6F C08TA MESA BUILDING DIM" DEVELOPMENT SERVICES DEPARTMENT PERMIT 714) r -W aae • WWW 10 eom-mmoo.Ci.w g1.E0MAL PERIYIiT 3333 BR)STOL ST 2610 41250107 OE FAZIO, JOE Phone: SM3354M zv -1."' r SOUTH COAST PLAZA AdCnu 'ILC J SERGERSTOM COSTA MESA, CA Phone' 3315 FAMVIEW RO Zip: 177920 Camact r: JOE DE FAZIO ELECTRICAL CONTRACTORS INC MOW' 976 VA41TBCOMB Phan: 82573S8203 QLENVORIAI, CA zm 91741 Lrcome: 749619 PERMIT !UMBER 601-00068 y1 FUR DRIYH. COSTA MISA, CA 171420 smwl: ISSUED Applled. 0112&12001 lewd: Otrt3r100t IssUED fit:: ELECTRICAL FOR TENANT IMPR WWA' REF: S00-01894 43 LIGHT F)XTS , 28 OUTLETS, 7 UMCHES �j�EHT$1 WTIC9: Tha work a 4hW430 by 092 garnet 2t11p cwr" wl(h a0 1ppncW* hnk9eap eccaa ra0utro nv to tardlr CaofOmta stalutam and ""W Ia91Malkrr. {Ord, N0, 92-28. $1, 12.21-02) ptpI�A7": ms pep n! shat avtOma "C j V" SW 0 mm a vald 0 wok Is not cmw*xod adthln ISO day, at it ww% in alapeowed a abamdvm la a p#W of 1$0 days. =P9CT10 W IM Order for 1t1/ Wit auN mind under ft perhe m be mm* rW %so, etch work mUm tangly win a9 applleabb coda, ON M raquhad Impmcilolt0 and fMet %wFaeal mull be ahlalnvd, Failure to COMM WdPodltm and IkW approval will roso In an asptr dm of thio pians. FOR 04110RCT104 CALL: fn 4f 7544929 10'd Wcl 2Y:fQ t0-zr-maj Quantity FFE SUMMARY OYlaOty ISSUE FEE 1143.60 T2rrrp 0111 Sytwn 1 Lghap W 00 0 Tromp somm teat $0.00 Dungy /100 ft $0.00 0 Res, arc paOAape $0.00 sts" ascbam $0.00 0 Now Ras (1.2 una) $0.00 0 MU EkOhkAl EOulpmam W.00 0 Naw Res (3+untls) 80.00 0 Transtanmsrs up 10 1 kvalkrr I0.00 0 POOI ! spa $0.00 0 up to 1 a kvalkw $0.00 a Ligh9ho rbu $38.79 43 .................up to W kvalkw 50.00 0 Re" OuNts 527.84 20 .,........., -up to 1W kv2Aw $000 0 Swdd+aa $1.70 7 .......Mr 100 kvarkw S000 0 Non Rms Apel $000 0 Law va" Equip fd Woo 0 Rn Appl low 0L Www 6ya rm I Ckl Woo 0 Sam" to 2002 $000 0 Mkc Catldua Woo 0 "N" to 10001 $0.00 0 mwb Cmtduaeor Woo 0 1 mcm. 0vu 1 M 10.00 0 Ciam (own at rk%) $000 0 Moloy to Ihp 20.00 0 Carus (mach rW or lights) 110.00 0 Motor to t my $0.00 0 Chrrsbnls Tram Stand $0.00 0 um n to Uft $0.00 0 1"irrra km ewmO $CAO 0 Motais m I00hp $000 0 Otfw EWcMI Fa $000 Maar aYw 10ghp sow 0 CommuNutlon drop? W 00 0 Itnutlptttlal FEE sow Sub panel to 2002 80 W a Plln Chodl Fag 30 W Pae Lehr Pkg $000 0 ReklspecOW Fme $0.00 Sign Ckcuis Tulp! wr PW $0.00 $0.00 0 0 TOTAL CALCULATFM FRED $97.97 I .4 Pats $000 0 �j�EHT$1 WTIC9: Tha work a 4hW430 by 092 garnet 2t11p cwr" wl(h a0 1ppncW* hnk9eap eccaa ra0utro nv to tardlr CaofOmta stalutam and ""W Ia91Malkrr. {Ord, N0, 92-28. $1, 12.21-02) ptpI�A7": ms pep n! shat avtOma "C j V" SW 0 mm a vald 0 wok Is not cmw*xod adthln ISO day, at it ww% in alapeowed a abamdvm la a p#W of 1$0 days. =P9CT10 W IM Order for 1t1/ Wit auN mind under ft perhe m be mm* rW %so, etch work mUm tangly win a9 applleabb coda, ON M raquhad Impmcilolt0 and fMet %wFaeal mull be ahlalnvd, Failure to COMM WdPodltm and IkW approval will roso In an asptr dm of thio pians. FOR 04110RCT104 CALL: fn 4f 7544929 10'd Wcl 2Y:fQ t0-zr-maj CITY OF COSTA MESA ? BUILDING DIVISION e > e 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 - Fax (714) 754-4856 - www.ci.costa-mesa.ca.us r �. FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BC11-00155 PERMIT TYPE: B_COMBO STATUS: ISSUED Sub Type: COM—ALT DATE ISSUED: .0412512011 ISSUED BY: CAC JOB ADDRESS:3333-2810,BRISTOL�'ST CM'' ' Suite/Unit: 2810 APN: 41250107 Zorll9 :PDC, , Vicinity: SPACE 185 l Primary;Occ'a Const Type: II -B SQ. FT: 1473 Valuation:, $120,000.00 - SCOPE OF WORK: 1,473 SF INTERIOR TI FOR "CHARLES DAVID", SPACE 2810. WORK TO INCLUDE: REMOVAL OF NON -LOAD BEARING WALLS, CEILING, INSTALLATION OF NEW CEILING, NON -LOAD BEARING WALLS, CASHWRAP, FINISHES AT SALES AREA WITH 1 VAV BOX, 16 LIGHT FIXTS, 2 OUTLETS, 1 SWITCH: OWNER: SOUTH COAST PLAZA., Address: 3315 FAIRVIEW ROAD Unit: Phone: City/State/Zip: COSTA MESA, CA 9d6ara APPLICANT: VRANKA, STEFAN Phone: 949-683-2760 CONTRACTOR: Phone: Cell: ARCHITECT: GRAHAM DOWNES ENGINEER: COMBINATION PERMIT FEE SUMMARY Building Plan Check: Building Fees: Electrical Fees: Mechanical Fees: Plumbing Fees: SMIP Residential: SMIP Commercial: Bldg Std Admin Fund TOTAL FEES: Address: City/State/zZip: License No. Address: ' Unit:/ f City/State: - License No.C19765 License No. $179.69 $1,105.75 $44.40 $34.15 $0.00` $0.00 $25.20 $ 5.00 $1,394.19 Unit: ' 1 ZipCode PHONE:619-234-2565 PHONE: 'Refer to fee receipts for all fees paid for project HOURS FOR CONSTRUCTION ACTIVITY: EFFECTIVE 3!1812010 - PER CMMC Sec. 13-279 Monday thru Friday - 7:00 am thru 7:00 pm. Saturdays- 9:00 am thru 6:00 pm. Prohibited all hours -Sundays and the following Federal`holidays`'? New Years Day, Memorial Day,_ Independence Day, Labor Day, Thanksgiving Day and Christmas Day NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12.21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval wil] result in the expiration of this permit. CODE d. INSPECTION TYPE DATE INTITIALS CODE N INSPECTION TYPE / DATE INTMALS Lo n 1616 Fixed System Final Fire Prevention 206 Final Mechanical X `t 0-11 i3h 1266 Pool Spa Final 208 Final Plumbing T 200 Final Re -Roof 210 Final Electrical 201 Final Mock/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 1203 , Final Sign 222 Final Site /1 204 Final Demolition 250 Final Building/Occupancy f l (j`/,��16j WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: Q 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the Ze ormance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by ion 3700 of the Labor Code. for the performance of the work for which this permit i issued. My workrerrs� compensation Insurance carrier and policy E umber. ❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become s bject to the workers' compensation provisions of Section 3700 of the Labor ode, I shall f hwith comply W ese provi ' ns. ignature WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PE=NALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PIROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND A?TORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and T. is in full force and effect. L Z CI s # VAA ((20xfcrSignatutto NSTRUCTION LENDING AGENCY: El i hereby affirm that there is a construction lending agency for the Performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that 1 am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption, Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): Q I, as owner of the property. or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of safe.). E3 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.), 0 1 am exempt under sec. Business and Professions Code for this reason: Signature Dale 3457-46 (3/07) Owner ID verified by dnense. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsewerk, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec, 341, Title 8, California ='.tny, raive Code). ❑ As owner -builder, I will not ne to dowork which would require a permit from the Division of Industrial Safety, as noted above, unfess such person has a permit to do such work from the division. Applicant's Signature Date Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Pian for emergency response to release or threatened release of a hazardous material? [:]Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or v4JI the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of Compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. if a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (if "yes', attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. ie al thyme . _ Dater Andlor Au zed Appli t r---Q3te (714) 754-5273 • Fax (714) 754-4856 www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 BUILDING PERMIT Job Address: 3333 BRISTOL ST Suite: 2810 Vicinity: SPACE 2810 (NATURALIZER) Parcel Number: 41250107 Applicant: HAGLUND, STEVE Address: Owner: SOUTH COAST PLAZA Address COSTA MESA CA 3315'FAIRVIEW ROAD Zoning: PDC PDC Phone: 714-550-9997 Zip: Phone: Zip: 92626 Contractor: DE JAGER CONSTRUCTION INC Address: 75 60TH STREET SW WYOMING, MI Zip: 49548 Phone: 616-530-0060 License: 375519 Status: ISSUED Applied: 01/21/2004 Issued: 06/11/2004 ISSUED BY: Arch : JEROME M ROTHENBERG Eng: Address: JENCEN ARCHITECTURE Address: CLEVELAND, OH Phone: 216-781-0131 Phone: 2850 EUCLID AV Zip: 44115 License: 21294 License: SCOPE OF PERMIT INTERIOR 838 SF STORE TI FOR "NATURALIZER" IN SPACE 2810. WORK TO INCLUDE NEW MARBLE CLADDING AT STOREFRONT AND NEW CASH WRAP IN SALES AREA. PATCH/REPAIR; PREP, PRIME, PAINT ALL WALLS; REMOVE FLOORING AND INSTALL NEW EBONY WOOD FLOORING. Plan Check: $339.98 Permit: $523.05 SMIP Res: $0.00 SMIP Cam: $7.88 Other: $0.00 Inspection: $0.00 Total: $870.91 SETBACKS MAIN STRUCTURE Front 0-0 ACCESSORY Front 0-0 PARKING Exi_ sting: 0 FEE SUMMARY Calc Valuation: $37,500.00 Claim Valuation: $37,500.00 PLANNING & ZONING Rear 0-0 Left 0-0 Right 0-0 Rear 0-0 Left 0-0 Right 0-0 Required: 0 Proposed: 0 FA NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 2446.40 (6100) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penally of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued, I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit Is Issued. My workers' compensation Insurance carrier and policy number are: Carrier: r V'1Ctr`, r- -% Policy Number: WC ZnhZ r) (This (This section need not be completed if the permit 1s valued at one hundred dollars ($100) or less.) ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that If I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisions. Applicant Signature: Date: WARNING; FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CAVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE J$I10,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provlslons of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is In full force and affect. Lia ff , 3 -ISS19 I -ISClass Contractor's Signature: 'R Date: fo — CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more then five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors license Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID veritiod by driver's license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec, 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ................................................................................................................................................................................................................_................_. 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume o1 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ................................ ....................... .._.......................... —............................._....................... ....................................................................................................................................................... _................ _......... __............. _ 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. _ ......... ................._........................----- ... - ....... . ..... 1111......_ ._.............................. ... ....................... _................ __..................................... __ .............-............................. ........... ......... _................ -.............. ................ .._ 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No ....................... .................................................... �........... ................................-.......... ................... .............................................................................. ..............-..............._...._-..... ................... -_­-----...__................. 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of thisti plication a Pemit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution Control district or agency? N Yes �l No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ... .................. ._.......... ............................................................................................................................................................................................................... ......... _..-............... ........... ........_......... 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). .................�---..............-.................................................................................... _................ ..........._ ............. 7 [f a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ............................................................._....................... .................................................................................................................................... -----.......................................................................................................................... B (I1 yras", attach certificate of compliance from the appropriate air pollution control officer), CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. i agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signa Of Legal ner(s) Date &. rj-ay And/Or AutKcrizod Applicant Date CODE t. INSPECTION TYPE PAN INTITIAL CODE INSPECTION TYPE j AM Ibmats 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy a M Job Address: 3333 BRISTOL ST .' :.-Status: ISSUED Suite: 2810 Applied: 07/2812005 Vicinity: SPACE 2810 (NATURALIZER) Issued: 08/25/2005 Primary Occ: M Display/Sale Merchandise Type of Construction: I -FR Parcel Number: 41250107 Zoning: PDC Applicant: LARRY VANDERPLOEG Address: 30665 OLD HIGHWAY 395 Phone: 760-751-5050 ISSUED BY: Arch :` JEROME M ROTHENBERG Eng:, ESCONDIDO, CA Zip: 92026 CLEVELAND; OH Phone: 216-781-0131 "° Phone ` t 2850 EUCLID`AV a `�` 441.15 s License 21294, License SCOPE OF PERMIT: ` 'A., ' y Owner: SOUTH COAST PLAZA::* ,' SEATING, RENOVATION DISPLAY FIXTURES, REPLACEMENT OF EXISTING TRACK LIGHTING 2, . h1 Address Calc l/aluati on:# $4o ti0000 Permit: $543 Wim` - 25 ` ' Claim Valuation: ""s` $40,000.00 v SM1P>Res: z$OOfl�`�' 8MIP Com: $8.4 �V COSTA MESA CA, i Phone: _ Inspection-: $0.00� 3395 FAIRVIEW ROAD :' ': "; Zip: "PLANNING & ZONINGy SETBACKS k ,y MAIN STRUCTUREFiont 0 Oy} .-.:Rear=>'0 0 Left M00`6 f Right 0-0 ` , ` Contractor: MICHAEL �&RAIN~BUILDER"S I"NC Flight Q 0 v PARKING Existing 0 Required 0 �Pr000sed 0> , n : Address: =306651OLHIGHWAY•395 Phone: 760 -MO -5050 ' ESCONDIDO; CA Zip: 92026 License: 450395 y Arch :` JEROME M ROTHENBERG Eng:, Address: JENCEN ARCHITECTURE Address:'' CLEVELAND; OH Phone: 216-781-0131 "° Phone ` t 2850 EUCLID`AV a `�` 441.15 s License 21294, License SCOPE OF PERMIT: ` 'A., ' y INTERIOR 1468 SF�STORE TI FOR!'NATURALIZER" IN SPACE 2810. WORK TO INCLUDE UPGRADE OF INTERIOR FINISHES"REPLACFEMENT OF SEATING, RENOVATION DISPLAY FIXTURES, REPLACEMENT OF EXISTING TRACK LIGHTING !WOR h1 Plan Check $8828 Calc l/aluati on:# $4o ti0000 Permit: $543 Wim` - 25 ` ' Claim Valuation: ""s` $40,000.00 v SM1P>Res: z$OOfl�`�' 8MIP Com: $8.4 �V # 4 Other: 40:00,h::;.. Inspection-: $0.00� :Total:{ $639.93 "PLANNING & ZONINGy SETBACKS k ,y MAIN STRUCTUREFiont 0 Oy} .-.:Rear=>'0 0 Left M00`6 f Right 0-0 ` , ` ACCESSORY , , Front • 0- 0, ;4 :Ream =0 Q .Left 0 0 Flight Q 0 v PARKING Existing 0 Required 0 �Pr000sed 0> , n : NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicabl" a codes, and all requlred Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the exr6 ation of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2"6-46 (6100) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. My wo. rsT' crolm nation Insurance carrier and policy number are: �. carrier ��Z_yt �t11) Policy N�uTmba _LqZI8 - - S (This section need not be completed if the permit is valued at one hundred dollars ($100) or less.) ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person In any manner so as to become subject to the workers' compensation laws of CaliforrjJ13 and ree that 111 should become subject to the workers' compensation provisions o1 Section 3700 of the Labor Code, I shall forthwith comply with these provisio -Ap�11[canYSfgnaturta: ' - �ate:����O 3 WARNING: FAILURE TO 5 E WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLO ER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOU ARE (S ), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION aM OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am lice ns d der rovi ion of Ch ter 9 (commencing with Section 7000) of Division 3.of,the.8usln and Professions Code, and my llcense Is in full force and "elle LClass'#- Con�s Sign=afore: Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is Issued. (Sec. 3097, Civil Code), Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which raqulres a permit to construct, alter, Improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or Improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby cerlity that no excavation five (5) or more feet in depth into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thlrty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, Califom[a Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Numbor: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the Califomia Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight o1 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a reglstratlon form for acutely hazardous malarials? ❑ Yas ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .......................................................I...............I......................................-------••------......................................................................................................................................................................,................................ 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. .................. 5............................................................................................................................,...---.........................,............................................_.............................................................................................................. .......................... .. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No --........._......._—.............................w............-•-------.....__........................._.......................__................-...—................._..—.................—.................................................................................._................_................._.....-1111. 5 Does Dr will the applicant or present or future building occupant require for the work which is the subject of this a�.Pplication e$ermit for such construction or modification from the South Coast Air Quality Management District Or from any other air pollution control district or agency? u Yes No (Section 65850.2 of the California Government Code requires that the requested Information be furnished on applications for non-residential building permits). _.._........................—..--- •................._._.........................._........................ ..................... ...................... _—......................... _.... ........................................... ......................1111---111..1------........_.....-1111 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes D No (If 'yes-, the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ........................................................................................................................................................................................................................................................._...........................................................................---............................ 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ....................................... .......................................................................................... .............................................. ... .............................................................................................................. .................................................................... 8 (If yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the informadon given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for Inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Slgnat Of Legal Owner(s) ate -92 ITGLe CDpEINSPECTeITPItTfFACODE: G ( jLS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final 51ie 204 Final Demolition 250 Final Budding/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.cl.costa-mesa.ICTRICAL PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 t' ,lob Address: 3333 BRISTOL ST Status: ISSUED Suite No 2$10 Applied: 08/25/2005 Vicinity: SPACE 2810, NATURALIZER Issued: 08/25/2005 Parcel Nunmber: 41250107 Applicant: LARRY VANDERPLOEG Address: 30665 OLD HIGHWAY 395 -161 Phone: 760-lM -5050 ESCONDIDO, CA Zip 92025 Owner: SOUTH COAST PLAZA Address COSTA MESA CA Phone: Quantity 3315 FAIRVIEW ROAD Zip:. 92626 Contractor: MICHAEL STRAIN BUILDERS INC 50.00 Address:' 30665 OLD HIGHWAY 395 Res. a/c package '1�1 Busway 1100 ft Phone: 760-1W4-5050 ESCONDIDO, CA Zip: 92026 0 License: 450395 SCOPE OF PERMIT 'ELECTRICAL PERMIT FOR INTERIOR 1468 SF STORE TI FOR "NA1 REMOVE EXISTING TRACK LIGHTING AND INSTALL NEW LIGHTIh FIELD INSPECTION PER SHA. REF#: B05-01258 WORK TO INCLUDE: 10 LIGHTING FIXTS ISSUED BY:' R" IN SPACE 2810. APPROVED SUBJECT TO FEE SUMMARY Quantity ISSUE FEE $23.50 Temp service test 50.00 Temp Dist System 1 Lighting Res. a/c package $0.00 Busway 1100 ft New Res (1-2 units) $0.00 0 New Res (3+units) $0.00 0 Pool 1 Spa $0.00 0 Lighting Fixts 511.00 10 Recept Outlets $0.00 0 Switches $0.00 0 Non Res Appl $0.00 0-.,. Res Appl $0.00 0 Service to 200a $0.00 0 Service to 1000a $0.00 0 Service over 1000a $0.00 0 Motors to 1 hp $0.00 0 Motors to 10hp $0.00 0 Motors to 50hp $0.00 0 Motors to 100hp $0.00 0 Motors over 1 00h $0.00 0 Communication drops $0.00 0' Sub panel to 200a $0.00 0': Pole Light Pkg 50.00 0 Sign Circuits $0.00 0 Temp Pwr Pole $0.00 0 Intermed Pole $0.00 0 ISSUED BY:' R" IN SPACE 2810. APPROVED SUBJECT TO FEE SUMMARY Quantity. Temp Dist System 1 Lighting $0.00 0 Busway 1100 ft $0.00 0 Standing Section $0.00 0 Misc Electrical Equipment $0.00 0 Transformers up to 1 kvalkw $0.00 0 ................up to 10 kvafkw $0.00 0 .............up to 50 kva/kw $0.00 0 ................. up to 100 kva/kw $0.00 0 ..................orier.100 kvafkw $0.00 0 Low Voltage Equipment..•. • .4 .$0.00 0 Low Volt Wiring System / Ckt $0.00 0 Misc. Conduit $0.00 0 Misc. Conductor $0.00 0 Circus ( gen or ride)..,.' $0.00 0 Circus (meth ride;or lights) $0.00 0 Christmas Tree Stand S0.00- 0 Fireworks Stand. $0.00 0 Other Electrical Fee $0.00 .Investigation Fee $0.00 Plan Check Fee $0.00 Reinspecti6n Fee- $0.00 TOTAL CALCULATED FEES $34.50 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or If work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all, apIs codes, and all required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result in the 4xplration of this permit. FOR INSPECTIONS CALL: (714) 754.5626 2446.46 (6!00) DECLARATiONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a Certifloate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is Issued. -I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit Is Issued. � My workers' compensation Insurance carrier and policy number are: -Cairie'r CIT.4 z V 200 "(Th7s section n4bd not be completed If the Permit is valued at oone hundred dollars ($100) or less,) ❑ I certify that in the performance of the work for which this permit is Issued, I shall not employ any person in any manner so as to became subject to the workers' Compensation laws of Call Is. a gree that If I should become subject to the workers' Compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with thesepro Applk antSignarine: LDate-, g 5 J WARNING: FAILURE TO E WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CAL RIMINPENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ,000), IN ADDITION TO THE DOST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under p on C tar 9 (commencing with Section 7000) of Division 3 of the Busine nd Professions Code, and my license Is in full forceend efEec Lic p' D ~ t Class 0 ContrectoYs'Slgnatur --1 [Da19: CONSTRUCTION LENDING AGENCY: l/ ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is Issued. (Sec. 3097, Civil Code). Lenders Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that i am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors U ense Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professions Coda: The Contractors License Lew does not appy to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or Improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ' ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not appy to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person Is required to descend, will be made In connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, An 2, Sec. 341, Title S. California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. C Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one lime during a reported year a quantity of hazardous materials equal to or greater then a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic foot of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .................................... _.................................... —_._.�._ _........................_.............. ..... ................. ........................ _.............................................................. ._..... ............... ..... ......... ...._................ ............... _ 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No LSoction 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5 Does or will the applicant at present or future building occupant require for the work which Is the subject of this a pllcalion a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? UYes No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ........................................I—-....._................................................ _........ _................ ....._............................................ ................. _....... — ............ ..._..._.....----....- -- 8 Will any part of file facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ........ ._.. ........................................_.__._...................._....._..._................._........_.............................................. ................. •.............................................. -•----._......... —•--•• ........._ —..._ 7 If a permit from the South Coast Air Ouality Management District or other air pollution control district or agency Is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No .......................•—...............................--..._.._._................................_..._................................................................................................................................................._..............................................._.., .. f3 (It Tres', attach Certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the abova-described property for Inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. ature 01 Legal Owner(s) 2 Oe A dlOr Airitta+ized Applicant__-_` Date1 CODE f• INSPEC110N TYPE RM 01116 BODE f INSPECTION TYPE U3 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1268 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical � r 201 Final Block/Refaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Bullding/Occuponcy (714) 754-5273 • Fax (714) 754-4856 www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 BUILDING PERMIT Job Address: 3333 BRISTOL ST Suite: 2810 Vicinity: Parcel Number: 41250107 Zoning: PDC PDC Applicant: BECK, KELLEE Address: Phone: 909 592-0870 Zip: Owner: SOUTH COAST PLAZA Address $125.25 SMIP Res: COSTA MESA CA Phone: SMIP Com: 3315 FAIRVIEW ROAD Zip: 92626 Contractor: FLUORESCO SIGNS Adcfress: 2778 POMONA BLVD. Phone: 909-592-0870 POMONA,CA Zip: 91768 License: 738628 Arch : Address: Eng: Address: ISSUED BY: Status: ISSUED Applied: 06/03/2004 Issued: 06103!2004 Phone: Phone: Zip: License: License: SCOPE OF PERMIT REMOVE EXISTING STORE FRONT SIGN & REPLACE WITH NEW STORE FRONT SIGN "NATURALIZER" NON -ILLUMINATED LETTERS. MOUNTED ON RACEWAY Plan Check: $81.41 Permit: $125.25 SMIP Res: $0.00 SMIP Com: $1.26 Other: $0.00 Inspection: $0.00 Total: $207.92 SETBACKS MAIN STRUCTURE Front 0- 0 ACCESSORY Front 0-0 PARKING Existing: 0 FEE SUMMARY Calc Valuation: $6,000.00 Claim Valuation: $6,000.00 PLANNING & ZONING Rear 0-0 Left 0-0 Right 0-0 Rear 0-0 Left 0-0 Right 0-0 Required: 0 Proposed: 0 6 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21.92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or If work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with alt applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 ?446.46 (e<00) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' Compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation InsuTWce carrier and policy number are: Carrier: C�_ C _ �_ _ y Policy Number: IV _7 CJ (This section need not be completed if the It Is valued at one hundred dollars ($ f 00) or fess.) ❑ 1 certify that in the performance of the ork for which this permit Is Issued, I shall not employ any person In any manner so as to became subject to the workers' compensation taws of Califomi , an grae that if I shout ecome "act to the workers' compensation provisions of Section 3700 of the Labor Code, shall forthwith comply with these provisions. 2 Applicant Signature: Date: - J WARNING: FAILURE 70 SECURE WORKS 5' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUaIECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP 70 ONE HUNDRED THOUSAND DOLLARE f $100,000). IN ADD ONTO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am Iicensdun er provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, ae my I' ens Is I lull force and effect. Lic. # t4�� Class # ( - C I Contractors Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Dato: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to Its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Coda) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec, 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or Improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Seo. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feel in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, Califomia Administrative Cade). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the Califomia Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ........................... __.........._._...................._....................... ................................... .............................................. ...._—._......_........... .._............ .............. occupant _ 2 Does or will the applicant or present or future building opant need to file a registration form for acutely hazardous materials? Yes [INo (Section 25533 of the Califomla Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ... ................................ .... ...............................-.................................. - .T -•- ............... --..... .............. ............................................................... —_...._._-._......... ............... ._............. ... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Sectlon 25534 of the Califomia Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Impartment of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ... ._ ...�._.._.............._._........................_........................................ .................._....—..--..--- ......._ - _ .�-- 4 If an RMPP is presently required, has Section 25534 of the Califomia Health and Safety Code been fully complied with? ❑ Yes ❑ No ............ .._............ -...................... ..............._...._. _ ........ _....-...................... ............................._..................................................................... ...............................--- ----.........___._......., .._....._._ 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication apermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes L] No (Section 65850.2 of the Califomia Government Code requires that the requested information be fumished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? [I Yes [I No (11 yes", the facility must meet the requirement of Sections 25534 and 42303 of the Califomia Health and Safety Code). ---.._......._.-------............------- _.__............._..._............................... --- --- 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by Califomia Health and Safety Code Section 42303 boon made? ❑ Yes ❑ No ......................................................... ................................................................................................................................... ....................................... ....... ......... 8 (If yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF MPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I ree t mply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above dost 'b roperty for in coon purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. S[ L IOwner(s) j e A dfOr tharized Applicant Dat CODE N, W11 ECTION TYPE 2AR Jam$ CODE I INSPEgTIQN UPE 2AH INTITIA$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Fine[ Block/Rotaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy 4 r . - , (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 BUILDING PERMIT .Job Address: 3333 BRISTOL ST Suite: 2810 Vicinity: SPACE 2810 - NATURALIZER Parcel Number: 41250107 Zoning: PDC PDC + Status: ISSUED Applied: 02/01/2001 Issued: 02/01/2001 Applicant: JOHNSON, MITCH ISSUED BY: Address: 5602 E LA PALMA AVE Phone: (714)701-1330 ANAHEIM, CA ; Zip: 92807 ' Owner: SOUTH COAST PLAZA Address %C J SERGERSTOM COSTA MESA, CA Phone: \� x,3315 FAIRVIEW RD._.'_ _ Zip: 92626 Contractor: DIVERSIFIEDSIGNS AND GRAPHICS _, Address:. 5602 E LA PALMA AVE i Phone: (714) 701-1330 -ANAHEIM, CA 1 1 . ' Zip:') ' 92807 License: '737055 Arch-: �, i - Eng` Address: Address l . Phone: Phone: \\\ 1 ',Zip: License: License: I SCOPE OF PERMIT INSTALL NEW HALO LIT, CHANNEL, LETTER SIGN'FOR "NATURALIZEW (SPACE 2810). `! REF: B00-01654 f' 1 — --- - - FEE SUMMARY/ ;P'Ian Gheck: `$45.01 Calc Valuation: �� ,� $i 000'.00 Permit: $69.25 Claim Valuation: ''%' - ' '�� - _ / t Z,o loo SMIP Res: $0.00 - .,�' $ o0 SNIP Com: , ,x$0.50 �� , � vOther:V _ ' $0.00 Inspection: $0.00,,"� ���1 ��Y \`\l� �/'� �•\ � I moi. .<•- _ v J ' f a.� J�«�F� .. /% // i r. /l�� Total: $114.76-\ PLANNING-& ZONING -' SETBACKS ���X MAIN STRUCTURE Front\�0� i "R r 0-0 Left 0-0 `� Right•,,�r-0� - 1 1, -� - ; _ � _ , ' , 1 r ACCESSORY Front 0-0 Rear: 0- 0 Left 0- 0 — Right�J !0- 0 PARKING Exi. sting: 0 Re uired:-.~-0 Proposed:_ -0 NOTES: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12.21.92) EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In ordor for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration. of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446.48 (8100) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ f have and will maintain a certificate of Consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. TI have and will maintain workers' Compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. -- My workers' compenriettio_n Insurance c rner and poi number are: r Ca7rd0r_ � t4i1 _a>' !/V y POIIcy Number: 1 G Eaa /, 7 ~(This section need not ba completed i1 the pe it is valued at one hundr 'liars ($1 00) or lass.) `' f ❑ I certify that in the performance of the work for i this per s I shalt not employ any person in any manner so as to become subject to the workers' Compensation taws of California, an gr 1 should act to the workers' compensation provisions of Section 3700 of t La r Code, I shall forthwith comply with these provisions. ''Applicant Signature:— .— D"a!�'~� �`�� -WARNING:'FAILURE TO SECURE WORKER COMPENSATION GEIS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIE AND IVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE {5700,000), IN ADDI N TO THE COST PENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTE EST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS CLARATION: hereby affirm that l am licensed un r rovisions f Ater 9 (commencing with Section 7000) of Division 3 of the Business and Prof ions C nd my license is in full 41 force and effect.,Lic..N. .-- 7 L"'-Class fl Contractor's Signature: - =Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction landing agency for the performance of the work for which this permit is Issued. (Sec. 3097, Civil Code), Lender's Name: Landers Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any Violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not Intended or offered for sale. if, however, the building or Improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Set. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has e permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes' ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 1-2 .................................._............................._.....................�..................._....................__...................--_............ Does or will the applicant or present Or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 o1 the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight Of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 1111._ .. ............................ _.................................................. _.................. —................... —...................... __................ _._....................... _�.�....................... .......................... ..................... ............ 11..1---1.... -......... 3 Does or will theappplicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes 13ND Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire apartment of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department, ............_ ....................._..- -- - ----.................. __............................... _.................... .................... _........................................................................................................................... _.................... _....................... 4 If an RMPP Is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes [I No .............--.......................................................................................... _.................... _......................._................................................._............................................-•----..........._ .. 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ffrmit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes LJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ....... .............. ............................................................. ._......................................... ,................. ..........,..,............................................. --...........................,...................................-•---............................... ..................... _........................................... 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (it 'yes , the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code), ........................_...........................................-"-"."-.._ -—...................................._.--.................... .............................................. w.......................---............................................. _....................... _...................... _................ 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No .........._._..........................._-----------............._.......---..................-------...........----._..._.....--------------•--.__.................__....._..........................._...__.......---...........---.............---.................__..................---•--1111. 8 (if "yes'. attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above Is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHOR N.O NTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws c' or ' ances relating to building construction, and authorize representatives of the City of Costa Mesa to anter upon the above-described property for inspec ' pu es agr not to occupy or allow occupancy of any building authorized by this permit until final inspection. fur Of L a nor(s) Dat nd/Or o zed Appllcant ( to CODE i. 7Fixe p�l� ftQjlJb)<$ CODE 1 INSPECTION TYPE J�j�iNTITIALS 1616 ystem Final F' Prevention 206 Final Mechanical 1266 pa Final 248 Final Plumbing 200 Final Re-Root 210 Final Electrical 201 Final Block(Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building ecupancy 7 (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Suite No 2$10 Vicinity: Parcel Number: 41250107 Applicant: DON STRONG Address: MECHANICAL. PERMIT Phone: 909-623-2868 Zip: Owner: SOUTH COAST PLAZA Address: %C J SERGERSTOM COSTA MESA, CA Phone: 3315 FAIRVIEW RD Zip: 92626 Contractor: CRYSTALAIR SYSTEMS Address: 1305 E 2ND ST Arch 1 Eng : Address: Phone: 909-623-2868 POMONA,CA Zip: 91766 License: 775008 Phone: Zip: License: SCOPE OF PERMIT ALT COOLING SYSTEM FOR "NATURALIZEW STORE TI, RE:800-01654. FEE SUMMARY Status: ISSUED Applied: 01/22/2001 Issued: 01/22/2001 ISSUED BY:� Quantity Repair/ Alt Absorbtion Unit $0.00 Quantity ISSUE FEE $23.50 0 Inst FAU <100 k BTU $0.00 0 Inst FAU >100 k BTU $0.00 0 Repair 1 Alt Cooling/Heat $13.70 1 Inst 1 Rep. Recess Wall Htr $0.00 0 Refrig Sys <100 k BTU $0.00 0 Refrig Sys >100 k BTU $0.00 0 Gas Piping $0.00 0 Factory Fireplace $0.00 0 Hood wlMech Exhaust $0.00 0 VAV Box $0.00 0 Vent Fan I Single Duct $0.00 0 Appliance $0.00 0 Fire Dampers $0.00 0 Smoke Dampers $0.00 0 Inst or Relocate Appl Vent $0.00 0 Air Handlers < 10000cfm $0.00 0 Air Handlers > 10000cfm $0.00 0 Floor Furnace $0.00 0 Floor or Suspend Heater $0.00 0 FEE SUMMARY Status: ISSUED Applied: 01/22/2001 Issued: 01/22/2001 ISSUED BY:� Quantity Repair/ Alt Absorbtion Unit $0.00 0 Repair/ Alt Refrigeration Unit $0.00 0 Ventillation System $0.00 0 Evaporative Cooler $0.00 0 Commercial Incinerator $0.00 0 Domestic Incinerator $0.00 0 Compressors I Absorption Systems Up to 3 hp 1100 k BTU $0.00 0 3 To 15 hp 1500 k BTU $0.00 0 15 To 30 hp 1 1,000 k BTU $0.00 0 30 To 50 hp 11,750 k BTU $0.00 0 Over 50 hp! Over 1,750 BTU $0.00 0 Boilers Up to 3 hp $0.00 0 3 To 15 hp $0.00 0 15 to 30 hp $0.00 0 30 to 50 hp $0.00 0 Over 50 hp $0.00 0 Other Mechanical Fee Investigation Fee $0.00 Plan Check Fee $0.00 Reinspection Fee $0.00 TOTAL CALCULATED FEES $37.20 COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result In the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 , 2448-46 (8100) M DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to solf-Insuro for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain worker; compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work tot which this permit is Issued. Myw rk rs' compensation Insurance carrier and policy number are: / Carrier: ! AJI /t� A M _ Policy Number: r% 6 3176) (This sect! n need not be completed it th permit is valued at one hundred dollars ($100) or less.) ❑ I certify that in the performance of the work for which thi permit I5 issued, I shall not employ any person in any manner so as to become subject to the workers' compensation law i am a, a agree that if I Id become subject to the workers' compensation provisions of Section 3700 of the tabor Code, I shall forthwith comply with a provisions. Applicant SI turn' �` ✓ Date: WARNING FA ECURE WORKS E ATIONGE IS UNLAWFUL AND SHALL SUEUECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE J$1 00.000). IN ADDITION TO THE COST OF MPSI ATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Sectio 00) of Division 3 of the Business and Professions Code, and my license is infug force and effect. Lic. q Class fi Contractor's Signature: r— Dale:_��:?�'1, CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lenders Name: Lender's Address: Slgnature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Buslnnss and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7DD0) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation Of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than live hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not Intended or offered for safe. 11, however, the building or improvement Is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose o1 sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.a. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Tltle 6, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with same exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater then a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _..................................._.............................. ..._.......................----1_111...... ... ........... .... ....._............... ........... _ - _1111.-1111 ......... _ ... __.. 2 Daes or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes 0 No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mase Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .............._ _... .............. — ........... _ _---...__.._............._._..---••-...... ............._............... ..............— ................................................ .._........ ....................__._....._........... _—.... --- 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? . ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Castel Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. _ .................... _...................... _.........................-..................................._..............................._._................................ _._._................ ..............__....................... _..... ............................................... _............1111..._... ......... _ 1111 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No ..................................................................................................................„....................................._......................................-................................ -_.................................................................................._ ... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of thisa plication appermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? IH Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested Information be furnished on applications for non-residential building permits). ..............................................................................................................................................................--------............................................................................................. ........................................................................................ 6 WiII any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes ❑ NO (11 W. the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). --.................. ................ ...............__..._.___..................................................._.........................._ _..............._..........---- 7 It a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which Is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ..............—....................................._.. _......................... 1111__.—........................_._.--...................................................................._._..........................._......_........._......................_.....................-----------------. _................._...... 8 (It 'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to Comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given Is correct. I agree to comply with ail state taws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature Of Legal Owner(s) Date 7 And/Or Authorized Applicant Date CQOE 1I. INSPECTION TYPE CODEt INSPECTIONTYPE 2&H IIS$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 20D Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.cl.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT Job Address: 3333 BRISTOL ST Suite No 2810 Vicinity: Parcel Nunmber: 41250107 Applicant: DE FAZIO, JOE Address: Owner: SOUTH COAST PLAZA Address %C J SERGERSTOM COSTA MESA, CA 3315 FAIRVIEW RD Phone: 626-335-6203 Zip: Phone: Zip: 92626 Contractor: JOE IDE FAZIO ELECTRICAL CONTRACTORS INC Address: 876 WHITECOMB Phone: 626-335-6203 GLENDORA, CA Zip: 91741 License: 749549 Status: ISSUED Applied: 01/2312001 Issued: 01/23/2001 ISSUED BY: e4ze 16/ SCOPE OF PERMIT ELECTRICAL FOR TENANT IMPROVEMENT. "NAUTRALIZER" REF: BOO -01654.43 LIGHT FIXTS., 28 OUTLETS, 7 SWITCHES COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspectlons and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: V14)754-5626 X FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 Temp Dist System 1 Lighting $0.00 0 Temp service test $0.00 Busway /100 ft $0.00 0 Res. a/c package $0.00 Standing Section $0.00 0 New Res (1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0 New Res (3+units) $0.00 0 Transformers up to 1 kvalkw $0.00 0 Pool 1 Spa $0.00 0 ................up to 10 kvalkw $0.00 0 Lighting Fixls $38.79 43 .................up to 50 kvalkw $0.00 0 Recept Outlets 527.64 28 .................up to 100 kvalkw $0,00 0 Switches 57.70 7 ..................over 100 kvalkw $0.00 0 Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0 Res Appl 50.00 0 Low Volt Wiring System 1 Ckt $0.00 0 Service to 200a $0.00 0 Mist. Conduit $0.00 0 Service to 1000a $0.00 0 Misc. Conductor $0.00 0 Service over 1000a $0.00 0 Circus ( gen or ride) $0.00 0 Motors to 1 hp $0.00 0 Circus (mech ride or lights) KOO 0 Motors to 10hp $0.00 0 Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 0 Fireworks Stand $0.00 0 Motors to 100hp $0.00 0 Other Electrical Fee $0.00 Motors over 100hp $0.00 0 Communication drops 5000 0 investigation Fee $0.00 Sub panel to 200a $0.00 0 Plan Check Fee $0.00 Pole Light Pkg $0.00 0 Reinspection Fee $0.00 Sign Circuits $0.00 0 Temp Pwr Pole $0.00 0 TOTAL CALCULATED FEES $87.83 Intermed Pole $0.00 0 COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspectlons and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: V14)754-5626 X DECLARATIONS WORKERS' COM PENSATSON DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain workers' compensat n irfburance, as required by section 3700 of the Labor Code, for the performance of the work for whi th1J permit Is Issued. My workers' compensatlo r e car r an licy number are: Carrier: Policy Number: (This Section Head not be completed it the pe r Is valued at o hundred dollars ($itNJ) or less.) ❑ I certify that in the performance of the fo whic permit is issued, I shall not employ any parson in any manner so as to become lect to the workers' compensation laws o1 CaUfomia, and g a at ould be oma subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisions. Applicant Signature: Date: WARNING: FAILURE TO SECURE ORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PE TIES AN CIVIL NES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATIO e I hereby affirm that I am licen undo pr 'sions o or om dng with Section 7000) of Division 3 o1 the Business and Professions Code, and my license Is in fult force and effect. Lic. N Class a Contractors Signature: if Date: CONSTRUCTION LENDIN AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lenders Name: Lenders Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License tow (Chapter 8 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors license Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or Improvement Is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a conlractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or dead): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (38) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title B, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .....................................................................................................................................................:.................................................................................................................................................................................................I................ 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantify of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .............. .................................. .... ....... ...... ............ ...........................,,.,,....................................................................... .............,...,,.,....,................................................................................. ,............. ,........................,,.................... ............. 3 Does or will theappplicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? - ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Cosid Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. -•............................................................................................................................."........................................................................................................................................,...............,,...,.......................................... 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? [:]Yes ❑ No ............................................................................................................................................................................................................................................................................................................................................................................ 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication aermit for such construction or mcdificatlon from the South Coast Air Guality Management District or from any other air pollution control district or agency? U Yes f No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). _................................_................................__............................._........................................................................_-.................__............._ 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries o1 a school? ❑ Yes ❑ No (It `yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ...........................................................................................................................................................................................................................................................................................-................... .......................................... _..... ............ 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by Callfornia Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ............................................................ ................................. ...................... ............................................................................................................................ ..................................... 11.11.. ............ --................................................... 6 (If yres", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the Information given is correct. I agree to comp!y with a laws avid city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described rtY r specti n pure es. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. ' Sigrt f Legal er(s) 1 D to And/Of Authorized Applicant b Date CODE !. 1WECTION TYPE 2&U lMMAL$ CODE I INSPECTION TYPE f2dIE INTITLALf4 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 1 200 Final Re -Roof 210 Final Electrical 201 Final Block/Relaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Sile 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa- FIREaSUPRESSION PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Suite: 2810 Vicinity: NATURALIZE (STE 2810) Parcel Number: 41250107 Zoning: PDC PDC Applicant: LOONEY, SHEILA .,. Address: 5200E HUNTER AVS ANAHEIM, CA Zip: 92807 Owner AsOUTH,COAST PLAZA Address %C J SERGERSTOM COSTA MESA, CA, X3315 FAIRVIEW FAD Contractor: ' ALERT FIRE PROTECTION IN Address: 5200 E HUNTER AV Status: ISSUED Applied: 0112412001 Issued: 02/06/2001 ISSUED BY: Phone: (714)993-2822 Zip: 92807 Phone: Zip: 92626 Phone: (714) 993-2822 7 ANAHEIM, CA , Zip: 92807 ' License: 316324 �, SCOPE OF PERMIT ADD 3 NEW AUTOMATIC FIRE SPRINKLER HEADS & RELOCATE 6 EXISTING AUTOMATIC FIRE SPRINKLER HEADS & PLUG 4 EXISTING HEADS FOR "NATURALIZER" IN SPACE 2810. REF: B00-01654 i FEE SUMMARY Plan Check: $45.01 Calc Valuation: $1,957.00 Permit: $69.25 Claimed Valuation: $1,957.00/ Other: $0.00 Total:• $114.26 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92.28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration -of this permit. FOR INSPECTIONS CALL: (714) 7545626 2446.48 (8700) DECLARATiONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate Of consent to self-Insure for workers' Compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compen{�a�io�n Insura�rm carrier and policy number are: Carver: PolioY Number: o (This section need not be completed it the pe it is valued at one hundred dollars ($ f 00) or fess.) ❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person In any manner so as to become subject to the workers' compensation laws of California, and ali that If I should become subject to the workers' compensation provisions of Section 3700 o1 the Labor Code, I shall forthwith comply with these provisions. / ` Applicant Signature: &Z Date: � -_S , WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAVAL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($103,020), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 Of the Business and Professions Code, and my license is in full force and effect. 110 Class 0 Contractors signature: Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance o1 the work for which this permit is issued. (Sec. 3097, Evil Code). Lender's Name: Lenders Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered far sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title B, California Administrative Code). ❑ As ownor-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ............................................................................................................................................................................................................................................................................................................................................................................................ 2 Daes or w€ll the apps€cant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal t0 or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ...................................... ................ ................................_.._ -.. _..................._....................................................................... ...................... _............... .............................. .......................................................................................... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. _ ............................_._... ...................... _..........................— ....................._ .................... ................_ ................ -....................__.................... _................. .. 4 If an RMPP is presently required, has Section 25534 of the California Health end Safety Code been fully complied with? ❑Yes ❑ No .......... -- .........................................................................---............................................._.......................__...—.................._._....................................................................................................................................... 5 Does or w111 the applicant or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes � No (Section 65650.2 of the California Government Code requires that the requested information be furnished on applications for non-rosidential building permits). _......................._.._..------.............................................. _.....................- _ _.............................................................................._.__.............. 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 Of the Califom€a Health and Safety Code). ................... ........... .................... ----------...........................................................--................_....................._•-....----............-_.......... .........__._.................................. ................................................. 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by Calilom€a Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ..... .............................---......------........................................................................................................................................................................................................................................ 6 (If j�es", attach certificate Of compth liance from e appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION.OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Si tura 01 at Owner(s) V Date And/Or Authorized Applight Date C/ CODE N. 1NSPECTIONTYPE un, 1NTITJ_ALS 0001i INSPEOTIONTYPE Qgj jNTMAj� 1616 Fixed System Final Fire Prevention ' 1 j _V_44-) 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical t� 201 Final Block/Retaining Wall 212 Final Fire Prevention Gl—i LJ' 21 I 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.usNG PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Suite: 2810 Vicinity: SPACE 2810 Parcel Number: 41250107 Zoning: PDC PDC Applicant: MYSLICKI, JOE Address: 10505 CORPORATE DR Contractor: WISCONSIN LAKEVIEW CONSTRUCTION INC STE 200 Phone: 262-857-3336 SMIP Res: PLEASANT PRAIRIE, WI Zip: 53158 Owner: SOUTH COAST PLAZA Address %C J SERGERSTOM COSTA MESA, CA Phone: 3315 FAIRVIEW RD Zip: 92626 Contractor: WISCONSIN LAKEVIEW CONSTRUCTION INC Address: 10505 CORPORATE DR SMIP Res: STE 200 Phone: 262-857-3335 PLEASANT PRAIRIE, WI Other: Zip: 53158 License: 671201 Arch : JENCEN Address: 2850 EUCLID AVE Eng: Address: ISSUED BY: Status: ISSUED Applied: 10113/2000 Issued: 1 212 212 000 Phone: (216)781-0131 Phone: CLEVELAND, OH Zip: 44115 License: License: SCOPE OF PERMIT 1468 SO FT INTERIOR STORE T.I. FOR "NATURALIZER" (SPACE 2810). Total: $508.41 PLANNING & ZONING SETBACKS MAIN STRUCTURE Front 0-0 Rear 0-0 Left 0-0 Right 0-0 ACCESSORY Front 0-0 Rear 0-0 Left 0-0 Right 0-0 PARKING Existing: 0 Required: 0 Proposed: 0 NOTES: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work Is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 2"6.46 (6=) FEE SUMMARY Plan Check: $70.22 Calc Valuation: $28,750.00 Permit: $432.15 Claim Valuation: $28,750.00 SMIP Res: $0.00 SMIP Corn: $6.04 Other: $0.00 Inspection: $0.00 Total: $508.41 PLANNING & ZONING SETBACKS MAIN STRUCTURE Front 0-0 Rear 0-0 Left 0-0 Right 0-0 ACCESSORY Front 0-0 Rear 0-0 Left 0-0 Right 0-0 PARKING Existing: 0 Required: 0 Proposed: 0 NOTES: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work Is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 2"6.46 (6=) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of pelury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insuro for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. lLl I have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit Is Issued. ! \ My workers' compensation Insurance carrier and policy number are: Carrier: Policy Number: {This section need not be completed if the permit is valued at one hundred dollars ($100) or less.) ❑ I certity that in the performance of the work for ich this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisions. Applicant Signature:Date: ��--- oo WARNING: FAILURE TO SECURE WORKER COMPNS TION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FIFES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the BusinessProfessions Code, and my license is in full force and effect. Lic. # Class # _ Contractor's Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is Issued. (Sec. 3097, Civil Code). Lenders Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit to file a signed statement that he qr she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) (Jr that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.), ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. _ Business and Professions Code for this reason: Signature: Date: Owner iD verified by driver's license. ❑ Yes ❑ No Driver's license No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ ; 1 hereby certify that no excavation five (5) or more feet in depth Into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building Structure, scaffolding, falsawork, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, Catifomla Administrative Code). ❑ . As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signalure: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous -material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ................................................... .... ..............................................................__._............................... .............................._........................ .._....................................................... ....................�................_.............................. ............ 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes 0 No (Section 25533 of the Califorrlie Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater then a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ................. _............. .. ­­._............................................... ... _.............................................. _............................. ....... ................... ...... ..........................._..__.._.... ................................... ............................ .......... ........_........................... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. _..—.,.........................................................................................................................__...................._..__..............................._................_._.................... __..... .............. __................_................. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No .....................................................................................................................................................................................................................................................................................................................................I................. 5 Does or will the applicant or present or future building occupant require for the work which is the subject of thisa plication agarmil for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? 6 Yes LJ No (Section 65650.2 of the California Govemmeni Coda requires that the requested information be furnished on applications for non-residential building permits). .........................................................'b'a..................''t,'a.............. r il...............- -- ----•- ........................f'e.............................................. n'd'................................................................................................................................................... 6 WIII any part of the facility to be constructed under [his permit be within 1000 feet from the outer boundaries of a school? ❑Yes ❑ No (11 'yes". the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ............................r'm.'-'f................................................................................................ n't---..................................a-i'r...................,,'c" n1'-o"I--.....'l-c"t........................................lio'.....f'o-i................................................................................... 7 I If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which Is the subject of This application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No .................................................................................................................................................................................... ................................................................... 8 (If 'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Dale: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the Information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. e f egplOvener(s) D to !2 --7f -no An Or uthorized Applicant Date CODE 1. INSPECTION TYPE Q ifs$ CODE i INSPECTION TYPE i? RMALli 1616 Fixed System Final Fire prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy Job Address: 3333 BRISTOL ST Suite: 2225 Vicinity: STE 2225 CHLOE Status: ISSUED Applied: 10/14/2005 Issued: 11114!20 a Parcel Nunmber: 41250107 Zoning: PDC..PDC. - ISSUED BY. / Applicant: LOONEY, SHEILA,/"' Address: 5200 E HUNTER-AV Phone: 714-993-2822 ANAHEIM; CA"1 `� :Zip_ 92807 Owner. SO0TH.COAST P1 4ZAA`. Address ��.,•' '��r�/�C%�'��� :�� .���� -COSTA MESA CA j r' Phone: r 3315 FAIRVIEW ROAD Zip: 92626 Contractor:` ALERT FIRE PROTECTION INC Address: 5200 E'HUNTER AV !Phone: 714-993-2822 , ANAHEIM, CA Zip: 92807 • ; - ,',License: 316324 -SCOPE OF PERMIT RELOCATION OF 20 EXISTING SPRINKLER HEADS AND ADDITION OF 5 -NEW HEADS AND PLUG OFF 4 EXISTING HEADS IN CONJUNCTION WITH THE INTERIOR 2445 SF STORE TI'FOR "CHLOE', IN 'SUITIf 2225. WORK TO INCLUDE NEW ARCHITURAL FINISHES, LIGHTING, FIXTURES, AND SUSPENDED CEILING REF: B06-01655 - r r;F '.I ;, ,. , , ter,; • .- FEE SUMMARY Plan Check: $72.31 Calc Valuation: $5,000.00 Permit: $111.25 Claimed Valuation: $5,000.00 '-Other: , $0.00 Total: $183.56 11-1-705 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, g 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void -it work is not commenced within 160 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for, the work authorized under this permit to -be considered legal, such work must comply with all applicable codes, and at] required. Inspections and flnaCapproval must be obtained. Failure to obtain Inspections and.finai approval'will'result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5628. - - 2"846 (SM) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificalq of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Cade, for the performance of the work fol which this permit is issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit a issued. My workers' p atlon surance rner and policy number are: / r/ Ca 7.PoRcy Number. /�� (This section need not be completed if the permit Is valued at one hundred dollars ($100) or less.) ❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers'' compensation laws of CaliforniaAarla that should be me subject to the workers' compensation provisions of Section 3700 of the Labor Code, i shall forthwith comply with these provisions. Applicant Signature:'t�A tItI ;,F LtjRE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAW L AND SHALL SUBJECT AN EIaiPCOYER 70 CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am ticensed de o 0 f hapter 9 (commencing with Section 7000) of Division 3,of-the. Business Prof s;€ons Code, and my license Is in full V V L_/ forceandeffecl�Lic'p�r•.. Class.4_ '� C,Contract�gnature: T Dater r CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, C€vii Code). Lender's Name: Lenders Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty Of POdUry that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, sitar, improve, demolish, or repair any structure, prior to Its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Cede: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his Or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement Is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, Ea. - property tax bill Or deod): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet In depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, talsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Tittle 6, Cafifomia Administrative Code). ❑ As owner-buildor, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? Q Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, Or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ...................................................... ............................................................................................................................-...................................................................... .........._............................ -.._.................. __.......... 2 Does or w ii the appl€Cant or present or future building occupant need to file a registration farm for acutely hazardous materials? ❑ 1 as ❑ No (Section 25533 Ot the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has On hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic foot of compressed gas at standard temperature and pressure). ..........._ ..---....._........._...... ,_..........................................._-.............. ----................ ---............. ................................................ ......................... .........._.... _ ..- ........................... ...... 3 Does or will the applicant Or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ............................................._.....................t"o,'r..............all,.................f"o....................................._............Ii*e' ........................ ....................................._.................................. 4 It an RMPP is presently required, has Section 25534 of the California Wealth and Safety Code been lolly complied with? ❑Yes ❑ No _ .. ..................... .........-----._._...... ,........................... "-o"",******* ._..................__..................__.......................__...........................-............................................................_.......,...........-......................................-............... 5 Does or will the applicant or prasent or future building occupant require for the work which is the subject of this a plication aggermit for such construction or modification from the South Coast Air duality Management District or from any other air pollution Control district or agency? LJ Yes [No (Section 65650.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). .......... ............................................ ....----- -----.................__.....................__._...............................—_................__.._....... fi W€LI any part of the tacit€ty to be constructed under this permit be within 1000 feet from the outer boundaries of a school? Q Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). -._...._....................._.........-, ....................... _.__....................... .._....................... —.................... _-........................ ............_............------ .—-•--.......... __..._..................... .................... ....... _ ........... 7 If a permit from the South Coast Air Quatjty Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosurgs prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No .......... s"......................tIfj...........................................'ro, ........a a.....................ai'r.p6,11u4i'o"n........................."er'............................................................................................................................................. ...................................... 8 (I1 'yes", flttech certificate Of tempi€ante from the appropriate air pollulLon centro! officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct, I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Data: CERTIFICATE OF COMPLIANCE AND AUMORIZATLON OF ENTRY: f certify under penalty of perjury that I have read this applica0on and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. AndlOr'Authorized pplicant �- CODE it, )N$pECTION TYP-CODEINSPECTION TYPE 2AU mn & 1616 Fixed System Final Fire Prevention 208 Final Mechanical 1266 Pool Spa Final 206 Final Plumbing 200 Final Re-Roof 210 I Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 1147-0S 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy _ __ (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa. BUILDING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Suite: 2225 Vicinity: Primary Occ: M DisplaylSale Merchandise Type of Construction: I -FR Parcel Number: 41250107 Zoning: PDC Applicant: DUSTY WATSON Address: ,Phone: • 714-662-7933 Zip. ISSUED BY: Status: ISSUED Applied: 07/13/2005 Issued: 07/26/2005 Owner: SOUTH COAST PLAZA Address ;> 'Phone: 818-704-6292 COSTA MESA CA Phone: F' WOODLAND HILLS, CA 3315 FAIRVIEW ROAD Zip: Zip: 91364 License: C12736 .:92626 Contractor: WATSON CONSTRUCTION INC. '. Addre`ss:, 1260 LOGAN AVE, .�; UNIT 6002 Phone: (714) 662-7933 COSTA MESA, CA Plan Check: } $1#63.31 Zip: 92626 License: 705797 ISSUED BY: Status: ISSUED Applied: 07/13/2005 Issued: 07/26/2005 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § i, 12-21-92) EXPIRATION: This permit shall automatically expire and become vold if work Is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codas, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 cwrvro yawl Arch JOHN FABROCINI­ • # Eng; Address: 21319 PROVIDENCIA ST Address: 'Phone: 818-704-6292 _ Phone: - WOODLAND HILLS, CA Zip: 91364 License: C12736 License: 4 SCOPE OF PERMIT,...: '. NON-STRUCTURAL`; INTERIOR DEIAOLITION-bF`SPACE 2225, FOR "CHLOE", { :;•.y. FEE SUMMARY Plan Check: } $1#63.31 Calc Valuation_ $15,000#.00 Permit: $251.25 •Claim Valuation: . +¢ $15,000.00 'SMTP Res:'- $0:00 SMIP Com: $3.15 Other: $0.00 - lnspection: $0:00 Total: $417.'71" r'PLANNING:&ZONING SETBACKS MAIN STRUCTURE NFront 0-,0' ,` ;, - Rear,' 0 0 ;Left � ',:0 0 Right 0- 0 `' ACCESSORY Front. 0- 0 Rear; .0-0 y Left 0- .0- Right 07.0 N PARKING Existing: 0� Required: .0 w Proposed: r 0 NOTES: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § i, 12-21-92) EXPIRATION: This permit shall automatically expire and become vold if work Is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codas, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 cwrvro yawl DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. !Lj9* 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. My workers' compensate Insurance carrier and policy number are: 1 r ,Ca�iiar- otcy'Nurnbert?�1� �Z"E� ). fFhlsaedfon need not be completed i/ the permit is valued at one hundred dollars ($100) or less.) ❑ 1 certify that in the p "mance of the work for whi this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws f alifomia, and agree that if a outd become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shalt forthwith comply with these p cions. Appfltan - _ IgnaFure: NIatm e ° r NG: FAILURE TO SECURE WORKERS' PENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN Ail RTO CRIMii�fAL PENALTIES AND CIVIL F1NE5 UP TO ONE HUNDRED THOUSAND DOLL.ARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3.of•tMe.Business and Professions Code, and my license is in full e,and effect. Lic. Nlass q Contt$[xo�s°Signature:-NOR A 1� 1W. 9 ~lCONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ i, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-buitdor will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractors) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type o1 document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feat in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the Califomia Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ............................................................................................................................................................................................................................................................................................................................................................. 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the Califomia Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ............................................................................................................................................................................................................................................................................................................................................................................ 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ iJo (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ................................................................................................................................................................................................................................................................................................................I.,............................ 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? [3 Yes No ..... ....................................................................................................................................................................................................................................................................................................................................................................... S Does or will the applicant or present or future building occupant require for the work which is the subject of thisa plication agermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Byes LJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). .................._..................................................................................................................................--.......................................------------------------...........................-............... ......... ..................--------.---......---........................................ 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ........................................... ................................................................... ..----................................... .................................................................. .................................... ............................--................................ 7 It a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes j] No ................................................................................................................................................................................................................................................................................................................................................... attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Dale: CE FICATE OF COMPLI CE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is ,or I agree to plyff ll state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the abo - ascribed pro e fpection purposes. i agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. ignature Of Legal Owner(s) Date r — �And/or Authorized Applicarite aW;. CODE P. INSPEOON TYPE 1 IN CODER INSPECTION TYPE t) � IHTmALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy 2 Job Address: 3333 BRISTOL ST Status: ISSUED Suite: 2225 Applied: 09/20/2005 Vicinity: SUITE 2225 CHLOE Issued: 11114/2005 Primary Occ: M Display/Sale Merchandise Type of Construction: I -FR Parcel Number: 41250107 Zoning: PDC Applicant: IMSRIALE, PAT 1 Address: 22600-A LAMBERT ST SUITE 705 - Phone: - 949-465-9900 ISSUED BY: LAKE FOREST, CA Zip: 92630 =` Owner: SOUTH COAST PLAZA` ^ Address COSTA MESA CA ,'�. - 1 Phone: 3315 FAIRVIEW ROAD' Zip:1'«92626;- Contractor- 26; Contractor — 'BUSCH CORPORATION -DBA RF DEVELOPMENT Address: 22600-A LAMBERT ST .. STE 705, s Phone: 949-465-9900 LAKE FOREST, CA Zip:.' 92630 License: 804959 �x Arch JOHN FABROCINI t Eng: ` Address: . ,21319 PROVIDENCIA ST Address: Phone: ;'818-704-6292^ Phone: 'WOODLAND HILLS,.CA Zip: _ 91364 License ' C1273fi i License: SCOPE OF PERMIT INTERIOR 2445 SF STORE TI FOR "CHLOE" IN SUITE 2225. WORK TO INCLUDE NEW ARCHITURAL FINISHES, LIGHTING, FIXTURES, AND SUSPENDED CEILING., _ REF: B05-01171 r ; s ,- 1=" n" -7 z r FEE SUMMARY Plan Check: $645.94 :�' Calc Valuation: $100,000.00 Permit: $993.75 s. '; Claim Valuation: $100,000.00 SMIP Res: $0.00 SMIP Com: $21.00 Other: $0.00 �y Inspection: $0.00 Total: $1,660.69 PLANNING & ZONING SETBACKS '' ; ; _ - : ' . �', ,:, :- .;• � �, .> � '� MAIN STRUCTURE Front 0- 0 �'� Rear 0- 0 ' Left . 0- 0 Right %i 0= 0 ACCESSORY Front 0-'0, Rear. 0-0, Left M r, 0-' 0 PARKING Existin �0 Required: 0 • Pr000 ed: --0 NOTICE: The -work authorized by this permh.shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No.'92-28, § 1, 12-21-92) EXPIRATION: This permit shall �automatically expire and become.void,if workis not commenced withln'180 days, or if work is suspended or abandoned for a period of 180 days. I l ,INSPECTIONS: In order for :the workauthorized, under this parmit.to be considered•iegal;'such work must comply with all applicable.codes and a[I required. Inspections and.final approval -must.be obtained. Failure to obtain inspections'and final approval will result in.the explratlon o .this permit. FOA.iNSPECTIONS CALL: (714) 754-5626 /! 2446.48 (OW) DECLARATIONS WORKERS' COMPENSATION DECLARATION. I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to sell -insure for workers' compensation, as provided for by section 3700 of the Labor Code, for, the performance of the work for which this permit is issued. �= !`have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. �Ivly workers' c mpenAW Ion Ins lance carrier and policy number are: -L'afrie�r Policy INuniber`0 � OIC „ 4ThL9,section need not be completed i1 the permit is valued at one hundred dollars ($100) or less.) ❑ 1 certify that in the performance of the work for which this permit is issued, I shall not omploy'any person in any manner so as.to become subject'to the workers' compensation laws of Califomia, aAd agree that i I should become subject to the workers' compensation provisions of Section 3700 of the Labor Coda, I shall forthwith comply with these PI -19-111 o s. `Applicant-Slgnature:-- Date:`s i — ~ p WARNING:'FAILURE TO 68CURE.WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER 'TO -CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. INTSREST, AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am tic ns dand r rovl ns of Chapter 9 (commencing with Section 7000) of Division.3.al.the.Busin and Professions Code, and my license is in full 14 04� force ariif effect. Lfc. Class N �• CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lenders Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty o1 perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alley, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSER CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: ^ Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type o1 document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Data: Division of Industrial Safety Permit Number! HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the Califomia Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume o1 55 gallons, or top cubic feet of compressed gas at standard temperature and pressure). .................... ---..._...W_.................__..._.....—_..............._...—.............._.............................,................................................................................................ ....._........................ _ _.................... 2 Dges or will thea applicant or resent or future building occupant need to file a registration form for acutelyhazardous materials? Yee PP P 9 P Id. ❑ ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ---� ..._ - _.............—........_......-...................... _._................................................. .................................................... ...... _.... ---._........ ---- 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, Cariification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safely Code been tuUy complied with? ❑Yes C] No ........................................................................................._._................ ...................................................................................................................................................................................................... ............................ _...... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of thls application aPPermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes LJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residehtial building permits). a_.................................................._..........................................................m-*'I.................in,............1,e.....................................................ria,.............................................................................................................................. ......... 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes ❑ No (If 'pas", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). .... .........................................- - - ---11-1.1 --..._.......................---•-------------................................................................................................................................................................................... --- .. ........................__— .. 7 It a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ NO ----•------------_.._.................__.....—.._....................-•-•----�---_............................................................................................ ---------.......... ....................... —.............. ......... _........... 8 (If 'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certity that under penalty of perjury the information given above is correct. 1 agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. l agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. rat a Of egal O mer Data —Arl:irDr AMIkFbAz&cIApp{icar}t r ewe_ CODE 0. • INSPECTION TYPE j GALE IiTITIAL$ GODS 1, INSPECTION TYPE 2&3 JKrMAL,t 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof '210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place r i ' 220 Final Planning Approval , 203 Final Sign 222 Final Site ?Oa Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4656 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 82626 .lob Address: 3333 BRISTOL ST Suite No 2225 Vicinity: 2225 Parcel Number: 41250107 Applicant: DAWN DONE Address: 2144 S WRIGHT ST SANTA ANA, CA - MECHANICAL PERMIT Phone:- 714-436.1652 Zip: 92705 Status: ISSUED Applied: 1111412005 Issued: 11/14/2005 ISSUED BY Owner: SOUTH COAST PLAZA Address: ; y' COSTA MESA CA Phone: 3315 FAIRVIE�W ROAD Zip: 92626 Contractor: ALLIANCE HEATING AND AIR CONDITIONING INC. Address: 2144 S WRIGHT ST f Phone: 714-436-1652 SANTA ANA, CA Zip: 92705 License: 840838 SCOPE OF PERMIT.,- ERMIT.-SUITE SUITE2225 CHLOE REF B05-01655. 3 VAV BOXES 1 VENT FAN AND 1 SMOKE DAMPER. - FEE SUMMARY Quantity. „ Quantity ISSUE FEE $23.50 : Repair 1 Alt Absorbi n Unit $0.00 0 Inst FAU <100 k BTU $0.00 : 0 Aepair'1•Alt Refrigeration Unit $0.00 0 Inst FAU > 100 k BTU S0.00 0 Ventillat'son System $0.00 0 Repair/Alt Cooling/Heat $0.00 0 Evaporative Cooler $0.00 0 , Inst / Rep. Recess Wall Htr $0.00 0: Commercial Incinerator $0.00 0 Ref rig Sys <100 k BTU- ' $0.00 ._0:-:_ - Domestic Incinerator;..;' s- $0.00 0.., f Ref rig Sys >100 k BTU $0.00. 0-' - Compressors'1 Absorption Systems Gas Piping $0.00 0 Up to 3 hp/100k BTU $0.00 0 Factory Fireplace $0.00 0 3 To 15 hp 1500 k BTU $0.00 0 Hood w/Meeh Exhaust $0.00 0 15 To 30 hp 1 1,000 k BTU $0.00 0 VAV Box $31.95 3 30 To 50 hp 11,750 k BTU $0.00 0 Vent Fan/ Single Duct $7,25 1 Over 50 hp / Over 1,750 BTU $0.00 ❑ Appliance $0.00 0 Boilers Fire Dampers , ` $0.00 0 Up to 3 hp $0.00 0 Smoke Dampers $7.25 1 3 To 15 hp",` . ; ; $0.00 0 Inst or Relocate A I Vent $0.00, 0 %' PP 15 to 30 h p` $0.00 0 Air Handlers < 10000cfm $0.00 0 i 30 to 50 hp _ $0.00 0 Air Handlers > 10000cfm $0.00 0. - Over 50 hp t ; ` $0.00 0 Floor Furnace $0.00 0 Other Mechanical Floor or Suspend Healer. $0.00 0 . `' . Investigation,Fee $0.00 Plan Check Fee $0.00 _ Reinspection Fee $0.00 .TOTAL:CALCULATED.FEES $69.95 COMMENTS ! SPECIAL CONDITIONS - NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-26, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or If work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 c.awo jnruu7 DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. ❑ 1 have and wlll malmtaln workers' compensation Insurance, as required by section 3700 of Labor Code, for the performance of the work for which this permit is Issued. My workers' cvmpgnsation Ifpsurance carrier and policy number are: _ Carrier. �I, CL Policy Number: 5 (This section need not be complered if the permit is valued at one hundred dollars ($100) or less.) ❑ I certify that in the performance of the work for which this permit Is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation Iowa of Calilomla, and agree that if I should become subject to the workers' compensation provisions of Section 3 00 of the Labor Code, I shall forthwith comply with these p Applicant Signature: Date: WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE 1S UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($10(),000), IN ADDITION TO THE COST OF OOMPENSA ncN, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licons d under provisions of Chapter 9 (commencing with Section 7 ) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Llc. N 3 `15! Class N Contractor's Signature: — / Dese: _ Il_ 7I1 - CONSTRUCTION LENIIING AGENCY: ❑ I hereby affirm that there is a construction fending agency for the performance of the work for which this permit is Issued. (Sec. 3097, Civil Code). Lenders Name: Lenders Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that undor penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requlres a permit to construct, altar, Improve, demolish, or repair any structure, prior to Its Issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the aiiegad exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sac. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her awn employees, provided that such improvements are not intended or offered for sale. It, however, the building or Improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). - [3 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Coda: The contractors License Law does not apply t0 an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Data: Owner ID verified by driver's license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, l.a. - property tax big or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth Into which a person is required to descend, will be made In connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirtysix (36) feet high, (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant Or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 Of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous matoriats equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of SW pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No {Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ..........................i y' r' q'u*...................................................................California full...._.....pile_-. lth,....'........................................._..........,._r_.-_................................. a If an RMPP is presently required, has Section 25534 01 the California Health and Safety Coda been fully complied with? ❑Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a ermit tot such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? [I Yes LJ No (Section 65850.2 of the California Government Code requires that the requested information be fumishad on applications for non-residential building permits). 6 Will any part of the fatality to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes 0 No (If yes-, the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). _ .----- - —._ ................... ----•---_......... ...._._...._. 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safaty Code Section 42303 been made? ❑ Yes ❑ No _ B _.1 --.............. .... _.._._............. ...................... —.......... _.--... ........... ...... __.... __...... es,acertficate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to Comply with a)) state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the Information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. SI f Legal Owner 5L—.— Date And/Or Authorize �T �lDate CODE # INSPECTION TYP 2M IfflITIALS CODE INSPECTION TYPE QAIE 1616 Fixed System Final Fire Prevention 206 Final Mechanical U-19 -0S 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final BlocklRgtaining Wall 212 Final Fire Prevention 202 Final Factory l ire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 2134 Final Demolition 250 Final Building/Occupancy r P (714) 754-5273 • Fax (714) 754-4856 • www.cl.costa-mesa.ca.usNG PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Suite No 2225 Vicinity: Parcel Nunmber: 41250107 Applicant: DARRYL JOHNSON Address: Phone: 714-799-1907 Zip: Status: ISSUED Applied: 11/14/2005 Issued: 11/14/2005 ISSUED BY: Owner: SOUTH COAST PLAZA , ... . FEE SUMMARY. Address -COSTA MESA CA -1. Phone: AMT 3315 FAIRVIEW ROAD Zip: 92626 Contractor: JOHNSON'S DISCOUNT PLUMBING $23.50 Address: ' 12262 GEORGIAN ST 0 Sump Pump $0.00 0 Phone: (714)799-1907 0; GARDEN GROVE, CA Zip: .92814 Swimming Pool $0.00 License: 724339 SCOPE OF PERMIT INSTALL 1 KITCHEN SINK FOR "CHLOE" STORE TI, RE:805-01655. TOTAL CALCULATED FEES: $33.30 COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work Is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 2448-48 (OM) , ... . FEE SUMMARY. AMT QTY AMT QTY AMT QTY ISSUE FEE $23.50 Laundry Tub !Washer. $0-00' 0 Sump Pump $0.00 0 Backflow irrigation $0.00 0; Landscape Irrigation $0.00 0 Swimming Pool $0.00 0 Backflow Prevente`r $0.00 0 P -Trap $0.00 0 a Trap Primer $0.00 0 Bathtub WOO 0 Pressure Regulator $0.00 0. Urinal $0.00 0 Clarifier System $0.000.:.: ` Process, Piping (per 10 ft) $0.00, 0 Vacuum Brkr Bkflow(1-4) 50.00 0 Connect (1ce,Soda,etc) $0.00 , ", > • 0 . Receptors .- $0+0d"- '.0 Vacuum Brkr Bkflow(5+) $0.00 0 Dental Units $0.00, 0 Septic Tank $0.00 0 Wash Basin . $0.00 ; 0 Dishwasher $0.00 0 .t Sewer Cap for Demo $0.00 0 Wash Basin Set' $0.00 ' . 0 Drain, Floor $0.00 0 Sewer Connect $0.00> 0 Waste and Vent System $0.00, 0 Drain, Rainwater $0.00 0. Sewer Private Line $0.00. . 0 Water Closet (Toilet) $0.00 0 Drain, Roof $0.00 0 Shower $0.00 0 Water Heater! vent $0.00 0 Drinking Fountain $0.00 0 Sink, bar $0.00 0 Water Piping (Inst or Rep.) $0.00 0 Expansion Tank $0.00 0 Sink, commercial $0.00 0 Water Re -pipe $0.00 0 Gas Earthquake Valve $0.00,. 0 Sink, Floor $0.00. 0 Water Service $0.00 0 Gas (1-4 outlets) $0.00 0 Sink, kitchen $9.80 1 Water Softener 50.00 0 Gas (Over 4 outlets) $0.00 0 'Sink. servicelmop $0,00 "0. OTHER $0.00 Gas Repipe $0.00 0 Spa (private) $0.00 0 VIOLATION $0.00 Gas Service $0.00 0 Spa (public) $0.00 0 PLAN CHECK $0.00 interceptors (Grease, Oil) $0,00' 0 REINSPECTION $0.00 0 Interceptors (Sand Auto) $0.00 0 TOTAL CALCULATED FEES: $33.30 COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work Is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 2448-48 (OM) �i R-2 DECLARATIOMS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declaratlons: ❑ 1 have and will maintain a cortificate of consent to self -Insure for workers' compensation; as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is Issued. ❑ I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit Is Issued. My workers' compensation Insurance carrier and policy number are: Carrier: Policy Number: (This sectfon need not be completed If the permit As valued of one hundred dollars (S f } or less.} I certify that In the performance of the work for which this permit Is Issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Califoml pd agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these pr i Applicant Signature: Date: WARNING: FAILURE TO:;E WORKERS' OOMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND C'.IVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECnON 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is In full force and effect. Llc. N % 7 %,! Class N Contractors Slgnature: Date: CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty o1 perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031,5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more then five hundred dollars ❑ I, as owner of the property, or my employees with wages as their solo compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not Intended or offered for sale. If, however, the building or improvement Is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ' ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sac. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ Na Driver's License No. Expires; Verification o1 Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby cert•:fy that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feel high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, 1 will not employ anyone to do work which would require a permit from the Division of Industrial Salety, as noted above, unless such person has e permit to do such work from the division. Signature: Data: Division of industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Masa Fire Department by every business which has at any one tlma during a reported year a quantity of Hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure), 2 Does or will the applicant or present or future building occupant need to file a reglstretlon form for acutely hazardous materials? ❑ Yes [J No (Section 25533 o1 the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). . .......... _............................................................................................................................................................................................................................................................................................................................................. 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costs Mesa Fire Department may require the preparation, certification and filing with the Fire Deparlment of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required, has Section 25534 of the Califomia Health and Safety Code been fully complied wHh? ❑ Yas ❑ No _. _._D.... .......................................... __ _ v..... .._ ....... ----............................................. __.......... I ................. ............. 5 oes or will the applicant or present or future building occupant require for the work which is the subject of this a plication armit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? )U Yes ippaNo (Section 65850.2 of the Califomia Govemment Coda requires that the requested information be furnished on applications for non-residential building permits). _.__ _...... ..— ............................ ---- –_........—........................—_.................................... - _. � ..... — . _................ 6 Will any part of the faGliiy to be constructed under this permit be wi[Hln 1000 feet from the outer boundaries of a school? ❑Yes ❑ No (if yes', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control dislrlct or agency is required for the work which Is the subject of this application, have all of the disclosures proscribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No --- - - - . _._....................................._ .......................-... _— _............. ---..................... ......................._..._...._...--- --._—............. ............................................ 8 (If yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and dry ordlnanoea regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the Information given is correct. I agree to compty with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature 01 Legal Owner(s) Date AndlOr Authorized Applicant Date 000E E. INSAECMN TYPE RAI INT ITA.$ t:ODE I . INSPECTION TYPE �6I,E , , INITM 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final BlocklRetaining Wall 212 Final Flre Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition '250 Final BuildinglOccupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa ftftTRICAL PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Suite No 2225 Vicinity: 2225 Parcel Nunmber: 41250107 Applicant: ORUNA,'ROLAN D Address: 15166 VIA MARAVILLA Status: ISSUED Appiied: 11/14/2005 Issued: 1111412005 ISSUED BY: l &K= _ Phone. 909- 597-5760 . NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California sand related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit,shall automatically:expire and. become. void if work Isnot commenced' within- 1 80days,.or, if.work .is suspended or abandoned for a period of 180 days. INSPECTIONS: In. ardor -for •the,work: authorized, under- this: permit, tot be considered legal; such.work:must:comply with all applicable codes, and all required Inspections, and:final: approval: must be. obtained: Failure to obtain• inspections and'finalIapproval-will-result In the expiration of this permit. FOR: NSPECTIONS'CALL':. (714) 754-5826 2448 -as (W) � v CHINO HILLS, CA �! Zip 91709 i ` Owner: SOUTH•COAST'PLAZA Address r f COSTA MESA CA J l �'� -' Phone: J s' 3315 FAIRVIEW ROAD , Zip: 92626 Contractor:",- ROLAND ELECTRIC Address: 15166 VIA MARAVILIA Phone:' 909- 597-5760 CHINO HILLS, CA i Zip: 91709 - , License_: 600011. �.: SCOPE OF PERMIT FOR CHLOE SUITE 2225 REF 605-01655.28 LIGHTS 24 OUTLETS 6 SWITCES 2 MOTORS TO 1 HP 1 SUB PANEL TO 200 AMPS 14 LOW VOLTAGE. FEE SUMMARY Quantity! ' \ Quantity ISSUE FEE $23.50 - Temp Dist System 1 Lighting $0.00 0 Temp service test $0.00 Busway 1100 ft $0.00 0 Res. a/c package $0.00 Standing Section $0.00 0 New Res (1-2 units) $0.00 "0./ ', •Mise Electrical Equipment $0.00 0 New Res (3+units) $0.00 = 0'..---_ - - Transformers up to 1'kv5tkw $0.00 0 Pool 1 Spa $0.00 0 - ......... p to 10 kvafkw $0.00 0 Lighting Fixts $27.84 28 up to 50 kvafkw $0.00 0 , Recept Outlets $24.92 24 .............:...up to,100 kvalkw ,$0.00 0 Switches $6.60 6 ..................over 100 kva/kw $0.00 0 ' Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0 Res Appl $0.00 0 -.. ,= Caw Volt Wiring System 1 Ckt $0.00 G/ ; Service to 200a $0.00 0 Misc. Conduit $0.00 .:•0 Service to 1000a $0.00 0 Misc. Conductor,- $0,00'"""1", 0 Service over 1000a $0.00 0 _ `Circus,.( gen or ride) $O.OD �, " D ' Motors to 1hp $9.50: ! _ =- '2 . Circus (mech ride or -lights),: '$0.00/ 0 Motors to 10hp $0.00 0 'Christmas Tree Stand ., - :$0.00 ,-- o Motors to 50hp $O.aD :' ; 0 - Fireworks Stand $0.00 � ,!i 0. ' -, " Motors to 100hp $0.00. 0 _ . Other Electrical Fee ' , _s: . ' $0.00' Motors over 100hp $0.00 0 Communication drops $95.40 ,'.. ',14 lnvestigation:Fee ' . 50.00 Sub panel to 200a $30.501, Plan Check Fee $0.00 Pole Ligh4�Pkg . "$0.00 0 - Reinspection Fee Sign Circuits so -00 Temp Pwr Pole $0.00,_-,- 0 TOTAL` CALCULATED FEES $136.26 Intermed Pale $0.00 � - � 0 F., y , ' .; • ' - . - , COMMENTS !-SPECIAL"CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California sand related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit,shall automatically:expire and. become. void if work Isnot commenced' within- 1 80days,.or, if.work .is suspended or abandoned for a period of 180 days. INSPECTIONS: In. ardor -for •the,work: authorized, under- this: permit, tot be considered legal; such.work:must:comply with all applicable codes, and all required Inspections, and:final: approval: must be. obtained: Failure to obtain• inspections and'finalIapproval-will-result In the expiration of this permit. FOR: NSPECTIONS'CALL':. (714) 754-5826 2448 -as (W) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one o1 the following declaridoAs: !1 Al ❑ 1 have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by section 3700 of the Labor Coda, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for ince of the work for which this perdt Is issued, work 'corn nation Ins mer a icy number are: artier: olicy Number: 1 ion Head nal be completed ifthe permit is valued at one hundred dollars ($100) or fess.) ❑ I certify that in the perfo the work for which ' ' perm is lssdred, I shall not employ any person in any manner so as to become subject to the workers' compensation taws o lifomia, an roe that I Id be a subject to the workers compensation provisions of Section 3700 f the Labor Code, I shall forthwith provision !cant Slgnatura: �� ate: RM o SECu WORKERS' T10N COVERAGE IS UNLAWFUL AND SHALL SU91ECr AN EMPLOYER TO CRIMINAL PEN&ES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARE (5100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR ODDS, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I here a am licensed nder provisions of apter 9 (commencing with Section 7000) of Division uslness and Professions Code, and my license Is in full fca ort a e a O Contra i s S lure: CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is issued, (Sec. 3097, Civil Code), Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter. Improve, demolish, or repair any structure, prior to Its Issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a parrnit subjects the applicant to a civil penalty of not more than five hundred dollars (5500).): ❑ I, as owner of the property, or my employees with wages as their sole Compensation, WILL DO THE WORK, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors license Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or Improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or Improve for purpose of sale.). - ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITFI LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition Or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, An 2, Sec. 341, Title 6, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 WIII the applicant or present or future building occupant need to file and certify a Business Pian for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be tiled with the Costs Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater then a weight o1 500 pounds, or a volume o1 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _ ........ ............ _— ........ ..... .._W....___.___•__ _ _ .... _ ........ .................. _................. ...---.._... ................. __..... . 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ............................_._.---•.................................................................................................,........................---.................... —_._...__.. 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ...................... _.........................................................................................................................................................................................................---..._..........._.... 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No .......... . ..._....-----_..........— ................—.—._...................... - —---.._.._.—_.-.. S Does or will the applicant or present or future building occupant require for the work which is the subject of this application aermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes jf No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). .. ............................................................................ _.. _........................ _... _._........................ ................ ............................................................................- .._.............. .. ......1...111.111111-1111.11.... .. ................ �._...__._...— fi Will any part of the facility to be constructed under this permit be within 1000 foot from the outer boundaries of a school? [)Yes ❑ ._..... o (!f yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). _................................._....-----._._.._.........__..._.— ....... _. ............. ................. ---......................................... ............ .._,.______ __........ ....—....... ..-...... _.--......... .- 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? []Yes ❑ No --- --1111_.._....___. ..........--- ................ 6 (If fres". attach certificate of compliance from the appropriate air pollution control officer). _ CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is Correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the Information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection e I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. ai Owner(s) ate �AnWOrthorized scant Da CODE t• INSPECTION TYPE r P6IF.' IIITITIAL C_OOE / INSPECTION TYPE j1sIE f1!TITR$ 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Poo! Spa Final 208 Final Plumbing 200' Final Re- Roof* 210 Final Electrical 5� 201 Final Block/Retaining Well 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Fina! Site 204 Final Demolition 250 Final Building/Occupancy r 'TY OF COSTA MESA _ BUILDING DIVISION r DEVELOPMENT SERVICES DEPARTMENT PERMIT NUMBER PERMIT E99-01243 (714) 754-5273 r Fax (714) 754-4856 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT Job Address: 3333 BRISTOL ST Status: ISSUED Suite No 2225 Applied: 12/23/1999 Vicinity: 2225 Issued: 12/23/1999 Parcel Nunmber: 41250107 Applicant: PAUL CALLSION Address: 31716 PACIFIC COAST HWY $0.00 CA Res. a/c package SOUTH LAGUNA Owner: SOUTH COAST PLAZA Address %C 'J SERGERSTOM New Res (3+units) COSTA MESA, CA 0 3315 FAIRVIEW RD Phone: (949) 499-9700 Zip: 92677 Phone: Zip: 92626 I Contractor: SUMMIT GENERAL CONTRACTOR Address: 31716 PACIFIC COAST HWY 'N CAPhone: (949) 499-9700 SOUTH LAGUNA ' Zip:- 92677 License: 624235 r ISSUED BY: /YPL- SCOPE OF PERMIT S, 12 SWITCHES, 25 OUTLETS, 1 SERVICE UP TO 100AMP, 10 TRANSFORMERS UP TO 1 KVA, 1 GONDcff7 T-2ftT BRUNOI MAGLI. Z,LtS- FEE SUMMARY Quantity ISSUE FEE $23.50 Temp service test $0.00 Res. a/c package $0.00 New Res (1-2 units) $0.00 0 New Res (3+units) $0.00 0 Pool / Spa $0.00 0 Lighting Fixts $23.65 25 Recept Outlets $23.65 25 Switches $13.20 12 Non Res Appl _ $0.00 0'. Res Appl $0.00 0 Service to 200a $0.00 0 Service to 10000 $62.15 1 Service over 1000a $0.00 0 Motors to 1 hp $0.00 0 Motors to 10hp $0.00 0 Motors to 50hp $0.00 0 Motors to 100hp $0.00 0 Motors over 1 00h $0.00 0 Communication drops $0.00 0 Sub panel to 200a $0.00 0 Pole Light Pkg $0.00 0 Sign Circuits $0.00 0 Temp Pwr Pole $0.00 0 Intermed Pole $0.00 0 Temp Dist System / Lighting Busway 1100 ft Standing Section Misc Electrical Equipment Transformers up to 1 kva/kw ........:.......up to 10 kva/kw .................up to 50 kvalkw .................up to 100 kva/kw ..................over 100 kvalkw Low Voltage Equipment Low Volt Wiring System 1 Ckt Misc. Conduit Misc, Conductor Circus ( gen or ride) Circus (mech ride or lights) Christmas Tree Stand Fireworks Stand Other Electrical Fee Investigation Fee, Plan Check Fee Reinspection Fee Quantity $0.00 0 $0.00 0 $0.00 0 $0.00 0 $47.50 10 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $18.20 1 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 $0.00 $0.00 $0.00 TOTAL CALCULATED FEES $211.85 COMMENTS 1 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 DECLARATiON-S WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to sell-insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Cade, for the performance of the work for which this permit is issued. My workers' cotnpgasation Insurance carrier and policy number are:� Carrier: .��i7/ r rCJ&_ Policy Number: (This section need not be completed if the permit Is valued at one hundred dollars ($100) or less.) ❑ I certify that in the performanc a work which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Calitor ' t if I should become subject to the workers' compensation provisions of Section 3790 of the or Code, I shall forthwith comply with these provisio Applicant Signature: Date: WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL P64ALTIES14D CSV FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECPON 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am lice and r provi to ting with Section 7000) of Division 3 of the Busine rofessions C de, and y license is in full force and effect. Lic. # Class # Contractors Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lenders Name: Lenders Address: Signature: _ - - _. Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that 14m EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement thatfie aishe is licensed pursuant to the provisions of the Contractors license Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions' Code)"or that'he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalfy of riatm, to than five hundred dollars (5500).): '•�f J 1j1> ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Coda:Tfie,Cgrltractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own omptoyees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the ownar-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner o1 the properly, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: _ Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e, - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION; ❑ I hereby certify that no excavation five (5) dr more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec, 341, Title 8, California Administrative Code). ❑ As ownor-builder, I will not employ anyone tty do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: - Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or wilt the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _.-..._. __----_ — -- - - - - - -- -------------------------- ------------------------ - ---- - — -- -- --_..- -- ---- - 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication aggermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency. Yes LJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? (:]Yes ❑ No (It 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (if 'yes , attach certificate o1 compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described pro erty tot inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature Of Legal Owner(s) /Z r D / AndlOr Authorized Applicant / / Date INSPECTION TYPE III»>IAL$ CODE INSPECTION TYPE 128iE IRMAlS 1616 Fixed System Final Fire Prevention _ 206 Final Mechanical 1266 Pool Spa Final _ 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Welt 212 Final Fire Prevention 202 Final Factory Fire Place _ 220 Final Planning Approval 203 Final Sign _ 222 Final Site 204 Final Demolition 250 Final Building/Occupancy 2446-46 (714)754-5273 • Fax(714)754-4856 CITY OF COSTA MESA BUILDING DIVISION DEVELOPMENT SERVICES DEPARTMENT PERMIT PERMIT NUMBER B99-01914 77 FAIR DRIVE, COSTA MESA, CA 92626 BUILDING PERMIT Job Address: 3333 BRISTOL ST Status: ISSUED Suite: 2225 Applied: 12/2/1999 Vicinity: 2225 Issued: 12/2/1999 Parcel Number: 41250107 Zoning: PDC PDC Applicant: MITCHELL, MAT `n Address: 31716 PACIFIC COAST HWY ISSUED BY: /fes C - PLANNING &ZONING SETBACKS MAIN STRUCTURE Front 0-0 Rear 0-0 Left 0-0 Right 0-0 ACCESSORY Front 0-0 Rear 0-0 Leff 0-0 Right 0-0 PARKING Existing: 0 Required: 0 Proposed: 0 - NOTES: d2,-- $4.000.0 0 2 $4,000.00 $4,000.00 c �-- 0 C NOTICE: The work authc 0 iia statutes and related regulations. (Ord. No. 92-2 EXPIRATION: This permit ispended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 CA Phone:. (949)499-9700 SOUTH LAGUNA Zip: 92677 Owner: SOUTH COAST PLAZA Address %C J SERGERSTOM . COSTA MESA, CA` - + Phone: 3315 FAIRVIEW RD -" ; . Zip'_ 92626' .. f Contractor -/SUMMIT GENERAL CONTRACTOR Address: 31716 PACIFIC COAST HWY CA / -" Phone: (949) 499-9700 SOUTH LAGUNA Zip: 92677 License:- 624235 Arch Eng: ; Address: �� Address: Phone:,, - . - - ' Phone: Zip: f License: License: SCOPE OF PERMIT ' DEMOLISH ENTERIOR NON BEARING WALLS -IN ,� PREPARATION FOR FUTUREtTjy. FOR BRUNO MAGLI STORE. REF B99-01777. FEE SUMMARY Plan Check: ' $0.00 . Calc Valuation: Permit: $97.25 t Claim Valuation: SMIP Res: $0.00 SMIP Com: $0.84 ` Other: $0.00 Inspection: $0.00 - Total: $98.09 - PLANNING &ZONING SETBACKS MAIN STRUCTURE Front 0-0 Rear 0-0 Left 0-0 Right 0-0 ACCESSORY Front 0-0 Rear 0-0 Leff 0-0 Right 0-0 PARKING Existing: 0 Required: 0 Proposed: 0 - NOTES: d2,-- $4.000.0 0 2 $4,000.00 $4,000.00 c �-- 0 C NOTICE: The work authc 0 iia statutes and related regulations. (Ord. No. 92-2 EXPIRATION: This permit ispended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 DECLARATIONS WORKERS' COMPENSATION DECLARATION: " I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My work ompan sat�ion Insu/r n e rrler and policy number are: Carrier: _� T v _ - Policy Number: (This secdon!nee of be cc tpleted if the permit is valued at one hundred dollars ($100) or less.) ❑ I certify that in the pert nce of the work for which this permit is issued, I shall not employ any person in any manner so as to be ome subject to the workers' compensation laws oW11a a ree a1 ' I should become subject to the workers' compensation provisions of 5eotion 370 of 1 Labor Code, I shall forthwith ly wilh.ih a pr 16U93D ignature:Date:AIL SECURE WORKERS'COMPENSATIO VERAGE IS UNLAWFUL AND SHALL SUBiECT AN EMPt: O CRIMINAL PE TIES ND CIVIL FINES UP TO ONE HUNDRED DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, MEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby�Yi rmrthat' am licen nd pro ipgs�han+ta� 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full for/and gtfect. Lic- k S —Gass tf Canir o/res Signatur � Date: C�STRUGTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lenders Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation Of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Cade: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Dover's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ---------- .._.. ___,_.,_,....--- —-------- ------ --- ----- - ------------ - ---- - -- - -- -- -- -- - ------ -------------- ---- 2 Does or wOl the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ....... -............................. ,.------------------------ --..----------------------------------------------------- ,.,_----,.,...-....-_._,. ----------------- --------------- -- ---------- - ------ ---------------------------- - ------------------ ------- — - — - -...-..-- -_-----_ 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No ---.,. - ----.,.------- ---.,.- -1 --"a'n__---4--.-.-_re-,s , "r-f"t' _, 1__� __a_��1 _r_4 --------- ------..-_- __,..,....,------------------ .,..,..-., -- "i's..... ..,..,.-..,..,. -----..,"i,o, .,.-..---.-..,c-- n-' ..,. .,. .,..,.--.,..,.. .,-.-.,..,.. 5 Does or will the appicant or present or future building occupant require for the work which is the subject of this Eyes a ermit for such construction or mpdihcation from the South Coast Air Quality Management District or from any other air pollution control district or agency? E Yes H No (Section 65850.2 of the California Government Coda requires that the requested information be furnished on applications for non-residential building permits). 6 Witt any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code), 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ---....,..,o ---i---._.-.,..--ro -- ...,r'o, ,.-------- a-.,..,.---I-_-,..-_,.- .- ...... ....................................................................... ............................. -_-, .-..----- 8 (if'j�es",attach certificate of compliance from the appropriate air pollution control officer}. CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described propert for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. r D e Or Autf ofrize App I t Date CODE k• N�N&ECTION TYPE VATS' INTMAL CODE w INSPECTION TYPg DATE INTITIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy 2446-a6 (714)754-5273 • Fax(714)754-4856 Job Address: 3333 BRISTOL ST Suite: 2225 Vicinity: SOUTH COAST PLAZA CITY OF COSTA MESA BUILDING DIVISION DEVELOPMENT SERVICES DEPARTMENT PERMIT BUILDING PERMIT Parcei Number: 41250407 zoning: PDC PDC Applicant: MARY RYAN Address: -Phone: (949)582-3735 PERMIT NUMBER B99-01777 77 FAIR DRIVE, COSTA MESA, CA 92626 Status: ISSUED Applied: 11/05/1999 Issued: 12/23/1999 ISSUED BY: f A NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21,92) . EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 Zlp. FEE SUMMARY Owner: SOUTH COAST PLAZA Plan Check: $159.21 Address %,C J SERGERSTOM _. Calc Valuation: $98,000.00 Permit: COSTA MESA, CA Phone: -Claim Valuation: $98,000.00 3315 FAIRVIEW RD Zip; 92626 Contractor. SUMMIT"GENERAL CONTRACTOR SMIP Com: Address: 31716 PACIFIC COAST HWY CA Phone:- (949) 499-9700 SOUTH LAGUNA Inspection: $0.00 Zip:. 92677 License: " 624235 , $1,159.54 Arch : THE TRICARICO GROUP Eng: Address:. 500 VALLEY ROADI ;J PLANNING & ZONING Address: .. Phone: (973)692-0222 Phone: WAYNE. NJ;. ' MAIN STRUCTURE Front 0- 0 Rear .- -0- 0 Left 0-0 Zip: 7470 License: ACCESSORY License: Rear 0-0 Left 0-0 Right 0-0 PARKING SCOPE OF PERMIT i 2,431 SF TI FOR "BRUNO MAGLI" STORE. " NOTES: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21,92) . EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 FEE SUMMARY Plan Check: $159.21 - -,— Calc Valuation: $98,000.00 Permit: $979.75 �W- '�. -Claim Valuation: $98,000.00 SMIP Res: $0.00 ' SMIP Com: $20.58 ' Other: $0.00 _- Inspection: $0.00 Total: $1,159.54 PLANNING & ZONING SETBACKS MAIN STRUCTURE Front 0- 0 Rear .- -0- 0 Left 0-0 Right 0-0 ACCESSORY Front 0-0 Rear 0-0 Left 0-0 Right 0-0 PARKING Existing: 0 Required: 0 Proposed: 0 NOTES: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21,92) . EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 DEC"RATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the tabor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier; _ Policy Number: (This section need not be completed if the permit is valued at one hundred dollars ($100) or less.) ❑ I certify that in the performance of tV ork for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' co a + ws Of Cakifornia, arm t if I should become subject to the workers' compensation provisions of Ssctio 3700 of he Labor Code, I shall forthwith provisions. y Applicant Sign Date- Z : FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT O CR NAL PE IES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED TRACTOR DECLARATION: tf rm I y aat I am Iic sed elnd ry�ris' e ing with Section 7000) of Division 3 s rofessior)s Code, and my license is in full force and ect- Lic. If ss # Contractors Sign e: /l Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lenders Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Coda: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of properly who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the properly, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: _ _ Date: Owner ID verified by driver's license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, wiff be more than thirty-six (36J feet high, (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title B, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: — - Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, _ or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 5S gallons, or 200 Cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4.. ...... .... ..........--....,.- ._.----------..-...,..._,.....,....,,,..- - - -- _---•--------.-------------_..,..--------._., - -- ------------ If an RMPP is presentlym....,_ required-. , has. -.. Section -..._ _.._.25534....-.. - the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the Subject of this application aermil for Such construction or modification from the South Coast Air Ouality Management District or from any other air pollution control district or agency? U Yes Jf No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ----------------------- ---------- .------------------------- -- - - -- -- _-------- _.------------------------ — - - - ... - _ m __ --- ------------------.,.-------------_-_,.-------- 6 W ill any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes ❑ No (If "yes", the facility must meet the requirement Of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Duality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (If "yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the Information given above is correct. I agree to Comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: _ Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state taws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. t agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature Of Legal Owner(s) Z Bate And/OrAoThorl2ed App A ant to CODE M. INSPECTION TYPE DATE IMMIAL CODE! INSPECTION TYPE DATE INTMALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy ' " 2446-46 MFS CITY OF COSTA MESA ` y4 BUILDING DIVISION PERMIT NUMBER r DEVELOPMENT SERVICES DEPARTMENT W PERMIT M99-005$2 (714) 754-5273 • Fax (71 d) 754-4856 77 FAIR DRIVE, COSTA MESA, CA 92626 MECHANICAL PERMIT ,lob Address: 3333 BRISTOL ST Suite No 2225 Vicinity: 2225 Parcel Number: 41250107 Status: ISSUED Applied: 1 212 311 999 Issued: 12/23/1999 ISSUED BY: JiT� Applicant: PAUL CALLSION Address: 31716 PACIFIC COAST HWY CA Phone: (949) 499-9700 SOUTH LAGUNA Zip: 92677 Owner: SOUTH COAST PLAZA Address: %C J SERGERSTOM COSTA MESA, CA Phone: 3315 FAIRVIEW RD Zip: 92626 Contractor: SUMMIT GENERAL CONTRACTOR Address: 31716 PACIFIC COAST HWY CA Phone: (949) 499-9700 SOUTH LAGUNA Zip: 92677 I License: 624235 Arch / Eng Address: Phone: Zip. License: SCOPE OF PERMIT 25 LIGHTS, 12 SWITCHES, 1 SERVICE UP TO 100AMP, 10 TRANSFORMERS UP TO 1 KVA, 1 CONDUIT, 1 ALTER DUCT SYSTEM, REF B99-01777, UNIT 2227.'BRUNOI MAGLL FEE SUMMARY ` Quantity Quantity ISSUE FEE $23.50 Repair 1 Alt Absorbtion Unit $0.00 0 Inst FAU <100 k BTU $0.00 0 Repair/ Alt Refrigeration Unit $0.00 0 Inst FAU >100 k BTU $0.00 0 Ventiliation System $0.00 0 Repair I All Cooling/Heat $13.70 1 Evaporative Cooler $0.00 0 Inst /Rep. Recess Wall Htr , $0.00 0 Commercial Incinerator $0.00 0 Ref rig Sys <100 k BTU $0.00 0 Domestic Incinerator $0.00 0 Ref rig Sys >100 k BTU $0.00 0 Compressors, / Absorption Systems Gas Piping $0.00 0 Up to 3 hp 1100 k BTU $0.00 0 Factory Fireplace $0.00 0 3 To 15 hp/500k BTU $0.00 0 Hood wlMech Exhaust $0.00 0 15 To 30 hp 11,000 k BTU $0.00 0 VAV Box $0.00 0 30 To 50 hp 1 1,750 k BTU $0.00 0 Vent Fan I Single Duct $0.00 0 Over 50 hp / Over 1,750 BTU $0.00 0 Appliance $0.00 0 Boilers Fire Dampers $0.00 0 Up to 3 hp $0.00 0 Smoke Dampers $0.00 0 3 To 15 hp $0.00 0 Inst or Relocate Appl Vent $0.00 0 15 to 30 hp $4.00 0 Air Handlers < 10000cfm $0.00 0 30 to 50 hp $0.00 0 Air Handlers > 10000cfm $0.00 0 Over 50 hp $0.00 0 Floor Furnace $0.00 0 ' Other Mechanical Fee Floor or Suspend Heater $0.00 0 Investigation Fee $0.00 Plan Check Fee $0.00 Reinspection Fee $0.00 TOTAL CALCULATED FEES $37.20 COMMENTS/ SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALLi (714) 7545626 DECLARATiONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the k for which this permit is issued. I have and will maintain w s compensation insurance, as required by section 3700 of the labor Code, for the performance of the work for which this permit Is issued. y works pe 1' surance mar and policy number are: Carrier: /`� Policy Number: (This se ion need not be completed if the pe it is valued al one hundred dollars ($100) or less.) ❑ I certify that in the performance fo this permit is Issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Californl 6 ould become subject to the workers' compensation provisions of Section 370 of the Labor Code, I shalt forthwith comp) visions ZAGNINCa t S nature: Date: Z2 O SECURAGE iS UNLAWFUL AND SHALL SUBJECT ANE RIMIN NALTIE D C1VI NE$ UP TO ONE HUNDRED D DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTERE , AND ATTORNEY'S FEES. LICENSED CO AC D ARATtON: I hereb Irm that I m licensed a pro si commencing with 5oclion 7000) of a essions Code and my license is In full I, and effect. Li +t Class # corrector s Signature: ate: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is Issued. (Sec. 3097, Civil Code). Lender's Name: _ Lender's Address: Signature: Hate: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or County which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than We hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Cade: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: _ Date: Owner ID verified by driver's license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more toot In depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, lalsowork, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Cade requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard lemperaturg and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25634 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a ptication a ffrmil for such construction or modification from the South Coast Air Quality Managgment District or from any other air pollution control district or agency? jJ Yes No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the tacitly to be constructed under this permit be within 10DD feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (it'yes", attach certificate of compliance from the approprialo air pollution Control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emigslons. Signature: _ _ _ Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the Information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property f ' peat purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. nature ,ne / 2 2 � An u orited Applica - e CODE 4. INSPECTIONTYPE QM til MAL CODES INSPECTION TYPE INTMA 1616 Fixed System Final Fre Prevention 206 Final Mechanical 00 v 1266 Pool Spa Final 208 Final Plumbing 200 Final Rte --Root 210 Final Electrical 201 Final BlocklRete inns g Weft 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Silo 204 Final Demolition 250 Final Building/Occupancy 244&46 39432 COSTA MESA BUILDING -SAFETY DEPARTMENT P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626 AP LIATION FOR BUILDING PERMIT For n t F!ll.rn l2 that the above information Is correct and agree to comply with R= I E pP E Ry E! D D 1 5 E BUILDING i�l� ADDRESS 'E O_�_O PERMIT NO, OWNER A.P, NO. MAIL,Q� 1:90 I4^ I�O BUILDING RtS� L VC .k ADDRESS 1 ADDRESS - �C �" THE AMOUNT SHOWN UNDER VALUATION IS FOR CITY NO (�f /�d. G3i78 6Z/-7 p p TRACT LOT BLOCK ION W LENSTRUCT NDER HCY OWNER BRANCH Slonature of ADDRESS � r n -y] L �]�� 5 6I~t` 0Loa--J SHOE STVKFi $ t' v " ARCHITECT %f TEL�t�, IN -NO.(oma FIRE �f ZONE YP �z GROUP v ADDRESS _ L APPROVED CONTRACTOR BY DATE ADDRESS TEL. ZO I NO. OF r� C — S PLANS USE OF NEW lam` BUILDING CITY NO, IJ Com- �T , STATE CITY YARDS APPROVED YARDS APPROVED LIG. NO. --�:5� LIC, NO. MAIN BUILDING ACCESSORY BUILDING SIZE NO. OF BLDGS. (FROM C/L STREET) OF LOT NOW ON LOT FRONT FT. FT. USE OF /jG16f !! _S EXISTING BLDG. ,` �P'GI� FT SIZE OF�` I� / NO, OF NEW BLDG. N ROOMS STORIES L. SIQE F FT. EXTERIOR WALL' ROOF -L- COVERING-/szh COVERINGJ�� REAR FT. FT. MED U BUILNANWORKTOBE F DISTANCE BET. BET. MAIN & ; h 1207- i' MAIN 81 -DGS. ACCESS. BLOCS L / / VAR. 14L DATE _moi 0 ��IQlT��L/jl/777TC!%JI.7b/Ir� _.d.4J C.U.P.* APPROVED ' (LJl%T�'(yi�� �/1G► /%%�,/ STi�/�GI� �gfj4' APPROVEDI/iC111 I hereby acknowledge that I have read this application and state that the above information Is correct and agree to comply with all laws regulating building construction, and I shall not employ any person in violation of the workman's compensation laws of the State of California. m TAX I hereby certify that I em properly licensed as a contractor under SO, FT. O the State of California Business and Professions Code, Division 3, 'iarca THE AMOUNT SHOWN UNDER VALUATION IS FOR Chapter 9, and the% such licenses are In fu and ellecl, or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: am exempt from the provisions of the St a pf California Business end Professions Code, Dl�lsion 3, Chapte 9, — VALUATION m t PERMIT FEE $ ", Slonature of m Permittee - ' $ F I J -)I PLAN CHECK $ `� E Authorized Agant LL TOTAL FEE $ COSTA MESA BUILDING -SAFETY DEPARTMENT P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626 For Applicant to Fill in Completely ADDRBUILDING �3Z� 157-04 ADDRE5S rr��J OWNER L E -s MAIL ADDRESS TEL. CITY NO. CONSTRUCTION LENDER BRANCH ADORESS ARCHITECT TEL. OR ENGINEER ADDRESS CONTRACTOR ADDRESS TEL. CITY NO. STATE CITY LIC. NO. LIC. NO. 512E NO. OF SLDGS, OF LOT NOW ON LOT USE OF EXISTING BLDG. SIZE ONO. OF NEW BLF ROOMS STORIES EXTERIOR WALL ROOF COVERING COVERING USE OF EIUl DING AND WORK TO BE PERFORMED YARDS APPROVED ACCESSORY BUILDING (FROM CIL STREET) I hereby acknowledge that I have read this application and state that the Above Information Is correct and agree to comply with all laws regulating building construction, and I shall not employ any parson In violation of the workman's compensation laws of the State of California. I hereby Certify that I am properly licensed as a contractor under the State Of California Business and Professions Code, Division 3, Chapter 9, and that such licenses are in full force and effect, or I am exempt from the provisions of the State of California Business and Professions Code, Division 3, Chapter 9. Signature of Permittee Authorized Agent -7rP':L-00 'I 65Y ***13520 ,APPjICAfl1ON FOR BUILDING PERMIT R= DATE RECEIVED DA E ISSU T A.P. NO. BUILDING +� ADDRESS6s-=13 Tbt. TRACT I LOT BLOC OWNEG--*Qq(.b ie FT. c /� VALU$ BET. MAIN & R �K L ACCESS. SLOGS. FIRE S DATE ZONE PE GROUP •L9y o APPROVED r APPROVED i3 Y PATE ZONE NO. OF USE OF NEW PLANS BUILDING YARDS APPROVED MAIN BUILDING YARDS APPROVED ACCESSORY BUILDING (FROM CIL STREET) FRONT FT. FT. REAR FT. SO. FT. FT. DISTANCE BET. VALUATION BET. MAIN & MAIN SLDGS. PERMIT FEE S �" a ACCESS. SLOGS. VAR.+ S DATE C.U.P- 46 •L9y o APPROVED APPROVED 0 SO. FT. THE AMOUNT SHOWN UNDER VALUATION IS FOR THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: m VALUATION PERMIT FEE S �" a m S E PLAN CHECK SLL •L9y o TOTAL FEE 0360 '.% • COSTA MESA BUILDING -SAFETY DEPARTMENT PO. BOX 1200 COSTA MESA, CALIFORNIA 92626 Z . aUj U _ZQ O En a Cr J J aW C13 J � C!1 _a U Q ZCr W 0. , w W Z J 0 _m Z J CC w w O Z� U.1 Ir �0 Il CL a 0 N Z O E- U 0 Z IIS PA=L�� i��+'f tr3rtffc g APPLICATION FOR BUILDING PERMIT dor Applicant to Fill in Completely RECEIV BY TE RECEIV D TE SUED 31, ' BUILDING " Tb ADDRESS r / PERMIT O. �'O OWNER A.P. NO. / MAIL BUILDING ADDRESS ADDRESS/CJ TE L. CITY NO. TRACT LOT BLOCK CONSTRUCTION LENDER BRANCH OWNEjh ADDRESS + V UE ARCHITECT TEL. OR ENGINE R t1o. FIRE ADDRESS — ZONE TYPE G480VP CONTRACTOR �f�.i:,yl� APPROVED BY DATE ADDRESS 3 TEL N NO.OF USE OF NE CITY NO. PLANS � BUILDING STATE �j / CITY �G YARDS APPROVED YARp PPROVED LIC. NO. L� J LIC. NO. MAIN BUILDING ACCESSORY BUILDING SIZE NO. OF BLDGS (FROM C/L STREET) OF LOT NOW ON LOT RONT FT. FT. USE OF TF 1 4�S EXISTING BI.. FT. fT. SZE OF ' ��FiOOMS NEI" B DG STORIES L SIDE FT. FT. EXTERIOR WALL ROOF COVERING COVERING R R FT. USE OF BUILDING AND WORK TO BE PERFORMED DIST BET. MAIN & MAIN BLDGS. ACCESS. BLDGS. APTCUyyV 'D� APPROVED APPROVED I hereby acknowledge that I have read this application and state that the above information is correct and agree to comply with all laws regulating building construotlon, and I shall not employ any person in violation of the workman's compensation laws of the State of California. I hereby certify that I am properly licensed as a contractor under SO. FT. THE AMOUNT SHOWN UNDER VALUATION IS FOR the State of California Buslness and Professlons Code, Division 3, Chapter 9, and that such licenses are In full force and effect, or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: am exempt from the provisions of the State of California Business VALUATION and Professions Code, piV 3, Chapter 9. PERMIT FEE Signal re oAA rn Permitt $ �a'1 �— PLAN CHECK $ �] Authorized nt wJ TOTAL FEE $ g PROJECT ADDRESS: 3333 BRISTOL ST UNIT: 2 2 2 5 OWNER'S NAME: C.J. SEGERSTROM & SONS ADDRESS: 3 315 FAIRVIEW RD COSTA MESA CA 92626 (714)546-0110 ARCHIENGINEER: REO.NO.: ADDRESS: UNIT: PERMITTEE: ALLREADY FIRE SPRINKLER (818)913-6720 - ADDRESS: 818 N. GRAND AVE COVINA CA 91723 LICENSED CONTRACTOR DECLARATION: I hereby affirm tha I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, a y lic nse is in full for and effect. CITY UC-: 0 3 5 2 6 3 STATE LIC -:358795 — 6 Date: its — ,7 f:J, 90 Signature: lt Lo WORKERS' COMPENSATION DECLARATION: 1 hereby affir that ve a certificate at consent to sell -insure or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Sect! n 38 Lab, C). POLICY NO.: PC992187 P.D E: 04/04/91 COMPANY: REPUBLIC INDEM Certified copy is hereby furnished. M Certified copy d 'ih tit city Building lois n. Date: —2-C-7 — [ U Applicant: EXEMPTIDN FROM WORKERS' COMPENSATION DECLARATION: (This io need not be completed i1 the permit is fa one hundred ($100) or less). I certify that in the performance of the work for which this permit i issu d, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California. Date: Signature: NOTICE: If, after making this declaration, you should become subject to the Workers' Compensation provisions of the Labor Code. you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Section 3097, Civ. C), LENDER: i ADDRESS: OWNER BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractors' State License Law for the following reason (Section 7031.5 Business and Professional Code: Any city of county which requires a permit to construct, after, improve, demolish, or repast any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that helshe is licensed pursuant to the provisions of the Contractors' State License Law (Chapter 9 (commencing with Section 70DO) of Division 3 of the Business and Professions Code) or that he/she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty o1 not more than five hundred dollars (5500). I, as owner of the property or my employees with wages as their sole compensation, will do the work, and the 0 structure is not intended or offered for sale (Section 7044, Business and Professional Code: The Contractors' State License Law does not apply to an owner of a property who builds or improves thereon, and who does such work himself/herself or through his or her own employees, provided that such improvements are not intended or offered for sale. It, however the building or improvement is sold within one year of completion, the owner will have the burden of proving he/she did not build or improve for the purpose of sale). 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Section 7044, Business ❑ and Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon and who contracts for such projects with a COntractorts) license pursuant to the Contractors' State License Law). I am aware that proof of their Worker's Compensation insurance should be provided to me. I am exempt under Section: B. 6 P. C. for this reason: Date: Owner: I do hereby certify that I am aware of and understand the requirements of California Health and Safety Code Sections 25505, 25533, and 25534 and that I or any future building occupant will/will not (circle one) need to comply with said state codes and the requirements tot a permit for construction or modification from the Air Duality Management District. Residential Construction applications are exempt from these provisions. Date: Applicant: I hereby certify that I have read this application and state that ordinances and state laws relating to building construction and h property for inspection purposes. Date: 4 'Z- C� — ?n Signature: _ Driver's License or Social Security M� 1641-46 White—Building; Green—Code Enforcement; mation is 0rre I tee to comply with all city and represeMaf es o thfs to enter upon the ab -me M A alIV- Pink—Revenue; Goldenrod—Assessor CITY OF COSTA MESA •: BUILDING PERMIT PERM NO: F 047816 PERMIT NO: F 047816 PLAN CHECK NO: 04435-90 S GOVT: N SUPP: N CONSTRUCTION TYPE; PERMIT TYPE: FIR PURPOSE: ALT JOB DESCRIPTION .: FIRE SPRINKLER ALT SQ FT: CLAIM VALUE; 2,500,00 CALC—VALUE: GROUP OCC: B-2 / COMMENTS; RE: G47565 PRIMARY BLDG. PERMIT, iE iE iE #'lE �f ?E'r(9E'lf•'rE iE if'rE if• !E � iE iE # # iF 9F iE iE iE iF iE it �E # *'k 9t # ie 9E 9E # 9E # 9E # � # iE it- iE # iP * iE jE �r # if 'lE � iE dh �E iE iE iE # it # iktiE 3E iF �E iE iE iF iF iE'# iE Z O N I N G R E Q U I R E M E N T S S E T B A C K S ------------ MAIN BUILDING ----------- -•--------- ACCESSORY BUILDING----- FRNT- FT IN REAR: FT IN FRNT. FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN PARKING REQ: PROV: PARCEL: 41250102 ZNE: REF NO: PLANNING NOTES> # i[• # 9F aF ir- iti! 3E it if'rF •!E iE ir- ib iL- i{• � iI• �'i(• it i(- # iE � � � * iE• •]k it: ik iF iE ir• if 'E jF iE 9F iE TE # j4 iE iE # iE'r4'k'iE # # iE iF iE # iF # 9I- # # iE •!F iE iE 9E 1E # �E i!' iE it 9E iE 9t 3t D E V E L O P M E N T S E R V I C E S R E Q U I R E M E N T S ZONING APPROVED BY DATE; BUILDING APPROVED BY : DATE: APPLICATION ISSUED BY: DATE: # �I-'k •1E �E 9E 9E jF if �E dE 1E iE i4 iE iF iE iE iE iE aF'rE � iF � # TE iE iE aE 9E dE # 3E 3EiF9E#9EdE#9FiE3E#TF3E##df#3EiE###ir'rE•9E�iE9EiF3E####3E#3E##�E 3E�E 3EiE#iE##TEFF###TF�E�FiE#iF3E#iEiE####iE9Ei��##-11TF LEGALIZATION:N F E E S U M M A R Y STRUCTURAL SEGMENT:N BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT54.00 65% SMTP /NON --RES PLAN 35.10 ISSUE FEE BUILDING—DIV—> PERMIT ISSUE PLAN—CHECK TOTAL PAID DUE TOTALS ---- > 54.00 0.00 35.10 89.10 89.10 ,00 REVENUE DIVISION TOTALS--> COLLECTED: 54.00 OVER/SHORT: ,00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN—CHECK 54.00 -3E * aF iE dF # � aE if iE •IE -!E 3E di �E � iE iE iE # -><- -IF aE ir- -)(• aE dt• •lE• iE iE ir- iF aE � )E if• -fE ?E # �E 3E aE •3fit• 3E iE• � 9F TE # 3E # � �F iF �E if # �E iE iE # �E -1E # iF iE iE i(-iE ->E # iE .N. * #- 9t iE 9t I N D I V I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST FIR 54 FIRE EQUIP FEE (FROM BLDG VAL TABLE) 1.00 54.00 END OF FEES r r� r Y 01 09063540-000635401 TCI T DATE: 06/20/$0 TIME. 11:22 14.00 CONSTRUCTION AND PLANNING Date APPROVALS Permit # 1 . Inspector POOL ...-SPA APPROVALS Permit # Date Inspector . ..I 1._Temporary Electrical Service or Pole 52. Pool & Equipment Location , 2. Soil Pipe-Undrgrnd. ' 53. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. 54, Forms 4. Electrical Conduh-Undrgrnd. 55. Electrical Bonding 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6• Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE 7. Footings 58. Electrical Conduit•Undrgrnd. 8. Foundation 59, Gas Pipe, ❑ Undrgrnd., Test 9. Water Pipe-Undrgrnd. 60. Backwash Lines, P-Trap, ❑ Undrgrnd. 10. Structural Floor System 61. APPROVAL TO DECK 11. Property Sewer Line & House Connection 62. Backwash & Receptor-Final 12. Sewer Cap - 63. Heater & Vent-Final 13. Roof Drains _ 64. Plumbing System - Final 14. Rough Plumbing 65. Electrical-Final 15. Rough Electrical-Conduit _ 66.'Solar System-Final 16. Rough Electric Wiring 67.- Fencing & Access Approval 17. Rough Wiring Sign 68. APPROVED FOR PLASTERING 18. Rough ElectricalT Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Hough Heating & Air Conditioning FIRE DEPT, REQUIREMENT APPROVALS Permit # 20. Rough Factory Fireplace 21. Ducts, in Structure 70. Underground Hydro 22. Ducts, Ventilating 71. Product Piping ❑ Gas ❑ Oil 23. Gas Pipe-Rough & Test 72. Underground Flush 24. Roof Framing 73, Undergrnd. Storage Tank ❑ Gas ❑ Oil 25. Roof Sheathing 74, Overhead Hydro Zq -41) TPVA 26, T-Bar Ceiling (Structural) & Monocoat 75. Dry Chemical 27. Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding 77. FIXED SYSTEM FINAL 29. Insulation 78: .FIRE PREY. FINAL 30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat 79. FINAL INSPECTION ..32. Electrical Power Meter-Final 80, FOOD CERTIFICATE ISSUED 33. Final Electric Notes: 34. Final Heating & Air Conditioning 35. Final Gas Pipe-Test 36. Hood or Canopy - 37. Final Factory Fireplace G' i 38. Final Plumbing 39, Water Service-Final 40. Gas Service-Final 41. Solar Domestic•Finil 42. Backflow Preventer 43. Backflow Irrigation 44. Landscape Irrigation System 45. Sound Attenuation 46. Handicap Regulations ' 47. FINAL STRUCTURE & BUILDING 48. FINAL PLANNING 49. Electric Release to Edison 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY No. Date IApplicant to fill In all spaces except those within heavy border lines and sign all appropriate declarations. CITY OF COSTA MESA PERMIT.NO. TRACT NO. LOT NO.. BLDG. -.N7' Application Issued By Data CONSTRUCTION PERMIT Dishwasher Solar Piping p 9 Cooking Unit , less) - I certify that in the performance of the work for which this permit is issued, I Drinking Fountains Solar Tank Dishwasher Project Address 1 L TYPE OF CONS RUCTION NEW ADD ALTERATION REPAIR :_ Floor Drains Swimming Pool vv/Spa Dryers ❑Gas ❑Electfic 2 Applicant's Mailing Address. J3�✓3 ls QL ❑ CdIVVERSIpN ❑ pEMOt,15�1 OT E A.P. + Owner's Name COA&T DESCRIPTION OF WORK , K(� d S Gas Service Outlets Water Closet F,A.U. Heating System & Ducting ❑0-100,000 BTU 0100,0008 •� ne ��I�TEh-t S Main Building: Device Boxes Address L _ TYPE OF PERMIT GRADING FOUNOAT11 STRUCTURAL T Front Lavatories Outlets p_Tra p Arch/Eng, License No. ❑ TENANT ❑ ELECTRICAL ❑ PLUMBING MECHANICAL B Rear Garbage Disposal Address ' ❑' OTHER A Generator 00-5 KW ❑5 15 K Contractor's Nam ` wr1h``1o'ne 2• PROJECT DESCRIPTION SQ. FT. OCCUPAN Y C Right L1 dF Addresslmailingl�4`7 n�7sry� �NfFRE1M C0NSTRUCTIONTYPE VALUATION $ •� g Left _� CIty,License No, O4 .7 7 ZONE - GRADING CU.YDS. ACRES 'Ping. Ref. # LICENSED CONTRACTOR DECLARATION Remarks: - Parking Req./Provided ]:hereby affirm that I am licensed under provisions of Charter 9 (commencing with section 7000) of Division 3 of the Business and Professions Code, and Use of Building: my license is In full fort and ffect. �+ / �• , License C ss nse No. MiE, PLUMBING FEES Planning Notes: �U Date Signature a+-r+- Bar Sink Showers 'ORKERS' COMPENSATION DECLARATION ereby affirm that I have a certificate of consent to self -insure or a certificate Backflow Preventer - Service Sink' Workers' Compensation Insurance, or a certified' copy thereof (Section 3800, Lab, C.)r — 17 fIl /, Backflow Irrigation Sewer Cap Policy No. r 7 Company , 7264 8/281214 Zone C141 Accessory, Building: IPark.Fees $ ELECTRICAL - FEES Transformer 1115-50 KW ❑ 50+ KW Meter ❑up to 100 amps Meter Clover 100 amps Sub Panel Motors C10-11 HP❑1%-8 Inc. Solar 09.15 HP E] 16-15+ Microwave Pole Light Range Sign Standing Sections W Trash Compactor Z O N N G R E a Ul R E ' M E N T I, as owner of the property or my employees with wages as their sole ReinspeCtiOn Fee $ compensation, will do the work, and the structure Is not Intended or offered MECHANICAL FEES for sale (Section 7044, Business and Professional Code: The Contractor's PUBLIC SERVICES REQUIREMENTS: License Law does not apply to an owner of a property who builds or improves Boiler Hood or Type 1 ❑ thereon, and who does such work til mself/herself or through his or her own Zoning Approved By employees, provided that such Improvements are not intended or offered for Canopy Type 11 ❑ ' sale. If, however, the buildingor Improvement is sold within one year of cpm• Duct - Under Ground Building Approved By Issue Fee $ 3 pletlon. the owner will have the burden of proving he/she did not build or Im- rave for the purpose of sale). ❑ corrified c py is h reby furnished- a Ll�Certified Is f d ' ith the city Build n 4v ion. Date Applicant7r. Bathtubs Sewer Connection Automatic Washer Clarifiers Solar Collectors Construction Pole Sub. Application Issued By Data EXEMPTIO FROM w RKERS' COMPENSATION DECLARATIO (This section need not be completed if the permit is for one hundred ($100) or Dishwasher Solar Piping p 9 Cooking Unit , less) - I certify that in the performance of the work for which this permit is issued, I Drinking Fountains Solar Tank Dishwasher shall not employ any person In any manner so as to become subject to the Workers' Compensation Laws of California, Floor Drains Swimming Pool vv/Spa Dryers ❑Gas ❑Electfic Date Signature NOTICE: If,{after making this declaration, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith Firepl/Fact. Bit. ICBG # Floor Sinks Urinal , Fan Gas Service Outlets Water Closet F,A.U. Heating System & Ducting ❑0-100,000 BTU 0100,0008 comply with such provisions or this permit shall be deemed revoked: CONSTRUCTION LENDING AGENCY I hereby affirm that there Is a construction lending agency for the performance of the work for which this permit is Issued (Section 3097 Civ. C.) Interceptors Water Heater Fixtures Kitchen Sink Water Service Device Boxes Lender's Name y i o Lender's Address OWNER BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5 Business and Professional Code: Any city or Lavatories Outlets p_Tra p Switches county which requires a permit to Construct, alter, improve, demolish Or repair Roof Drains Garbage Disposal Issue Fee + $ 3 any structure, prior to Its Issuance, also requires the applicant for such permit to file a signed statement that he/she Is licensed pursuant to the provisions of . Generator 00-5 KW ❑5 15 K Ihe Contractor's License Law (Chapter 9 (commencing with Section 7000) of 7ivlsion 3 of the Business and Professions Code) or that he/she Is exempt herefrom and the basis for the alleged exemption. Any violation of Section Reinspection Fee $25 issue Fee $ 3 1031.5 by any applicant for a permit subjects the applicant to a civil enalty of not more than five hundred dollars (5500). 7264 8/281214 Zone C141 Accessory, Building: IPark.Fees $ ELECTRICAL - FEES Transformer 1115-50 KW ❑ 50+ KW Meter ❑up to 100 amps Meter Clover 100 amps Sub Panel Motors C10-11 HP❑1%-8 Inc. Solar 09.15 HP E] 16-15+ Microwave Pole Light Range Sign Standing Sections W Trash Compactor Z O N N G R E a Ul R E ' M E N T I, as owner of the property or my employees with wages as their sole ReinspeCtiOn Fee $ compensation, will do the work, and the structure Is not Intended or offered MECHANICAL FEES for sale (Section 7044, Business and Professional Code: The Contractor's PUBLIC SERVICES REQUIREMENTS: License Law does not apply to an owner of a property who builds or improves Boiler Hood or Type 1 ❑ thereon, and who does such work til mself/herself or through his or her own Zoning Approved By employees, provided that such Improvements are not intended or offered for Canopy Type 11 ❑ ' sale. If, however, the buildingor Improvement is sold within one year of cpm• Duct - Under Ground Building Approved By Issue Fee $ 3 pletlon. the owner will have the burden of proving he/she did not build or Im- rave for the purpose of sale). Duct - Structural Refrigeration System Application Issued By Data 1, as owner of the property, am exclusively Contracting with licensed con- tractorsto construct the project (Section 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of properly who builds or improves thereon, and who contracts for such projects with a con- tractor($) licensa pursuant to the Contractor's License Law)- E]I am exempt under Section B. & P. C. for this reason 00-1100.000BTU ❑100,000 BTU Duct - Ventilating SUM ARY FEES ' 3,5 BUILDING PERMIT $ SMIP $ PLAN CHECK $ PERMIT PLUMBING' $ ISSUANCE $ ' PLAN CHECK 25% $ ENERGY P.C. $ ELECTRICAL $ GRADING $ Exhaust System ❑ Multiple ❑ System Repair/Alteration Firepl/Fact. Bit. ICBG # Date Owner 1 hereby certify that 1 have read this application and state that the above - r Information Is correct. 1 agree to comply with all city and County ordinances Heating System & Ducting ❑0-100,000 BTU 0100,0008 and state laws relating to building construction, and hereby authori a repre- sentatives of' this city o enter upon the above-mentloned prort or Inspection purposes. p Signature Date Drivers' Llcense or SS = PLAN CHECK 50% $ MICROFILM $ MECHANICAL - $ TOTAL FEE $ •� PLAN CHECK 25% '$ Reinspection Fee $25 Issue Fee + $ 3 CMF 0865-46 rev. 12/83 White - Building; Canary -Applicant; Pink -Accounting; Goldenrod -Assessor �i -CONSTRUCTION AND PLANNING Date • APPROVALS - Permit # Inspector POOL . SPA APPROVALS Permit # Date Inspector J- Temporary Electrical Service or Pole 52. Pool & Equipment Location _ u - :. 2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement 3, Electrical Conduit Utility-Undrgrnd. 54. Forms 4: Electrical Conduit-Undrgrnd. 55. Electrical Bonding _ 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test _ 6. Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE 7. Footings 58. Electrical Conduit-Undrgrnd. 8. Foundation 59. Gas Pipe, 0 Undrgrnd., Test ' 9. Water Pipe-Undrgrnd. 60. Backwash Lines, P -Trap, ❑ Undrgrnd. 10. Structural Floor System 61. APPROVAL TO DECK 11. Property Sewer Line & House Connection 62. Backwash & Receptor -Final 12. Sewer Cap 63. Heater & Vent -Final 13, Roof Drains 64. Plumbing System - Final 14. Rough Plumbing 65. Electrical -Final 15. Rough Electrical -Conduit 66, Solar System -Final 16. Rough Electric Wiring 'Rough 67. Fencing & Access Approval - 17. Wiring Sign 68. APPROVED FOR PLASTERING 18. Rough Electrical-T,Bar Ceiling 69. POOLISPA SYSTEMS FINAL 19, hough Heating & Air Conditioning n41 FIRE DEPT. REQUIREMENT APPROVALS Permit # ; R 20. Rough. Factory Fireplace 21. Ducts, in Structure 70. Underground Hydro 22. Ducts, Ventilating _ 71. Product Piping C3 Gas ❑ Oil 1.23. Gas Pipe -Rough & Test 72. Underground Flush k 24, Roof Framing 73. Undergrnd. Storage Tank ❑ Gas 0 Oil 25. Roof Sheathing - 74, Overhead Hydro 26. T -Sar Ceiling (Structural) & Monocoat 75. Dry Chemical ,--27. ,Frame and Flashing r28. 76. Dry Standpipe Lathing & Siding 77. FIXED SYSTEM FINAL - 29. 'Insulation 78. FIRE PREY. FINAL F• 30. Drywall Nailing .HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat 79. FINAL INSPECTION 32. Electrical Power Meter -Final 80. FOOD CERTIFICATE ISSUED 33. Final Electric Notes: 34• Final Heating &`Air Conditioning 35. Final Gas Pipe -Test 36. Hood or Canopy' 37. Final Factory Fireplace w 38. Final Plumbing 39. Water Service -Final r 40. Gas Service-Finai 41. Solar Domestic -Final 42. Backflow Preventer 43. Backflow Irrigation 44. .Landscape Irrigation System 45, Sound: Attenuation r 46. Handicap Regulations ' 47, FI NAL STRUCTURE & BUILDING - 48. Special Requirements Completed 49. Electric Release to Edison 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY No. Date - ' q L . PROJECT ADDRESS: 3333 BRISTOL ST DNR' 2 2 2 5 OWNER'S NAME: C J . SEGERSTROM & SONS ADDRESS: 33B FAIRVIEW RD V 6VX4 r COSTA MESA CA 92626 (714)546-0110 -�ARCNrENGINEER: CHARLES W. SMITH REG.NO.: 14 3 13 -4r ADDRESS: 3160 CROW CANYON RD UNIT: 160 SAN RAMON CA 94583 53P•o?W PERMITTEE: CHARLES WAKEFIELD SMITH ( 415) 8-�6-5.56 ADDRESS: 3160 CROW CANYON RD 160 SAN RAMON CA 94583 UCENSED CONTRACTOR DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my I arise i In full fie and effec CITY LIC.: 0507 16 STATE Uc.; 5 4 9 4 7 s s: Date: _ S- ,3�-9Q _ Slgnature: + WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Section 3800, Lab. Q. ' POLICYNO.: 1193367-90 EXP. DATE: 0 5/ 31 / 9 0 COMPANY: STATE FUND Ceitified copy is hereby fumished. [R Certified copy is Til with t city Pulding Divi Date: 5^ - 3 Applicant: A EXEMPTION FROM WORKERS' COMPENSATION DECLARATION: (This section need not be completed if the permit a for one hundred ($100) or less♦. I certify that in the performance of the worts for which this permit is issued. I shall not employ any person i tarty manner so as to become subject to the Workers' Compensation Laws of California. , Date: Signature: NOTICE: If, after making this declaration, you should become subject to the Workers' Compensab(;n provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for 0e1performance of the work for which this permit is issued (Section 3097, Civ. Q. f ' LENDER: ADDRESS: OWNER BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractors' State License Law for the following reason (Section 7031.5 Business and Professional Code: Any city of county which requires a permit to construct, after, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to fie a signed statement that helshe is licensed pursuant to the provisions of the Contractors' State License Law (Chapter 9 (commencing with Section 700D) of Division 3 of the Business and Professions Code) or that he/she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than fine hundred dollars (S50m). I, as owner of.the property or my employees with wages as their sole compensation, will do the work, and the ❑ structure is not intended or offered for sale (Section 7044, Business and Professional Code: The Contractors' State License Law ,.does not apply to an owner of a property who builds or improves thereon, and who does such work himselllherse8 or through is or her own employees, provided that such improvements are not intended or offered for sale. 11, however the building or npmvernent is sold within one year of completion, the owner will have the burden of proving helshe did not build or Improve ;;rr the purpose of sale). 1 �' 1, as owner o1 tha property, am exclusively contracting with licensed contractors to construct the project (Section 7044, Business �u and Prolassions Code: The Contractors' State License Law does not apply to an owner of properly who builds or improves thereon and who contracts for such projects with a contractors) license pursuant to the Contractors' Slate License Law). I am aware ,that proof of their Worker's Compensation Insurance should be provided to me. 1 am exempt under Section: B. & P. C. for this reason: Date: Owner: I do hereby certify that I am aware of and understand the requirements of California Health and Safety Code Sections 25505, 25533, and 25534 and that I or any future building occupant will/will not (circle one) need to complywith said state codes and the requirements for a permit for construction or modification from the Air Duality Management District. Residential construction applications are exempt from these provisions. Date: Applicant: I hereby certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction and hereby horize represen ives of this enter upo above-mentioned property for inspection purposes. Date: -f ^ 3O __ Signature:LAI Driver's License or Social Security M: PYII 1641.46 While -Building: Green -Code Enforcement; Canary -Applicant: Pink -Revenue; Goldenrod -Assessor L CITY OF COSTA MESA - BUILDING PERMIT PERM NO: G 047565 PERMIT NO: G 047565 PLAN CHECK NO: 04251-90 A GOVT: N SUPP: N CONSTRUCTION TYPE: 1FR SPRINK PERMIT TYPE: ELE MEC PLU STR PURPOSE: ALT JOB DESCRIPTION : COMMERCIAL T.I. (RETAIL SALES) SQ FT: 140,000 CLAIM VALUE: 140,000.00 CALL -VALUE: 140,000,00 GROUP OCC: B-2 / COMMENTS: Z O N I N G R E Q U I R E M E N T S S E T B A C K S ------------- MAIN BUILDING ---------- --------- ACCESSORY BUILDING--------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN PARKING REO. , PROV: PARCEL: 41250102 ZNE: ClS REF NO: PLANNING N TES> INTERIOR ALTERATIONS 2ND FLOOR SUITE (VILLEROY & BACH) > � F aF iF i6 i! ie dE � 3E 3k iE'!t if it•'1(• i6 iE iF �E iE dE iF i! i6 i6 � it i6 i6 i6 i! i! dE dE 9k 9F'TE iE TE iE TE �E �t if- iF TF lE �E �F iE iF iE it BF 9t it iE iF it if if ii iE � 9E � �E � iE r1E TE if �t it• iIit �t iE TE - f- D E V E L O P M E N;T S E R'. V I C E S': R E Q U I R E M E N` T S SCS �, 1 ' dd►► '' 'ZONING APPROVED BY � •r'E� DATE,: S -3 /^• O _ p BUILDING APPROVED BY S�- �., DATE: =APPLICATION ISSUED BY: �' �� DATE: # iF iF if- �E iE TF * �E i(- 9l• dE Tt if ri4 i[• � if �E �E iE * >A � 3f• df• !t �t dt iF riE TE iE * jE * 9E � 9E dE Tf iF � iE iF iE JE � * TE iE * it iF jE iF it * iP BE * iE iE 9F TF 9F T'E dE �E yE Tf'lE * if• * 9E iF LEGALIZATION:N F E E S U M.M A R Y STRUCTURAL SEGMENT:Y BLDG PMT PLUMBING 'ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT 779,50 16,00 78.'45 26.50 25% 50% - 25% SMIP/NON-AES PLAN 126.67 21.00 15.00 -DIV-> 3fSSUE BUILDING PERMIT PLAN --;-CHECK TOTAL PAID DUE TOTALS-----> 921.45 33.00 1: --,126.67 1081.12 1081.12 .00 REVENUE DIVISION TOTALS--> COLLECTED: 1081.12 OVER/SHORT: .00 BLDG PMT PLUMBING ELECTRIC MECHANIC -FIRE SMTP/TOT GRADING PLAN -CHECK 779.50 19.00 93.45 4.1.50 21.00 126.67 �Y iE iF iF ?'F 9F Tic il•'lliE'Jf iE �F 9E iE * � if• aF iF ix; �F iF �F iF iE iE iF jE at- * is di'lE iE 3E �E iE iF �E TE �E iF iE � if iF iE iE �E iE iE iF iE iE iF 9t * iE iE iF it it it iF aE iE �E jE jE iE �E �E iE 9E aF aE aE � fiE I N D I V I D U A I! f;F E E B R E A K D O W N TYPE QTY D E S C R I P T I.0 N UNIT COST TOTAL COST SFC 140000 ALTER BY VALUE COMMERCIAL NOZONE 1.00 140,000.00 ELE 20 FIXTURES, LIGHTING 1 ST 20• EA. .75 15.00 ELE 76 FIXTURES, LIGHTING ;.ADDITIONAL EA. .45 34.20 ELE 13 RECEPT/OUTLET 1 ST 20 EA. .75 9.75 ELE 18 RECEPT/SWITCH 1 ST 20'' EA. ,75 13.50 ELE 2 NON -RES APPLIANCE NOT OVER •1.0 HP 3.00 6.00 MEC 2 VAV BOX ' 6.50 13.00 MEC 1 VENTILATION FAN CONN TO SINGLE DUCT 4.50 4.50 MEC 2 FIRE DAMPERS 4,50 9,00 PLU 1 SINK, KITCHEN % 2,00 2.00 PLU 1 WASH BASIN 2,00 2.00 01 0000;2159-00062164 TOT 19s'. 12 DAME: 05/31190 TIME: 15:03 CON-TRUP88TION AND PLANNING Date APFre30VAl.S Permit # Inspector PO.'?' APPROVALS �y y <., # Date inspector 1. Temporary Electrical Service or Pole .. 52. Pool & Equipment Location 2. Soil Pipe•Undrgrnd. `": 53. Steel Reinforcement 3: ElecfricahCbnduit Utility-Undrgrnd - r t 54. Forms -4. Electrical.Conduit-Undrgrnd. v .� 55. Electrical Bonding 5. Steel ,Reinfarcerrient" - 56. Rough Plumbing & Pressure Test 6. Electrical UFERGrnd. 57, APPROVAL TO COVER-GUNITE �Z..Foot ings . 58. Electrical Conduit•Undrgrnd. 8: -Foundation ,{ 59. Gas Pipe, ❑ Undrgrnd., Test 9. Water Pipe•Undrgrnd. � �' 60. Backwash Lines, P -Trap, ❑ Undrgrnd. 10. Structural Floor System ' ��, - 61. APPROVAL TO DECK - y 11: Property Sevoer-Line & House Connection - 62. Backwash & Receptor -Final 12, -Sewer Cap 63. Heater & Vent -Final , 13. Root Drains - 64. Plumbing System - Final- + 14.' Rough Plumbing' • - • 1 Z%� (In 65. Electrical -Final 15.;Rough Electrical Conduit !�' -Final 66. Solar System r ' 16..ftough Electfic Wiring ` 67, Fencing & Access Approval i7. ,Rough Wir,ing'.Sign, 68. APPROVED FOR PLASTERING '18. Rough Electficz4 Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning �� FIRE DEPT. REQUIREMENT APPROVALS' Permit # ' - 20. -Rough Factory Fireplace 21, Ducts, in Structure -: • 70. Undergro'urid"Hydro 22.. Ducts, Ventilating ; ; 71. Product' Piping ❑'Gas © Oil 23. Gas.Pipe•Rough & Test �_ -. + : 72, Underground Flush 1- 24. Roof Framing' " ` ' `•73.4Undergrnd: Storage Tank D Gas ❑ Oil ' 25. Roof. Sheathing 74. 'Overhead Hydro " 26. T -Bar Ceiling {StrucuraE) & Monocoat j' 75.tiDry Chemical -� :f 27..Frame and Flashings __ - n -+ u .,v n 76. Dry StandP�ipe A 28. Lathing:& Siding -' -- - 77.wFIXED SYSTEM41 1,NAL. ' 29. Insulatigri �i r 76.`FIRE PRi<V. FINAL •� - "- '30. Drywall Nailing �' ���. !.0 •J -HEALTH .DEPT.'REQUIREMENT' -31. Plaster Brown,Coat, _ ,°}1x .79.•hNA' L INSPECTION 32. Eiectrical,Pow?r Meter -Final : ; `80. FOOD CERTIFICATE'ISSUED r t r •33._FinaI. Electric, +- _ ��? �Notes:,6 7 34. 'Final: Heating -& Air'Conditioning:: EST s '0� 35.'Final'Gas:Pipe=Test'P -• J �- 36. kood or Canopy 01 37. Sinai -.Factory Fireplace-. `- ��r� e �w 38. Final Plumbing j i 11 7 LC�i'- A: h Z '39.10tee Service -Final - ,40. Gas Service -Final X41. -Solar.Domestic-Final 42. Backflow Preventer'3 r' x .' 43. Backflow Irrigation 4 44. Landscape Irrigation System ;i :•� �•• - i3 - '" ' X45. -Sound Attenuation ` t - _46. Handicap -Regulations --Z. - 47.'FINAL STRUCTURE & BUIL'""DING • 1 i 48.'F.INAL PLANNING ,49. Electric Release to Edison , _50. Gas -Release to Southern California Gas Co • • • • . • • ' • • ' 51. CERTIFICATE OF OCCUPANCY No. Date - -- PROJECT ADDRESS: UNIT: OWNER'S NAME: ADDRESS: ARCHIENGINEER: REG.NO.: ADDRESS; UNIT: PERMITTEE: ADDRESS: LICENSED CONTRACTOR DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in fug force and effect. CITY UC.: STATE LIC.: CLASS: Date: Signature: WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure or a certificate of workers' Compensation Insurance, or a certified copy thereof (Section 3800, Lab. Q. POLICY NO.: EXP. DATE: �UPANY: Certified ropy is hereby furnished. ❑ Certified copy is filed with the city Building Division. Date: Appkaat: EXEMPTION FROM WORKERS' COMPENSATION DECLARATION: {This section need not be completed if the pemrt is for one hundred ($100► or less). I certify that in the performance of the work for wtkh this perp is issued. I shall not employ arry person in any manner so as to become subject to the Workers' Compensation Laws of California. Date: Signature: NOTICE: If, after mating this declaration, you Shedd become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith compty with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY., I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Section 3097, Civ, Q. LENDER: ADDRESS: OWNER BUILDER DECLARATION: t hereby affirm that t am exempt from the Contractors' State License Law for the following reason (Section 7031.5 Business and Professional Code: Any city of county which requires a permit to construct. atter, improve, demolish, or repair any Structure, prior to its issuance, also requires the applIcant for such permit to fie a signed statement that he/she is licensed pursuant to the provisions of the Contractors' State License Law (Chapter 9 (commencing with Section 70DD) of Division 3 of the Business and Professions Code) or that helshe is exempt therefrom and the basis for the alleged exemption. Any violation o1 Section 7031.5 by any applicant for a permit subjects the applicant to a blvd penalty o1 not more than live hundred dollars ($5011). '—, I, as owner of the property or my employees with wages as their sole Compensation, will do the work, and the structure is not intended or offered Lor sale (Section 7044, Business and Proiessiohal Code: The Contractors' State License Law does not apply to an owner of a property who Mrilds or improves thereon, and who does such work himself/herself or through jj his or her own employees, provided that such Improvements are not intended or offered for sale. If, however the building or J improvement is sold within one year of completion, the owner will have the burden of proving he/she did not build or improve i Lor the purpose of Sale). I, as owner of the property. am exclusively contracting with licensed contractors to construct the project (Section 7044, Business ❑ and Professions Code: The Contractors' State Licer= Law does not apply to an owner of property who builds or improves thereon and who contracts for such projects csth a contractors) license pursuant to the Contractors' State License Law), I am aware that proof of their Worker's Compensation insurance should be provided 10 me. ❑ I am exempt under Section: B. B P. C. for this reason Date: Owner: I do hereby certify that I am aware of and understand the requirements of Cahfomia Heath and Safety Code Sections 25505. 25533, and 25534 and that I or any future building occupant will/will no (circle one) need to comply with Said State codes and the requirements for a permit for construction or modification from the Air Quality Management District. Residential comtructlon applications are exempt from these provisions. Date: Applicant: I hereby certify that I have read this application and state that the above information Is correct. I agree to comply with all city and county ordinances and state laws relating to building construction and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. Date: Signature: Driver's License or Social Security Of: 1641-46 White—Building; Green—Code Enforcement; Canary—Applicant Pink—Revenue; Goldenrod—Assessor PERMIT NO: G 047565 PLAN CHECK NO: 04251-90 A PAGE: 2 TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST PLU 1 WATER CLOSET (TOILET) 2.00 2,00 PLU 1 WATER HEATER AND/OR VENT 2,00 2.00 PLU 1 FLOOR DRAINS 2.00 2.00 PLU 1 INSTALL/REPAIR WATER PIPING EQUIP. 2.00 2,00 PLU 2 P --TRAP 2.00 4.00 END OF FEES CO 7 CTION AND PLANNING APPROVALS Permit # Date Inspector %PA APPROVALS rermit # Date Inspector 1 . Temporary Electrical Service or Pole 52. Pool & Equipment Location 2, Soil Pipe-Undrgrnd. 53. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. 54. Forms 4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6. Electrical UFER Grnd, 57. APPROVAL TO COVER-GUNITE 7, Footings 58. Electrical Conduit-Undrgrnd. 8. Foundation 59. Gas Pipe, 0 Undrgrnd., Test 9. Water Pipe-Undrgrnd. 60. Backwash Lines, P -Trap, 0 Undrgrnd. 10. Structural Floor System 61. APPROVAL TO DECK 11, Property Sewer Line & House Connection 62. Backwash & Receptor -Final 12. Sewer Cap 63. Heater & Vent -Final 13. Roof Drains 64. Plumbing System - Final" 14. Rough Plumbing 65, Electricai-Final 15. Rough Electrical -Conduit 66. Solar System -Final 16. Rough Electric Wiring 67. Fencing & Access Approval 17. Rough Wiring Sign 68. APPROVED FOR PLASTERING 18, Rough Electrical -T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit # 20. -Rough Factory Fjr�eplaee 21. Ducts, in Structure 70. Underground Hydro 22. Ducts, Ventilating 71. Product Piping OGas 00il 23. Gas,Pipe-Rough & Test 72. Underground Flush 24. "Roof Framing ' - - 4 73. Undergrnd. Storage Tank E) Gas 0 Oil 25. Roof Sheathing 74. Overhead Hydro 26.•T -Bar Ceiling-{Str_uctyral) & Monocoat 75. Dry Chemical 27. Frame and FWhirrg' 76. Dry Standpipe 28. Lathing & Siding _ 77. FIXED SYSTEM FINAL 29. Insulation -' 78. FIRE PREY. FINAL 30. Drywall Nailing .�-,. HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat - 79. FINAL INSPECTION 32. Electrical Powef Meter -Final 80, FOOD CERTIFICATE ISSUED 33. Final Electric] r Notes: 34. Final Heating- -Air Conditioning r 35."Final Gas Pipe -Test.- 36. Hood or Canopy 'Y 37. Final Factory Fireplace 38. Final Plumbing 39.'Water Service -Final 40. Gas Service -Final 41..Solar Domestic -Final 42. Backflow,Preventer 43. Backflow Irrigation 44. Landscape Irrigation System 45. Sound Attenuation 46. Handicap Regulations 47, FINAL STRUCTURE & BUILDING 48. FINAL PLANNING 49. Electric Release to Edison 50. -Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY No. Date (114)754-5273 • Fax(714)754-4856 .lob Address: 3333 BRISTOL ST Suite: 2225 Vicinity: Parcel Number: 41250107 Applicant: DEHOYOS,JESSE Address: 818 N GRAND AV CITY OF COSTA MESA BUILDING DIVISION DEVELOPMENT SERVICES DEPARTMENT Pi T01�41�11ER PERMIT Zoning: PDC PDC Phone: (626) 913-6720 77 FAIR DRIVE, COSTA MESA, CA 92626 ISSUED BY: Status: ISSUED Applied: 12/30/1999 Issued: 01/2012000 J NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 160 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 COVINA,CA Zip: 91724 Owner: SOUTH COAST PLAZA Address %C J SERGERSTOM. ' COSTA MESA, CA Phone: 3315 FAIRVIEW RD Zip: 92626 Contractor: ' ALLREADY FIRE SPRINKLER CO Address: 818 N GRAND AV Phone: (626) 913-6720 COVINA,CA Zip: . 91724 License: 358795 s , SCOPE OF PERMIT RELOCATE 38 FIRE_ SPRINKLERHEADS FOR "BRUNO MAGI-]" SUITE 2225. + REF:B99-01777 FEE SUMMARY Plan Check: $63.21 Calc Valuation: $4,000.00 Permit: $97.25 Claimed Valuation: $4,000.00 Other: $0.00 - - - Total: $160.46 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 160 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 7rner: OMPENSATION DECLARATION: under penalty of perjury one of the following declarations: nd will maintain a certificate of consent to sett -Insure for workers'compensation, as provided for by section 3700 of the i abor Coda, for the performance of the r which thispermit is issued, nd will maintain workersompensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. kers' cam ensation Ins ren 1e carrier and policy number era: �� (1 S� _ Policy Number: (This section need not be completed if the permit is valued at one hundred dollars ($100) or less.) ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Celifognia, andAgree hat if Isho become subject to the workers' compensation provisions of Section 3700 of the Labor Code, i shall forthwith Comply with these provisi Applicant Signature: \g. ��X�f _ 1 r_ti'� Date: WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE CAST OF COMPENSAT30N, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed underrovisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Proles 'ons Code, and my license is in full force and effect. Lic. #Class 0 Contractors Signature: �a j Date: CONSTRUCTION LENDING AGENCY: ❑ J hereby affirm that there Is a construction lending agency for the performance of the work for which this pormit is issued. (Sec. 3097, Civil Code). Lender's Name: Landers Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the appf)cant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ f, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for safe (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WiTH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I em exempt under sac. Business and Professions Code for this reason: Signature: bate: Owner ID verified by driver's license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, l will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature; Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future b0cling occupant need to file and cerlify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materiels equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, 2 Does or will the t of compressed e sed gas standard - temperature pressure). g_.-.----.....-,_.--_ ..... - _ ... - , ------ � -,.... --------- or 200 cubic feet of cam rested as at s andard temperature an pressure - on uture buildingoccupant need to file a re istration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses wfifch are required to register acutely hazardous materfais with the Fire Department, 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this application a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? 0 Yes � No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (if 'yes', attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: f certify that under penalty of perjury the Information given above is correct. ) agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Dale: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this appiication and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. gn _WLegal 4ate L--r�-�� _ _ _ _ / -11;LG.- And/Or Authorized Applicant Date SDE 4, INSPECTION TYPE J)M INTMALS POE I INSPECTION TYPE DATE INTITIA6$ 1616 Fixed System Final Fire Prevention ;.-q-co Lgi 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention Z 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy 2448.45 CityoftostaNaa Development Services, Division of Building and Safety .1-1000400p; CERTIFICATE OF OCCUPANCY +L- This certificate is issued pursuant to,the requirements of" h,,Uniform Building Code, Section 308 adopt'e`d by the City of Costa Mesa certifies.that at the time ofits:issuance the building structure herein below described was inspected and5lp6ro�ed>for'occupancy.as foAows: lZi. Building Address 3333stol Street #2225 �. vBldg. Permit No. B-082345 Use 2b00SF Retail Store�kI..1l , .fit �J P�(1 • �!7 _ 1 . _�- .. - �j1, �• At Group M Type of,Consfruciion 1FR-SP Fire Zone --i, ' 1 `*' Use Zone B15 Owner of Building C.:I:+SAgPr'ratroin%& "s�y� -- y --hant Villeroy S Boch �^ Mfr Address 3 ,Roa \. Costa Mesar CA 2626: ` B BURDING OFFICIAL-COrip'V.Oe :�= .:�' J ' -` %~.�i\Date", rfi.May 20. 1997 r REQUIRED TO BE POSTED IN -A CONSPICOUS PLACE ADDRESS OF DIRU]M0, 3333 BRISTOL ST UNIT: 2225 WHER'SNMEIF00MN: C . J . SEGERSTROM & SONS ADD"M 3315 FAIRVIEW RD C:M. 92626 (714)546-0110 APDL. MAILING AODREss: ARCHITECT OR ENGINEER: PAUL J. R U F F I N G uc. No: C 4 2 6 4 ARCK OR EIn'S ADDRESS: 2701 HARBOR VIEW DR UNT; CORONA DEL MAR CA 92625 CwnTOn"AW-' DEVELOPMENT SUPPORT SERVI (714)957--8250 cONTRAcronull ND 1515 W ALTON AV ADORM SANTA ANA CA fic-NO.: 672025 92704 UNIT: LICENSED CONTRACTORS DECLARATION: I hereby affirm under Penalty d pwjwy Utas I f omens arxer 9 loommendnp with Section 7000) d Division 3 d the Business and Professions Cods. and is In IuS force and 00001. CITY LIC. "0-'-064532 LIC. CLAM: B LIC. No.: �, 7 2 EXP : 03/98 Date: Contractor: OWNER BUILDER DECLARATION: I hereby affirm under penalty of perjury Pt fon 1 Cerdractore Liana Law for the rotlowing reason {Section 7031.5 Business mid Prof ids Code: Any city or aourty said reTkas a 't to oasmct, cher, improve. wnofish. or repair any structure. prior to is issuance. also requires the app6mra for such permit to file a signed stelemwq that he or she liow,aed ptrslard to the proviskm of the Contmaors License Law tehapler g (cammsocieg with $Won 7000) of Division 3 of the dusinesa and Professions Coda) or thuya he or els is exempt therehom and the basis for the alleged exemp on. Any violation of Section 7031.5 by any applicant for a permit sabjsW the applicant to a dvi penalty at not mon than iwa hundred dollen [MD. p 1, as owner of the pwarty or my employees with waves as then sole compensation. wit do dna worn rad the structure is not mended or offered for safe (Section 704, Business std Professions Code: The Contractors License Law does not apply to an owner of property who bu;bs or improves lhweon. and who does such worn tinsel or handl or through he or her own employees. provided that such improvements we nil bdervied or armed for Sale. I, however. the building or improvamert is add within ons yew of completion. the owner-0ur1dor will have the burden of proving he or she did rot bard or improve far the purpose of sale). ❑ 1, as owner of the property. em exdWiV* contracting with licensed amtraclon to construct the proiea (section 7044. BRsiness and Professions cods: The Comraaan License Law does not appy to an owner of property who bw7dt or improves therson and who contrach for each pm*u with a eortrador(a) loused prasuard to the Contractors Liowe caw). ❑ I am exempt under section: B. a P.C.. far this reason: Data: owner. I do hereby certify tha I am aware of and undwstaM the requimna is of California Paahh and Safety Code Sections 25505,25M, and 25534, and that I or any Mune buildup ec6ryam will I will not (circle one) need 10 comply with said trate codes and the requirements for e permit fa construction or mod 1ication tram the Aiananganerl Distrid. Residwtid construction appicalons am axwnpl from these provisions. Data: APPlCara: WORKER'S COMPENSATION DECLARATION: i hereby affirm under penalty of perjury are of the fallowing dedwations: ❑ I have and will maintain a coMitale of ooruwtt to 9041 urn tar workers' oompansalion, as provided for by Section 3700 of the Lobar Code, for the parfanne nce of the work fol Mich this permit is issued. I have and wit mairtam worker,' compensation trseuanos, w requh by Stenon 3700 d the Labor code, for the performance of the work for which this permit is issued. My werken' compensation trsuranca orrisrand policy number aur. Carlo: STATF FUND _ ,_, EXPIRES Policy Number: /-01 /98 (This section need not be camplered t the permit is naw ora hnutdred datfars [$ tool or lea.V�E ❑ I certify pat in the Performance d the work lar which this Permit n issued. I fh on in any manner isoas to become wuhject to the workers' compensation laws d Cafdomie, and ag s subpar t0 the workers' compensationprovisionsof SWion 37o0 d the Labor Code. I shelf forthwith owns. Date: Warning: Fagan to aware wolki ra' comper"don Covent's to untatvhd, an feCf enfoloyw• to erfminal penddas and civil Ifnes W to ons hundred thoasend dollen (i10(;0W), In addtdon to Uta cut of oo tkk% danrsyas as provkfed flor In Section 37Is of me Labor Coda, Interns; and attorney's fees. CONSTRUCTION LENDING AGENCY: I hereby affirm under penalty of perjury that then in a construction lading agency for ds performance d the work far which this panni is issued (Section 3097, Civ. C). LENDER'S NAME: LENDER'S ADDRESS: I certify that I Mea reed this application and sate that the above irdamation is correct. I agrse to comply with all dry and county, ordinances and state laws relating to Wiketg cor iniclim and mtfcrirs reprss of this city to order upon the above•mentioned fib for inspection purposes. Dale: 4-?- 1? (5151.460P) Whao-tilding d safe!): Graar-we: canny-Appiaert: Pink4 avenim Goldenrod -Assessor CITY OF COSTA MESA -- BUILDING PERMIT PERM NO: B 082395 PERMIT NO: B 082345 PLAN CHECK NO: 01088-97 A GOVT: N SUPP; N CONSTRUCTION TYPE: IFR -SP PERMIT TYPE: STR PURPOSE: ALT JOB DESCRIPTION ; 2600SF RETAIL STORE TI SQ FT: 40,000 CLAIM VALUE: 40,000.00 CALC-VALUE: 40,000.00 GROUP OCC: M / COMMENTS: "VILLEROY & BOCH" Z O N I N G R E Q U I R E M E N T S S E T B A C K S JE___ _______MAIN BUILDING ------------ ---------- ACCESSORY BUILDING --------- NT: FT IN REAR: FT IN FRNT: FT IN REAR: FT INFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN PARKING REQ: PROV: PARCEL: 41250102 ZNE: CIS REF NO: PLANNING NOTES> TENANT IMPROVEMENT TO A 2600 SQ. FT. RETAIL SPACE (VILLEROY > & BOCH) i � if � �E ill �E �E ill ill �E ill ill iE'}F ill ill it ill f6 ill �F if ill �E �F ill ill ill ill ill ill ill iF lE 1E ill �E �E ill ill ill all ill ill � � ill 1E ill ill ill * * if• ill ill fE iF !E jE * lF ill dE � �E �E �,iE lE,�E ill ill ill ill � ill i6 �t D E V E L O P M E — NS T^ S E R V I C E S R E Q U I R E M E N �Tf'S ZONING APPROVED BY :� _ T _ DATE: 7 BUILDING APPROVED BY : DATE: 1'}. APPLICATION ISSUED BY: DATE: 4ll-.�% LEGALIZATION:N F E E S U M M R Y STRUCTURAL SEGMENT:Y BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT 484.75 SMIP/NON-RES PLAN 78.77 8.40 ISSUE FEE BUILDING -DIV-> PERMIT ISSUE PLAN -CHECK TOTAL PAID DUE TOTALS ---- > 493.15 0.00 78.77 571.92 571.92 .00 REVENUE DIVISION TOTALS--> COLLECTED: 493,15 OVER/SHORT: .00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMTP/TOT GRADING PLAN -CHECK 484.75 8.40 ill if .� � � � 3I -'YF ill ill ill ill * NE ft ill if• ill ?f ill ill � ill fE � )E it ill ill ill ill ill ill ill * fE * it �E ill 9E ill $E 4E iE�E i4�t ill i(ill 9t ill i� iF � �F ib �E �'1[- �E � 3F � ill � ill dE ill fF fE ill 1E �E # dt �E � I N D I V I D U A L F E E B R E A K D O W'N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST SFC 40000 ALTER BY VALUE The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § COMMERCIAL NOZONE 7.,00 40,000,00 END OF FEES 04-07-1997/02:28 Pitt/$493.15 REPT111:01-6004460 PERMIT:082345 I •CONSTRUCTION AND PLANNING APPROVALS Permit # Date 1. Temporary Electrical Service or Pole inspector POG ., SPR APPROVALS Permit # 52. Pool & Equipment Location Date . Inspector 2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. 54. Forms 4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6. Electrical LIFER Grad. 57. APPROVALTO COVER-GUNITE 7. Footings 58. Electrical Conduit-Undrgrnd. 8. Foundation 59. Gas Pipe, ❑ Undrgrnd., Test 9, Water Pipe•Undrgrnd. - 60. Backwash Lines, P -Trap, ❑ Undrgrnd. 10. Structural Floor System 61, APPROVAL TO DECK 1.1. Property Sewer Line & House Connection 62. Backwash & Receptor -Final ' 12. Sewer Cap '63. Heater & Vent -Final 13. Roof Drains 64. Plumbing System - Final 14. Rough Plumbing 65. Electrical -Final 15. Rough Electrical -Conduit 66, Solar System -Final 16. Rough Electric Wiring 67. Fencing & Access Approval 17, Rough Wiring Sign .68. APPROVED FOR PLASTERING 18. Rough Electrical•T Bar Ceiling '69. POOUSPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit # 20, Rough Factory Fireplace 21. Ducts, in Structure 70, Underground Hydro 22. Ducts, Ventilating 71. Product Piping Q Gas ❑ Oil _ 23. Gas Pipe -Rough & Test 72. Underground Flush 24. Roof Framing 73. Undergrnd. Storage Tank ❑ Gas 0 Oil 25. Roof Sheathing 74, Overhead Hydro 26. T -Bar Ceiling (Structural) & Monocoat 75. Dry Chemical 27. Frame and Flashing 76. pry Standpipe 28. Lathing & Siding 77. FIXED SYSTEM FINAL 29, Insulation 78. FIRE PREY, FINAL 30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat 79. FINAL INSPECTION 32. Electrical Power Meter -Final 80. FOOD CERTIFICATE ISSUED 33. Final Electric Notes: 34, Final Heating & Air Conditioning 35. Final Gas Pipe -Test 36. Hood or Canopy 37. Final Factory Fireplace 38, Final Plumbing 39. Water Service -Final 40, Gas Service -Final 41. Solar Dornestic-Final 42. Backflow Preventer 43. Backflow Irrigation 44. Landscape Irrigation System 45, Sound Attenuation 46. Handicap Regulations 47. FINAL STRUCTURE & BUILDING r 48. FINAL PLANNING 49. Electric Release to Edison 50, Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY No. Date RES" of 1uLwxk, 3333 BRISTOL ST UNIT: 2225 OWRER'6NAYEIFIQlo1OWC ,,x , SEGERSTROM & SONS 90IM 3315 FAIRVIEW RD C. -M-92626 (714)546-0110 APDL. MAILING ADDRESS: ARCHITECT 0R DI2NEER: PAUL J. BUFFING uc. No_ C 4 2 6 4 wKoRENG.sADDREss: 2701 HARBOR VIEW DR UNIT.. CORONA DEL MAR CA 92625 CONTRACTOR'SwuliE. DEVELOPMENT SUPPORT SERVI (714)957-8250 cCNTRAcrows Blum 1515 W AL TON AV AODI n:SANTA ANA CA ucNo.: 672025 '32Aofry UNIT: LICENSED CONTRACTORS DECLARATION: I hereby affirm undethat am licensed under pro-gWona d Chapter 9 looemerncing with Section 7000) d Division 3 ol the Business and Ircenae is in frill farce and Gonad. CITY LIC. +NrO.D 6 4 5 3 2 LIC. CLASS: B 5 EXP • 03/98 Data: 4 - Contractor: OWNER BUILDER DECLARATION: I hereby affirm under penalty exam the Comrarxom License Lew fol die following reason (Sadion 7031.5 Business and Professions Code: Aich requ a permit to oonatrud. filer, improve, ' imolish, or rep& arty structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she licensed pursuant to the praMsiorra of the Contractors License Law (Chapter 9 (oommencing with Section 7000) of Division 3 of the ,rainess and Professions Code( or that he or she is exempt therefrom and the basis for the alleged exemption. Arry violation of Section 7031.5 by any applicant for a permit subjects the applicant t0 a Civil penalty of net more than five hundred dollars [MD" ❑ I, as owner of the property or my employees with wages as Ih& We compensation, will do the work. and the structu-reis not intended or offered for sale (Section 7044, Business and Profe8310hS Code: The Contractors License Law does nil apply to an owner of prop" who builds or inproves thereon, and who does such work himself or hersell or through his or her own employees, provided that such improvements are not intended or offered for sale. N, however, the building or improvement is sold within one year d completion, the owmrrbuilder will have the burden of proving he or she did not build or improve for the purpose of sale). R� ❑ I. as owner of the property, am exdrpively contracting with licensed contractors to construct the project (Sedion 70th. Business and Prdassiom Coda: The Contractors License Law does not appy to an owner of property who builds or improves thereon and who convects for such projects with a oomrador(s) licensed pursuant to the Contractors License Lew). y .r . 1 am exempt under Section: B. 5 P.C., for this reason- Dale: owner. I do hereby eadify that I am aware of and understand the requirements of California Health and Safety Code Sed'25505, 25533, and 25534, and that I darty future building occupant will I will not (drele one) need to comp$ with said vete codes and the requirements for a permit la comtruciionor rnodiltmtionlromthe Aiwa-rity-Vanegemerd District. Residential wnalrudion appimtiomare exempt from these provisions. Data: ApplicmR: WORKER'S COMPEP48ATION DECLARATION: I hereby aflmrl under penalty d perjrsy one of the loRowing dedemions: Q I have and will maintain a Certificate or oonsem to selfinaure for workers' compensation, as provided for by Section 3700 of the Labor Code. for the performance of the work for which rhes permit to issued. I have and will maintain workare' canpernaW ion insurance, as required by Section 3700 of the Labor Code, for the performance of the }l work for which this permit is issued. My workers' oomperisation insurance Terrier and poky number are: Carrier. STATF FUND EXP RES Policy Numbr. ? -C17 /01/98 (Thi section need nil he comGlGred of Tits permit a for one hundrad dadars 1$'100) or lass. ❑ I caddy that in the padonnence, d the work hon which this permit is issued. I any person in arty manner so as to beodne subject to the workers' compensation lawn of California, and became subject to the workers' com�peensation provisions d Section 3700 d the Labor Cade, 1 shell forthwith comp ods Provraone- "S Date: — 3 — j, l _ App.: WGmlrry: Failure m ucraa tvorkars' comprnsaflon covenpa is emlawMf, end shell sub r , err 10ji err fo erlmfnef panalwas and clvU Ones W to an hundred Mousand dollars ($11140MI kr *Mtbn to tan cost of co damn" as pm~ foe In Section 9706 of ft Labor Coda, lntarwit, and effornWs faea CONSTRUCTION LENDING AGENCY: 1 hereby affirm under penapy, of perjury that there is a construction lending agency for do performance of the work for which this permit is issued (Section 3097, Civ. C). LENDER'S NAME: LENDER'S ADDRESS: I Candy that I have Head this application and slate I" above information is cared. I spree to campy with ell city and county ordinaries and state taws rotating to build'rgoorsstr labor autlror¢e repress d er this city to enter upon the above-meioned property for inspeclion purposes. MICHAEL H Data: (515146.WP) White -Building A Safety: Gree fl% Canary-Appkrem; Pink -Revenue; Ciddenrcd-Assessor CI'T'Y OF COSTA MESA - BUILDING PERMIT PERMIT NO: E 082346 PLAN CHECK NO: N CONSTRUCTION TYPE: IFR -SP PERMIT TYPE: ELE !JOB DESCRIPTION 2600SF RETAIL STORE TI (ELECTRICAL) ICLAIM VALUE; CALC-VALUE: PERM NO: E 082346 GOVT: N SUPP: N PURPOSE: OTH SQ FT: GROUP OCC: M / COMMENTS: "VILLEROY & BOCH" / RE: B82345 Z O N I N G R E Q U I R E M E N T S S E T B A C K S ------ ---- MAIN BUILDING--_-_-------------�--'- ACCESSORY BUILDING --------- FRNT: FT IN REAR: FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT: FT IN PARKING REQ; PROV: PARCEL: 41250102 ZNE: REF NO: PLANNING NOTES> d(- iE'rE iE iE iF hE iE iE iE iF iE � iE iF iE * iE- iF �(- dE 1E iE iE i6 hE iF hE iF iE iE iE iE �E iE iE iE * iE iF it• iE !F iF * * iE iE fE iE iE hE � iF hE iE iE 9E �[- �E iE iE iE * iE it• �E -)E iE iE iE• iE � � � �F iE iE !E D E V E L O P M E N T S E -R V I C E S R E Q U I R E M E N T S ZONING APPROVED BY DATE: BUILDING APPROVED BY : µ DATE: APPLICATION ISSUED BY: ,= DATE: * iF iE• h(• � #P 9(• � * � � � iE if- � � i6 * tiEli_ dE- � � 3E 4E � 1E �(- iE iF''E �E � iE LEGALIZATION:N F E E'( S U M PA R Y STRUCTURAL SEGMENT:N BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT 2.00 50t SMIP/NON-RES PLAN ISSUE FEE 22.00 BUILDING -DIV-> PERMIT ISSUE PLAN -CHECK TOTAL PAID DUE TOTALS ---- > 2,00 22,00 0,00 24.00 24.00 .00 REVENUE DIVISION TOTALS--> COLLECTED: 24,00 OVER/SHORT: .00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/TOT GRADING PLAN -CHECK 24,00 iE iE * iE )E iE if jE iE iE iE'lE * iE iE iE 4E iE iE iE iE iE # � iE 3F � iE iE * # �E'lE )E iE iE iE hF iE h6 hE �E iE * dF iE � * iE if !E iE 4E OE fE iE iE if * � iF 4E * >'E iF iE fE iE hE iE if # iE * it- iE iE hf if I N D I V I D U A L F E E B R E A K D O:W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST ELE 2 RECEPT/OUTLET The work authorized by this permit shall comply with all applicable handicap access requirements under California statute's and related regulations. (Ord. No. 92-28, § 1, 12-21-92) 1 ST 20 EA. 1..00 END OF FEES 2.00 04-07-1997/02:29 PM/S24.06 RCPY11:01-0084461 PERMIT:082346 CONSTRUCTION AND PLANNING - • 'Date ` APPROVALS Permit #., r''' Inspector Pdq. ;PR � APPROVALS Permit # Date Inspector 1. Temporary Electrical Service or Pale 52. Pool & Equipment Location ' . 2. SoiE Pipe Undrgrnd. 53. Steel Reinforcement 3. Flectrical Conduit Utility-Undrgrnd, ' 54. Forms - 4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding , 5" Steel Reinforcement I 56. Rodgh Plumbing & Pressure Test 6. Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE. 7. Footings 58, Electrical:Conduit-Undrgrnd. 8. Foundation 58. Gas Pipe, © Undrgrnd., Test 9, Water P"spe-Undrgrnd, 60, Backwash Lines, P•Tra3 , 0 Undrgrnd. '10. Structural Floor System 61. APPROVAL TO DECK 11. Property Sewer Line & House Connection 62. Backwash & Receptor,-Final k 12. Sewer Cap ,63: Heater & Vent-Final 13. Roof Drains 64. Plumbing System - Final 14, Rough Plumbing -65. Electrical-Final 15. Rough Electrical-Conduit .. Solar System-Final 16. Rough Electric Wiring 17. Rough Wiring Sign q-LS. 2. Fer}cing'&Access Approval 68. APPROVED FOR PLASTERING' .' 18. Rough Electrical-T Bar Ceiling 69. POOL/SPA SYSTEMS FILIAL 19, Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit # 20. Rough Factory Fireplace 21. Ducts, in Structure 70. Underground Hydro 22. Ducts, Ventilating 71. Product Piping © Gas © Oil r 23. Gas Pipe-Rough & Test 72. Underground Flush 24: Roof Framing 73. Undergrnd, Storage Tank © Gas O oil 25. Roof Sheathing 74. Overhead Hydro 26, T-Bar Ceiling (Structural) & Monocoat 75, Dry Chemical 27. Frame and Flashing 76. Dry Standpipe '" Q Zw r 28. Lathing & Siding 77. FIXED-SYSTEM- FINAL 29. Insulation 7$. FIRE PREY. FINAL Y 30, Drywall Na-sling _ HEALTH DEPT, REQUIREMENT 31. Plaster Brown Coat 79. FINAL INSPECTION 32, Electrical Power Meter-Final 80. FOOD CERTIFICATE ISSUED 33. Final Electric �•h��! Notes: 34. Final Heating & Air Conditioning - 35. Final Gas Pipe-Test 36. Hood or Canopy 37, Final Factory Fireplace ri 38. Final Plumbing - 39. Water Service-Final 40. Gas Sea�ice-Final ' 41. Solar domestic-Final 42, Backflow Preventer 43, Backflow Irrigation 44. Landscape Irrigation System 45, Sound Attenuation 46. Handicap Regulations 47. FINAL STRUCTURE & BUILDING , 48. FINAL PLANNING 49. Electric Release to Edison , i- 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY No. Date .— — CITY OF COSTA MESA ' r BUILDING DIVISION i 77 FAIR DRIVE, COSTA MESA, CA 92626 - (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BX10-00056 PERMIT TYPE B_MISC STATUS: ISSUED APN: 41250107 DATE ISSUED: 04/12/2010 Zoning: PDC, ISSUED BY: RMD JOB ADDRESS: 3333 1844 BRISTOL ST CM Suite/Unit: 1844 Vicinity: STORE FRONT SPACE 1844 Primary Occ: Const Type :?? SO. FT: 0 Valuation: $500.00 SCOPE OF WORK: INSTALLATION OF A NON -ILLUMINATED STORE FRONT SIGN FOR "FREE PEOPLE", SPACE 1844. OWNER: SOUTH COAST PLAZA City/State: COSTA MESA, CA Phone: APPLICANT: DISK, EVA G104 City/State: MURRIETA, CA Phone: 800-723-4948 Address:: 3315 FAIRVIEW RD Unit Zip Code: 92626 Address: 29910 MURRIETA HOT SPRINGS Unit: UNIT Zip Code: 92563 CONTRACTOR: GLOBAL LIGHTING AND SIGNS License No. 870582 Address: 29910 MURRIETA HOT SPRINGS G104 City/State: MURRIETA, CA Zip Code: 92563 Phone 800-723-4948 Cell: ARCHITECT: License No. Phone ENGINEER: License No. Phone FEE SUMMARY Building Plan Check: $15.28 Building Permit: $23.50 Electrical Permit: $0.00 SMIP Residential $0.00 SMIP Commercial $0.50 Bldg Std Admin Fund $1.00 Unit: UNIT TOTAL FEES $40.28 HOURS FOR CONSTRUCTION ACTIVITY: EFFECTIVE 3118/2010 - PER CMMC Sec. 13-279 Monday thru Friday - 7:00 am thru 7:00 pm. Satrudays -9:00 am thru 6:00 pm. Prohibited all hours - Sundays and the following Federal Holidays: New Years Day, Memorial Day, Independence Day, labor Day, Thanksgiving Day and Christmas Day NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE I. INSPECTION TYPE 9AN IN AL CODE i INSPECTION TYPE OATE INTMAL 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Root 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place i ry 220 Final Planning Approval 203 Final Sign % F;TI(��� '� 222 Final Site 204 Final Demolition JJJJ 250 Final Building/Occupancy W09KERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ [have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: am�'er " (This section meed not be completed a rhe permit a vaned ar one hundred dollars f E too) or less) P i Number' I certify that in the perforrnance of the work for which this permit is ,sued, I shall not employ any person in any manner so as to become subject to the worker compensation laws of California, and agree that if I should becorn, ubl t the pens ion pr visions of Section 3700 of the L ar C e s li o wit I applicants Signature P Res ovisio s. �J,D Division of Industrial Safety Permit Number: egna a Date C7}s*4., . WARNING FAI URE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UA TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THS COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. Owner ID verified by drive, . license. ❑ Yes ❑ No ,! Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap, 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code), ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. LICENSED CONTRACTORS DECLARATION: hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license" force an�ffect. r .� CONSTRgCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penally of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve. demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to en owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractors) license pursuant to the Contractors License Laws.). ❑ lam exempt under sec. Business and Professions Code for this reason: Signature 3057-46(3707) Date Dale HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4, If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? []Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'fres", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If "yes", attach certificate of compliance from the appropriate air pollution control officer), CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penally of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by 14is permit until final inspection. pr n CITY OF COSTA MESA P- 9 BUILDING DIVISION F77 FAIR DRIVE, COSTA MESA, CA 92626 - (714) 754-5273 - Fax (714) 754-4656 - www.ci.costa-mesa.ca.us FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: E10-00085 PERMIT TYPE ELEC STATUS: ISSUED APN: 41250107 DATE ISSUED: 05/20/2010 ISSUED BY: RMD JOB ADDRESS: 3333 1844 BRISTOL ST CM Suite/Unit: 1844 Vicinity: $COPE OF WORK: INSTALLATION OF A 200 A SERVICE PANEL LOCATED AT SPACE 1844. NO OTHER WORK AUTHORIZED UNDER THIS PERMIT. OWNER: SOUTH COAST PLAZA PHONE: APPLICANT: SCHELIN, KEVIN PHONE: 714-556-8591 CONTRACTOR: SMALLCOMB WIRING CORPORATION Address: 136 E GARRYUnit: PHONE: 714-556-8591 City/State: SANTA ANA, CA ZipCode: 92707 ELECTRICAL PERMIT FEES Electrical Plan Check Fee: $0.00 Electrical Permit Fee: $54.00 Reinspection Fee $0.00 TOTAL FEES $103.50 Address: 3315 FAIRVIEW RD Unit: City/State/Zip: COSTA MESA, CA Address: 136 E GARRY Unit: City/StatelzZip: SANTA ANA, CA License No. 145961 CELL: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. Cgol I IHS TIN 26A INTMAL CODE A INSPECi10NT1� DATE INTMAL 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical�� 201 Final BloclkJRetaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain workers' compensation insurance. as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. M workers' compensation Insurance carrier and policy number are: �Carr'ra (This section need not be rmrpfered d the pemW is valued a1 doifars (S100) or fess) 6;i y Nbmber: ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so a$ to become subject to th workers' comp sation Paws of California. and agree that if I should bec subje th rkers' compensation provisions of Section 3700 of the a r Co e, I rthwith comply with these provlsl ns. 1 viol A r-Oa1 WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and ;ic s is in full for and effect. C-4.0 o li-E aacicK Signature ,Date CONSTRUCTION LENDING AGENCY: T ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code), Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are riot intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature Date 3057-46 (3/07i Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, false'tiork, or demolition or dismantling thereof, will be more than thirty -sic (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Date Division of industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION; 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions. requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4, If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be fumished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If -yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to Comply with all slate laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: f certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspecho purposes. I agree not to occupy or allow occupancy of any building authorized 4v this perms pntil final inspection. Sign tui Owners) 111� tihwAalhortzt?' pp icanl ,V"T -_ CITY OF COSTA MESA T BUILDING DIVISION r 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 - www.ci.costa-mesa.ca.us �. FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BC10-00053 PERMIT TYPE: B_COMBO STATUS: ISSUED Sub Type: COM—ALT DATE ISSUED: 04/26/2010 ISSUED BY: RMD JOB ADDRESS: 3333 1844 BRISTOL ST CM APN: 41250107 Zoning:PDC, , Vicinity: SPACE 1844 Const Type: I -A SQ. FT: 1371 Suite/Unit: 1844 Primary Occ: Valuation: $250,000.00 SCOPE OF WORK: 1,371 SF INTERIOR TI FOR "FREE PEOPLE", SPACE 1844. WORK TO INCLUDE THE CONSTRUCTION OF NEW NON-BEARING INTERIOR PARTITION WALLS, NEW FINISHES ON FLOOR, CEILING AND WALLS, CONSTRUCTION OF A NEW ACCESSABLE RESTROOM, REPLACE EXISTING STORE FRONT FRAMING WITH 1 VAV BOX, 84 LIGHT FIXTS, 18 OUTELTS, 3 SWTICHES, 1 FLOOR DRAIN, 1 TRAP PRIMER, 1 WASH BASIN, 1 WATER CLOSET. OWNER: SOUTH COAST PLAZA Address: 3315 FAIRVIEW RD Phone: City/State/Zip: COSTA MESA, CA APPLICANT: HACKWORTH, STAN Address: Phone: 816-284-0126 City/State/zzip: CONTRACTOR: BURDG DUNHAM AND ASSOCIATES CONSTRUCTION CORPLicense No. 552625 1616 Fixed System Final Fire Prevention 206 Final Mechanical Phone: 816-583-2123 Address: PO BOX 157Unit: Cell: City/State: HAMILTON, MO ARCHITECT: License No. ENGINEER: REZAEI CONSULTING ENGINEERS License No.41068 COMBINATION PERMIT FEE SUMMARY 203 Final Sign 222 Final Site Building Plan Check: $1,191.94 Building Fees: $1,833.75 Electrical Fees: $115.32 Mechanical Fees: $34.15 Plumbing Fees: $62.70 SMIP Residential: $0.00 SMIP Commercial: $52.50 Bldg Std Admin Fund $10.00 TOTAL FEES: $3,300.36 Unit: Unit: : ZipCode 61644 PHONE: PHONE:949-975-1328 'Refer to fee recoipts for all fees paid for project HOURS FOR CONSTRUCTION ACTIVITY: EFFECTIVE 311812010 - PER CMMC Sec. 13-279 -"" •___, Monday thru Friday -7:00 am thru 7:00 pm. Saturdays- 9:00 am thru 6:00 pm. Prohibited all hours - Sundays and the following Federal holidays: New Years Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day and Christmas Da NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1. 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE 0. INSPECTION TYPE AST INTMAL5 CODE I INSPECTION TYPE DATE INiMALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing.1� 200 Final Re -Root 214 Final Electrical 1s— d 9 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 250 Final Buildin lOccu an 204 Final Demolition 9 P cY WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: 1_ arae. Gr/\l lAfA&I- JInSNI:a^tt CR,. -n. (This section need nor be cemple+ed I the pemar is vai al one nurdreO (S700) ) «fess) PdticNumber: ❑ I certify that in the performance of the work for which this permit is issued, t shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor ode, t s //.. 11/Iforthwith comply with these provi(siionsJ. /�Lyl /JYWI..0? • r -ji7 - to pp ws pnaturer­ 1 WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. lass# %3 ac. -/o C ofSSignature rey CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - properly tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby Certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty -sic (36) feet high. (Chap, 3.2, Grp 2. Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Date Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the Califomia health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds. or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? []Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the Califomia Health and Safely Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the Califomia Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if -yes-, the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by Califomia Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If 'fres", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. eirature I at Owners) Date Signature Gate 3057-46 (U07) � �,.AndW wrized,Apprrmnt~^"� CIPAIC __�:__, CITY OF COSTA MESA o� jW , BUILDING DIVISION f 77 FAIR DRIVE, COSTA MESA. CA 92626 • (714) 754-5273 • Fax (714) 754-4856 www.ci.costa-mesa.ca.us t- �.� FOR INSPECTIONS CALL: (714) 754-5626 F10-00068 FIRE SUPRESSION PERMIT Jab Address: 3333 BRISTOL ST Suite: 1844 Vicinity: SUBTYPE: OVERHEAD Parcel Nunmber: 41250107 Applicant: CARRASCO, SONIA Address: 1642 S CLEMENTINE ST Phone: 714-502-0211 XT 11 ANAHEIM, CA Zip: 92802 Owner: SOUTH COAST PLAZA Address 3315 FAIRVIEW 8D Phone: COSTA MESA, CA Zip: 92626 Contractor: PACIFIC FIRE SUPRESSION Address: 1642 S CLEMENTINE ST Phone: 714-502-02i1 ANAHEIM, CA Zip: 92802 License: 423418 Status: ISSUED Applied: 05/0412010 Issued: 05/04/2010 SCOPE OF PERMIT: FIRE SUPPRESSION PERMIT TO ADD 17 NEW FIRE SPRINKLER HEADS IN CONJUNTION WITH A 1,371 SF INTERIOR TI FOR "FREE PEOPLE-, SPACE 1844. REF#: BC10-00053 FEE SUMMARY Add'I Inspection Fees, $0.00 Total Fees: $176.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12.21.92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CQDE 0. INSPECTION DATE IN1mAL OM INS"CTIOH TYPE DATE IN AL 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final BlocklRetaining Wall 212 Final Fire Prevention L% _ 202 Final Faclory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to setf-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: _ Carrier: C %e-_ . t)- '�> {Trus section need not be completed d Are permd is valued atom hundred dot (S foo) w less,) PPolilccumber:-Z__Z__00 Q S 3 5(7 J 0 C5 L� 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should beco9T subject to the workers' compensation provisions of Section 3700 of theor Code, I shall forthwith comply with these provisions. 5-1isl,6 Applicant's Signature Date WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), 1N ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect, Lic. #�/ �r�'� % 8 Class # — 1 1 1�_'a-18 ) o Gen ractor's Signature Date CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ t, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to ttte Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature Date 3057-46 43107) Owner ID verified by drivers license. ❑ Yes ❑ No Driver's License No, Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high, (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Date Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? []Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be fumished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? []Yes ❑ No (If 'yes the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7, If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If "yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature of Legal Ownerls) �to '_/ d dlor Authorized Applicant Dale CITY OF COSTA MESA BUILDING DIVISION 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 • www,ci.costa-mesa.ca.us ". FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BC08-00477 PERMIT TYPE: B_COMBO Sub Type: COM—ALT JOBADDRESS: 3333 1844 BRISTOL ST CM APN: 41250107 Zoning:PDC, , Vicinity: SPACES 1844 AND 1848 Const Type: I -A SO. FT: 0 STATUS: ISSUED DATE ISSUED: 0112912010 ISSUED BY: RMD Suite/Unit: 1844 Primary OCc: M Valuation: $25,000.00 SCOPE OF WORK: RELOCATE AND MODIFY AN (E) DEMISING WALL BETWEEN SPACES 1844 AND 1848 IN PREPERATION FOR NEW TENANTS. OWNER: SOUTH COAST PLAZA Phone: APPLICANT: HAGLUND, STEVE Phone: 714-550-9997 Address: 3315 FAIRVIEW RD City/State/Zip: COSTA MESA, CA Address: CitylState/zzip: CONTRACTOR: RS HAGLUND CONSTRUCTION License No. 412567 Phone: 714-550-9997 Address: 502 S SANTA FEUnit: Cell: City/State: SANTA ANA, CA ARCHITECT: LANCE BROWN ENGINEER: COMBINATION PERMIT FEE SUMMARY Building Plan Check: Building Fees: Electrical Fees: Mechanical Fees: Plumbing Fees: SMIP Residential: SMIP Commercial: Bldg Std Admin Fund TOTAL FEES: "Refer to fee receipts for all fees paid for project License No.C19698 License No. $63.58 $391.25 $0.00 $0.00 $0.00 $0.00 $5.25 ?? $523.40 Unit: Unit: ZipCode 92705 PHONE: 714-427-0370 PHONE: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, g 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE I, INSPECTIONTYPE OSE INITIALS CODED INSPETONTYPE DATE INTI11AL5 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 '• Pool Spa Final 208 Final Plumbing 200 Final Re -Roof =V "� 210 Final Electrical 201 Final BlocklRetaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval j( 203 Final Sign 222 Final Site 1 204 Final Demolition 250 Final Building/Occupancy WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the tabor Code, for the performance of the work for which this permit is issued. ❑ 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy Cu0lber are: arne be S {fir cn need not be com*led d the permg is wdhied at one hundred dollars I'S f 00) or less.) P.olieyNumber: �O 3L(o 0301 ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisions. Apptcarttjkature Date WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and M y Gcens�jSjn full force and effect. -z ar s 5 asureI Date CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lenders Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, atter, improve. demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant 10 a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature 3057-46 (3/07) Dale Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than Thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Appbcants Signature Division of Industrial Safety Permit Number: Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present'or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the Califomia Govemment Code requires that the requested information be fumished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by Califomia Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If 'yes-, attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and stale that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature of Legal Owner(s) Date Anda Aulhortzed'App cant [e .:.rN+r� l ,,; % ; � �+: tl � ••-%r7� i-»rwy.� -lir �i-�-�u"l ;.n'f:%.i � Rrr{n�+i��"vJ �i+�..li",.y:��+r�.s:��r.^��'.�.S,1j5�.r^'L�+:.:.'i-+�T-M1 "•. �'.Y'4 C�� �- • i ,M"Y �'Y `r ..f=.r� = -"- Cr Y OF COSTA MF 'A Development Services, Division of Building and Safety CERTIFICATE OF. OCCUPANCY This certificate is issued pursuant to the requirements of the Uniform Building Code, Section 308 adopted by the City of Costa Mesa certifies that at the,time of its issuance the building structure herein below described was inspected and approved for occupancy as follows:' 3333 Bristol St. Sui.t.e 1622 B07-00437 Building Address Bldg, Per Number Commercial Use M -ALT-COM-'I-FR PDC Group Type of Construction - -'.Fire Zone Use Zone Owner of Building South Coast Plaza Tenant Allen Edwards Address 3315 Fairview Rd., Costa Mesa, CA 92626 By BUILDING OFFiCIAL-Khanh Q. Nguyen, C.B.O, i Kurt Mox� n, Chief Ylans Exam Date 7/16/2007 REQUIRED TO BE POSTED IN A CONSPICOUS PLACE iffR (714) 754-5273 • Fax (714) 754-4856 " www.ci.costa-mesa.B.IMLDING PERMIT 77 FAIR DRIVE, COSTA MESA, CAA 92625 Job Address: 3333 BRISTOL ST Status: ISSUED Suite: 1622 Applied: 0411012007 Vicinity: SUITE 1622 ALLEN EDMONDS Issued: 05/08/2007 Primary Oa: M Display/Sale Merchandise Type of Construction: I -FR Parcel Number: 41250107 Zoning: PDC Applicant: HILL, JAMES Address: Phone: ISSUED BY: Zip: Owner: SOUTH COAST PLAZA FEE SUMMARY Address Plan Check: $336.21 COSTA MESA CA Phone: $2,068.95 3315 FAIRVIEW ROAD Zip: 92626 Contractor. NATIONAL CONTRACTORS INC Address: 4300 BAKER RD $61.32 Phone: 952-881-6123 $0.00 MINNETONKA, MN � Zip: 55343 License: 879727 Arch Total: Eng: Address: Address: Phone: Phone: Zip: License: License: MAIN STRUCTURE SCOPE OF PERMIT TENANT IMPROVEMENT FOR "ALLEN EDMONDS"" 1414 SO. FT. MINOR INTERIOR WORK. NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all appligable codes, and all required inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 we (aroo) FEE SUMMARY , Plan Check: $336.21 Calc Valuation: $292,000.00 Permit: $2,068.95 Claim Valuation: $292,000.00 SMIP Res: $0.00 SMIP Com: $61.32 Other: $0.00 inspection: $0.00 Total: $2,466.48 PLANNING & ZONING SETBACKS MAIN STRUCTURE Front 0-0 Rear 0-0 Leff 0- 0 Right 0-0 ACCESSOB Front '0- 0 ., ` Rear 0-0 Leff 0-0 Right 0-0 PARKING Existing: 0 " ;' Required: 0 Proposed: 0 -- - NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all appligable codes, and all required inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 we (aroo) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the tutor Code, for the performance of the work for which this permit is issued. _Ej -.l have.and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit Is Issued. --Myworkers compensation Insurance carrier and policy number are: r Carries_ S7.4Tt _ " euelLro 1Ajm Laa a Fy.til Pollcy.Number. ff1 s•sectlon need not be comple ea it the pemrit is valued at one hundred dollars f00) or less.) C—. � ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person In any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' Compensation provisions of Section 3700 of the Labor Cade, I shall forthwith comply with thesA�UREWORKERS'OOMPENSATION visions. _Applicant.Sign tura:_�]-WARNING- FAILURE TO 5 COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLIARE ($100,000), IN ADDITION TOTHE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am lice d Ii er proyis of Chapter 8 (commencing with Section 7000) of Division 3 of the Busine and Professions Code, and my license is In full force'and effect.-Llc. M % Class ff Contractors Signature: Dale:--- - 11KI4S dF CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a Construction lending agency for the performance of the work for which this permit is issued. (Sec, 3097, Civil Code). Lenders Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the lollowing reason (Sec, 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to Ills a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Lew (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).}: ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professiohs Code: The Contractors License Law does not apply 10 an owner of property who builds or Improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 em exempt under sec. Business and Professions Code for this reason: Signature: _ _ Data: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Explres: Verification of Ownership by (type of document, I.e. - property tax bill Cr deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Adm€niMrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: " Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater then a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feetstandard temperature end pressure)_" •of compressed gas at st ..... ................... ............ ._........ ................................................ _ ............ _ ..... — ... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Coda, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). - —•---................. ................ —.......� .. 3 Does or will theapppl€cant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ fJ0 (Sectlon 25534 of the Californi>t Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by bu4inessas which are required to register acutely hazardous materials with the Fire Department. 4 it an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5 Does or will the applicant or prgsom or future building occupant require for the Work which Is tho subject of this application a germit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? U Yes L.1 No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ......... ............................................... .............. ......... ---............................................................................................................................. _......_..........---..._. _ 6 Will any part Of the facility to be constructed under this permit be within 1000 feel from the outer boundaries of a school? ❑Yes a No (If "yes", the facility must meal the requirement of Sections 25534 and 42303 of the California Health and Safety Code), ............................................. ......... _._.._............. ......_.._...... _......................1..._.......... ............................................................................................................................. _.............. 7 If a permit from the South Coast Air Quality Management District or other air pollullon control district or agencyis required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (If yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the Information given is correct. I agree to comply with all state taws and city ordinances relating to building Construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. l agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Aign ur Lep ar(s) r/S� O ata 1Ah prized Applicant, ^- J Dala�� coDE /, INSPECTION TYPE 2M INTMALS CODE I INSPECTION TYPE Q� t1l TRIAL,q 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Root 210 Final Electrical 201 Final Block/Retaining Well 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy 7 W (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 PLUMBING PERMIT Job Address: 3333 BRISTOL ST Suite No 1622 Vicinity: Parcel Nunmber: 41250107 Applicant: ROSS KLINE Address: 10341 KENWICK DRIVE VILLA PARK, CA Owner: SOUTH COAST PLAZA Address COSTA MESA CA 3315 FAIRVIEW ROAD Phone: (714)744-8025 Zip: 92861 Phone: Zip: 92626 Contractor: KLINE PLUMBING AND MECHANICAL Address: 10341 KENWICK DRIVE Phone: (714)744-8025 VILLA PARK, CA Zip: 92861 License: 853662 Status: ISSUED Applied: 05/24/2007 Issued: 05/24/2007 SCOPE OF PERMIT TENANT IMPROVEMENT FOR "ALLEN EDMONDS". 1414 SO. FT. MINOR INTERIOR WORK. REF.: B07-00437 PLUMBING INCLUDES: 1 FLOOR DRAIN, 1 TRAP PRIMER, 1 WASH BASIN, 1 WASTE AND VENT SYSTEM, 1 WATER CLOSET, AND 1 WATER HEATER. COMMENTS / SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work Is not commenced within 180 days, or It work Is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result In the expiration of thispermit. FOR INSPECTIONS CALL: (714) 7545626 2aa6.46 AM) FEE SUMMARY AMT QTY AMT QTY AMT QTY ISSUE FEE $23.50 Laundry Tub 1 Washer $0.00 0 - Sump Pump $0.00 0 Backflow irrigation $0.00 0 Landscape Irrigation 50.00 0 Swimming Pool $0.00 0 Backflow Preventer $0.00 0 P -Trap 50.00 0 Trap Primer $9.80 1 Bathtub $0.00 0 Pressure Regulator $0.00 0 Urinal $0.00 0 Clarifier System $0.00 0 Process Piping (per 10 ft) $0.00 0 Vacuum Brkr Bkflow(1-4) $0.00 0 Connect (Ice,Soda,etc) $0.00 0 Receptors $0.00 0 Vacuum Brkr Bkflow(5+) $0.00 0 Dental Units $0.00 0 Septic Tank $0.00 0 Wash Basin" 59.80 i Dishwasher $0.00 0 Sewer Cap for Demo $0.00 0 Wash Basin Set $0.00 0 Drain, Floor 1$9.80 1 Sewer Connect $0.00 0 Waste and Vent System $9.80 1 Drain, Rainwater 50.00 0 Sewer Private Line $0.00 0 Water Closet (Toilet) 59.80 1 Drain, Roof $0.00 0 Shower $0.00 0 Water Heater! vent 512.30 i Drinking Fountain 50.00 0 ' Sink, bar $0.00 0 Water Piping (Inst or Rep.) $0.00 0 Expansion Tank $0.00 0 Sink, commercial $0.00 0 Water Re -pipe $0.00 0 Gas Earthquake Valve $0.00 0 Sink, Floor $0.00 0 Water Service $0.00 0 Gas (1-4 outlets) $0.00. 0 Sink, kitchen $0.00 0 Water Softener $0.00 0 Gas (Over 4 outlets) $0.00 0 Sink, service/mop $0.00 0 OTHER 50.00 Gas Repipe 50.00 0 Spa (private) $0.00 0 VIOLATION 50.00 Gas Service $0.00 0 Spa (public) $0.00 0 PLAN CHECK S0.00 Interceptors (Grease, Oil) $0.00 0 REINSPECTION 50.00 0 Interceptors (Sand Auto ) S0.00 0 TOTAL CALCULATED FEES: $84.80 COMMENTS / SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void If work Is not commenced within 180 days, or It work Is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain Inspections and final approval will result In the expiration of thispermit. FOR INSPECTIONS CALL: (714) 7545626 2aa6.46 AM) DECLARATIONS WORKERS' COMPENSATION DECLARATION: i hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. „t.have and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit Is Issued. My wArk ra',j pensation Insurance carrier and policy number are: -Cefiriar 3R r (rhi9'86eflon n&W not be completed if the permit is valued at one hundred dollars ($100) or less.) ❑ I certify that in the performance of the work for which this permit Is Issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Calif.and agree that If I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisi0r3 (Applicant Slgnatilre. -`� �ste:_ -" 7 G1 —c -D WARNING: FAILURE TO SECUR WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPF-NSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm Ilcensed•under provisions of Chapter 9 (commencing with Section 7000) of Dlvls3o otthe.Busin ss and Professions Code, and my license is In full _force'8nd.effect. Ignatura: r .� %z—, Date„� Z `l^57:2 -- CONSTRUCTION LENDING AGENCY: t ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lendoes Name: Lender's Address: Signature; Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Professions Coda: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractors) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: e Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more foot in depth into which a person is required to descend, wit) be made In connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Coda). ❑ As owner -builder, I wlll not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 WIII the applicant or present or future building occupant need to file and certity a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or wilt the applicant or present or future building occupant need to file a registration form for acutoly hazardous materia)'? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the ep plicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Masa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5 Do99 or will the applicant or present or future building occupant require for the work which is the subject of this application aggerrmit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes iJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6 Will any part Of the facility to be constructed under this permlt be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If , the facility must meet the requirement of Sections 25534 and 42303 Of the California Health and Safety Code). ............................... _...-----._............................ _—.................. .._...................... ........................................................................................... ...._--....... _........................... ---------- 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ............. .... .................... _................... --..................................._.................................................................... ......................... ........................................ ..... a..........................---•------ 8 attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Dale: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of per<ury that I have read this application and slate that the Information given Is correct. I agree to comply with all slate laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above -de: sc�bed property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. LegalOwner(s) Date r —A Or•Authorize pplicant----___ CODE t. INSPECTION -IM 2M ICS CODE t INSPECTION TYPINTITIA 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing J - 15 61, 200 Final Ra -Roof 210 Final Electrical 201 Final BlockiRetaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolltion 250 Final BulldinglOccupancy (714) 754-5273 • Fax (714) 754-4856 • www.ei.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 MECHANICAL PERMIT Job Address: 3333 BRISTOL ST Suite No 1622 Vicinity: SUITE 1622 ALLEN EDMONDS Parcel Number: 41250107 Applicant: DALESSI, MARK Address: 629 TERMINAL WAY STE 27 Phone: 949-650-5061, COSTA MESA, CA Zip: 92627 Owner: SOUTH COAST PLAZA Address: Phone, 949-650-5061 , COSTA MESA CA Phone: COSTA MESA, CA 3315 FAIRVIEW ROAD Zip: 92626 Contactor: SUNWEST AIR CONDITIONING Address: 629 TERMINAL WAY ISSUED BY: Status: ISSUED Applied: 0512312007 Issued: 05/23/2007 STE 27 Phone, 949-650-5061 , COSTA MESA, CA Zip: 92627 License: 431394 `SCOPE OF PERMIT-'- TENANT IMPROVEMENTFOR "ALLEN EDMONDS" IN SUITE 1622. 1414 SQ. FT, REF:607-00437` 1 VAV BOX, 1 VENT FANISINGLE DUCT FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 - Repair 1 All Absorbtion Unit $0.00 0 Inst FAU <100 k BTU $0.00 0 Repair/ All Refrigeration Unit $0.00 0 Inst FAU >100 k BTU $0.00 0 Ventillation System $0.00 0 Repair/Alt Cooling/Heat $0.00 0 Evaporative Cooler $0.00 0 Inst I Rep. Recess Wall Htr $0.00 0 Commercial ln6in6rator $0"00 0 Refrig Sys <100 k BTU $0.00 0 Domestic Incinerator $0.00 0 Refrig Sys >100 k BTU $0.00 0 Compressors / Absorption Systems Gas Piping $0.00 0 Up to 3 hp 1100 k BTU $0.00 0 Factory. Fireplace $0.00 0 3 To 15 hp 1500 k BTU $0.00 0 Hood w/Meth Exhaust $0.00 0 15 To 30 hp 1 1,000 k BTU $0.00 0 VAV Box 1$10.65 1 30 To 50 hp 11,750 k BTU $0.00 0 Vent Fan I Single Duct $7.25 1 Over 50 hp 1 Over 1,750 BTU $0.00 0 Appliance$0.00 0 Boilers Fire Dampers $0.00 0 Upto hp'! ; . $0.00 0 Smoke Dampers $0.00- 'Os , .. 3 To 15 hp „ $0.00 0 Inst or Relocate Appl Vent , $0.00 0 15 to 30 hp $0.00 0 Air Handlers < 10000cfm ' . $0.00• 0 '30 to 50 hp $0-00 0 Air Handlers > 10000cfm $0.00 ; 01-1 , Over 50 hp , ' $0.00 0 Floor Furnace $0.00 0,` Other Mechanical Fee Floor or Suspend Heater ` $0"00 0 _ - Investigation Fee $0.00 Plan Check Fee. , $0.00 Reinspection Fee $0.00 TOTAL CALCULATED FEES $41.40 COMMENTS4 SPECIAL CONDITIONS NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2448-48(&+001/ 7 DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by sectign 3700 of the Labor Code, for the performance of the work for which this permit Is issued, My workers p ns ion InsWitnee carqqrand policy r re 'Carrier� 0 ij.1+1+3mber:.. (This section need nor be completed If the Armit Is valued of one hundred dollars KI00) or less.) ❑ I certity that in the performance of the work for which this permit Is issued, I shall not employ any person In any manner so as to become subject to the workers' compensation laws of C mia, and a r I if I should become subject to the workers' compensation provisions of Section 3 00 of the or Code, I shall forthwith comply with hase pro Applicant Signature: GData=' WARNING: FAILURE TO SE ORKERS' OMWENSAT10N COVERAGE IS UNLAWFUL AND SHALL SUaIECT AN EMPLOYER TO cRImiNWPENAL-nd AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARE (S1OD,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 37M OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am license nder p si f hapter 9 (commencing with Section 7000) o1 Division 3 of the Business nd P f ssIons Code, and my Iloense is in full force and effect. Uc"A,a CClass ar - Contractors Signature:- - Dater CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lenders Name: Lenders Address: Signature: _ _ Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penaltyof perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to Its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors Liconse Lew (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the appllrent to a civil penalty of not more than five hundred dollars (SSW).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for safe (Sec. 7044, Business and ProlMions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. it, however, the building or Improvement Is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ' ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors LICehSe law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Conlractors License Laws.). ❑ I am exempt under sec. _ Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Drivers License No, Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (39) feet high. (Chap. 3.2, Grp 2, Art 2, Sec, 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division o1 Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 WIII the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be tiled with the Costa Mesa Fire Department by every business which has at any One time during a reported year a quantity of hazardous materials equal to or greater than a weight o1 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a gyantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. __ ................ _�...—w _ — .... — ................. 4 If an RMPP Is presently required, has Section 25534 of the California Health and Safety Code been fully compiled with? ❑ Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of thisa plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? 8 Yes 15 No (Section 95950.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). .................................................................................................................................__............................-�---......................................................................................... .................._............. -.................... -............ . — fi Will any part o1 the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes ❑�Nv (If 'yes", the facility must most the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ........ ......................... .._,..... -......................................... _.......... ....T............. —_................ ....._........................................ ..........-----...- .... .............I--.-. .............—.__...._ 7. a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this apphcation, have all o1 the disclosures proscribed by Califomia Health and Safety Code Section 42303 been made? ❑ Yes ❑ No —..............._—..............._....�--.........._............----................_._._................................................................ ............................................................... ...................... ........ ......................... 8 (it 'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materiels and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the Information given is correct. I agree to compty with all state taws and city ordinances relating to building construction, and authorize representatives of the City of Costs Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. I he! Of L Owners) 7l2ata Qr.Awtttnrized Applicant :--� / L- t8✓' — CODE-!. INSPECTION TYPE 263 ItMIALS CODE ! INSPECTION TYPE PAN INM 1616 Fixed System Final Fire Prevention 206 Final Mechanical -) -07 1266 Pool Spa Final 209 Final Plumbing 200 Final Re-Root 210 Final Electrical 201 Final Block/Retalning Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesaUeCTRICAL PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Suite No 1622 Vicinity: Parcel Nunmber: 41250107 Status: ISSUED Applied: 05/10/2007 Issued: 05/10/2007 Applicant: BILL BYRD Address: 136 E GARRY _ `�/Phone:'714-556-8.591 ISSUED BY: SANTA ANA, CA ""� :�---Zips _ 92707 - = � I _ Owner: SOUTH COAST PLAZA Address ��' �'�_� t �� _. - COSTA MESA CA .� Phone;`_ �� /,, ,,,,3 31 FAIRVIEW ROAD'%� --- Zip: 92626 Contracto,rr: SMALLCOMB WIRING CORPORATION Address:' 136 E GARRY Phone' 714-556-8591 SANT ASIA, CA Zip: 92707 License: 145961 .-.SCOPE OF PERMIT TENANT IMPROVEMENT FOR "ALLEN EDMONDS". 1414 SQ. FT. MINOR INTERIOR,WORK:.REF",'' ' .607-00437` _ - - "j \\� "•, � = ��,. ,4 ELECTRICAL INCLUDES: 82 LIGHT FIXTURES, 20 OUTLETS, 13 SWITCHES AND 1 SUB PANEL'.TO r 200 AMPS. -"s �°FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 Temp Dist System !-Lighting $0.00 0 Temp. service fest $0.00 i / '�� � Busway 1100 ft� ;',�i' --�, $0.00 0 ' r Res: a/c package $0.00 -- --- - - -�—. -Slandinisection. - tj $0.00 D r, t s New Res (1-2 units) $0,00 " w 0 _ �" Mi sc Electrical Equipment - $0.00 0 New Res (3+units) $0.00 0 Transformers up to 1 kvalkw $0.00 0 Pool 1 Spa $0.00 0 .... up to 10 kvalkw $0.00 Lighting Fixts $67.26 82...... ... ...upt6 50 kvalkw $0.00 0'0.": Recept Outlet's $22.00 i 20 to 100 kvalkw 1$000 "'C', r Switches' »•° , $14,30 13 �K over 100 kvalkw $0.00 0l Non Res,Appl', $0.00 0 'Low Voltage Equipment ,$0.00 D Res Appl ;10.00 0 i=� " Low Volt.Wiring,System 1 Ckt $0.00 ; Service to 200a ` $0.00 0 '" • � : ,, ' `� M�sc. Conduit .. fie o �....... , _ $0;00' / 0 Service to 1000a 50:00;, ,i-�: 0�_`'''` Misc..Conductor,:,•'a: -- ,s'`"'!$O,OD' 0 Service over 1000a $0.00 0"" 6Circus ( gen or ride)` ` - $0.00/- 0 ' Motors to 1 hp $0.00 0 " .-Circus meth ride or lights), i hts = 0 Motors to 10hp $0:00 ��'\;0���� ° �rChtistmasTree Stand-f�$0:40 �%% Motors, to 50hp ; \ 50:00 j=4���h� 'Fireworks Stand.,= �� �,$O:OD Motors is 100hp \ `_ $0:00 f 4 ` -V ,Other Electrical Fee. �� �$0.00 f - -7 - Motors over 1 00h :��; $OAO� ; : foo -- �. E� Communication drops ��� `$0.00�:�'�� 03 �; -��� Investigation Fee( ,� �,v$O.OD;� V� Sub panel to 200a `,.$30:50 -,Plan Check`Fee-,1 1 $0.00' Pole Light Pkg $0.00` 0 ! j Reinspection• Fee`, Sign Circuits $0.00 _'0_- _' ��•� r '�� Temp Pwr Pole $0.00 `�'- 0 , `_ TOTAL CALCULATED•FEES�!$157.56 Intermed Pole $0.00 0- COMMENTS / SPECIAL CONDITIONS r NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit._ FOR INSPECTIONS CALL: (714) 754-5626 2448.48 (Bloc) 4j C DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 o1 the Labor Code, for the performance of the work for which this permit is issued. I,hava`and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the pertormance of the work for which this permit is issued. — My workers' compo sation Insurance carrier and policy number are: Q� Carrier: - �n'�C� A�trn[�C�-- -- P�olicy.Number: O O� (This section need not be completed if the permit is valued at one hundred dollars ($100) or less.) ❑ I certify that in'the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and a ree that If I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these pI atisie ,1Appllcant'Signature —_ _ =Date WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUWECT AN EMPLOYER TO CRIMINAL. PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and ailed. Lic. k'' Class q 12:7-A0 r �ontractoes-Slgnature:_ CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance o1 the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ' ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property lax bili or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: I Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one lime during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .............................................................................................................................................................................................................................................................................................................................................................. 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ........................................................................................................................................................................................................................................................................................................................................................................... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materiels with the Fire Department. ...................................................................................................................................................................................•-•-------................................................................................................................................................................... 4 If an RMPA is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No ...................................................... •-••--••............................................... .................................................................. ---............................................................................................ ......-.............................. .............................. ...... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a rmit for such construction or modification ge from the South Coast Air Quality Management District or from any other air pollution control district or agency? lJ Yes Q No (Section 65650.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). ........................................................................._......................'u'................................-- b"e w"It,'h"i.............................................u"t'.........................................c'h' ...........................................---..................................---............................... r3 � Wt11 any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑Yes ❑ No (it'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ...................i'tf..........................................._...................................................-n-1.................................................................'-----------....d"I's-..............................................ui'r'........................................i'c',.....................ub"j------- ......t'h"i'.... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ....................................................... ........-.............................................................I----.----------...................................................................................................................................................------.................................................................. 8 (If yes", attach certificate of Compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not 10 occupy or allow occupancy of any building authorized by this permit until final inspection. Signet Date Ld_ 02 And/Or 'Aut orizad Appficant (—Date —" CODE A, INSPECTION TYPINTIT1ALS CQDE NN INSPECTION TYPE IWITA 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place -220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy CITY OF COSTA MESA BUILDING DIVISION >` DEVELOPMENT SERVICES DEPARTMENT v PERMIT FIRE SUPRESSION PERMIT (714) 754-5273 Fax (714) 754-4856 www.ci.costa-mesa.ca.us ,lob Address: 3333 BRISTOL ST Suite: 1622 Vicinity: Parcel Nunmber: 41250107 Applicant: LOONEY, SHEILA Address: - Zoning: PDC PDC Phone: 714-993-2822 Zip: Owner. SOUTH COAST PLAZA Address COSTA MESA CA Phone: 3315 FAIRVIEW ROAD Zip: 92626 Contractor: ALERT FIRE PROTECTION INC Address: 5200 E HUNTER AV SUITE B Phone: 714-993-2822 ANAHEIM, CA Zip: 92807 License: 316324 77 FAIR DRIVE, COSTA MESA, CA 92626 Status: ISSUED Applied: 05/21/2007 issued: 05/30/2007 ISSUED BY: SCOPE OF PERMIT FIRE SUPPRESSION PERMIT TO INSTALL 6 NEW HEADS AND RELOCATE 12 EXISTING SPRINKLER HEADS FORA 1,414 SF INTERIOR T.I. FOR "ALLEN EDMONDS". REF:# 807.00437 FEE SUMMARY Plan Check: $63.21 - Calc Valuation: $4,000.00 Permit: $97.25 Claimed Valuation: 54,000.00 Other: $0.00 Total: $160.46 - J NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work Is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: /In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 7545626 2446.46 (6=) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to sell -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. Lha :and will maintain workers' Compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. Mq worker ensatl Incur nce carder and policy number are: Carc Policy9Numbar: !s section need not be completed t the permit is valued at one hundred dollars ($100) or less.) ❑ 1 certify that in the performance f t e work for which this permit is Issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Califami d a$re at if I sh99��Id become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply -7 these provisions. 1p'�'p pllcant a u e: 3 r�- �� ARNING: FAILURE TO SECURE WORKERS' COMPENSATION COAMRAGE 1 N, AWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: erabyf affirm that I am licensed under pro slons of Chapter 9 (commencing with Section 7000) of Division 3j22e iness ane r�fe�s€pn3 Code, and my license is in tali force and effect? ' . k lass fi -- _ Cont tato Signature: __ _ _ _ -30 - CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Cade). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Ohdslon 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (S50o).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL 00 THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. Il, however, the building or improvement Is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ' ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ i am exempt under sac. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, Le. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth Into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be acre than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Adminlslrative Cade). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number; HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the Calilomia Health and Safety Code requires, with Some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight o1 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). _._..................----..................... ........... .......... ....................................._....................---........................................ _...................... —_............. _............................... _ ..... ........ _........................ -._................_............. 2 Does or w€1] the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ... ...... .............. ...........................",............._................................................................................ ........................................... .................................................................................... ....................................................................................... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. ........ --• ispr._..........................._.............-----...................................._......alit............_.. al—.................__....................---.................................... .........................❑ No —....._ .............................................. —_........................ ..._................ _............... _..---..........---..........--..—.._... _..................... _...... _-..... ............... ..... -...................... ................. --.... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication a�e rmit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes LI No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). _—..............................._............_............................— ..................._...................--............. —.................. _..—... _._.................................. .................... _._.........................._.................... _.... _. 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). .......................... ................. ...................................................... 1 .......................... ........ ........ ............................................. ................... __._........................ ......... _.......................... .-._.... ........................... -................. _..................................... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the Subject of this application, ...., have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? 0 Yes [I No ._........................_.............................................. ................................................................._............................................._........................... ... _.._............................................ _.... ......................... ...... ................_............................. B (Ii yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given Is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described praporly for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. t SI jure 01 Owner s) to ATV641� u Appli .ate CODE l', INSPEOON TYPE 111 INTITI9CODEC INSPECTION TYPE QejE jt1TITALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 - Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final EleFire Prev rical 201 Final Block/Retaining Well 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesaR-lLpING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Suite: 1622 Vicinity: SPACE 1622, Primary Occ: M- Display/Sale Merchandise Parcel Number: 41250107 Applicant: EDDIE BARTH Address: DICKINSON CAMERON CONSTRUCTION INC Type of Construction: I -FR Zoning: PDC J.. Phone: 858-967-4325 Zip: Owner: SOUTH COAST PLAZA Address: 1101 DOVE STREET Address: Address SUITE 140 Phone: 949-660-8062 Phone: NEWPORT BEACH, CA COSTA MESA CA Phone: License: 3315 FAIRVIEW ROAD Zip: 92626 Contractor: DICKINSON CAMERON CONSTRUCTION INC Address: 140 LOMAS SANTA FE Plan Check: $333.42 SUITE 200 Phone: 858-793-9104 Claim Valuation: $37,000.00 SOLANA BEACH, CA Zip: 92075 License: 690239 ISSUED BY: Status: ISSUED Applied: 12112/2005 Issued: 01/05/2006 Arch : PAUL J RUFFING, AIA Eng: Address: 1101 DOVE STREET Address: SUITE 140 Phone: 949-660-8062 Phone: NEWPORT BEACH, CA Zip: 92660 License: C4264 License: SCOPE OF PERMIT DEMOLISH EXISTING SPACE 1622, CONSTRUCT DEMISING WALL TO DIVIDE EXISTING SPACE INTO TWO AND CREATE SPACE 1624 FOR FUTURE TENANTS. RELOCATE EXISTING ELECTRICAL ROOM, FEE SUMMARY Plan Check: $333.42 Calc Valuation: $37,000.00 .Permit: $512.95 Claim Valuation: $37,000.00 SMIP Res: $0.00 SMIP Com: $7.77 'Other: $0.00 Inspection: $0.00 Total: $854.14 PLANNING & ZONING SETBACKS MAIN STRUCTURE Front '0- 0 Rear 0-0 Left 0-0 Right 0-0 ACCESSORY Front 0-0 Rear 0-0 Left 0-0 Right 0-01 PARKING Existing: 0 Required: 0 Proposed: 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 1446-46 (stoo) aw -T DECLARATIONS WORKERS' COMPENSATION PECLAAATlOh: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier:�d11G�'f7 __ ! Policy Number: (This section nee no! be compldted if the permit 1s valued at on hundred doll s ($100) or less.) ❑ !certify that in the performance 1Wr.tthis rmit is is sh not employ any person in any manner sc as to become subject to the workers' compensation laws of Califo dho a om u e to th workers' compensation provisions of Se tion 37 0 of the Labor Code, I shall forthwith comply with these provisions. rioApplicant Signature: Date: -1 WARNING: FAILURE TO SECURE WORKER COMPENSATI COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRI NAL PE RETIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,0001, IN ADDITION TO THE COST F COMPENSATION, DAMAGES AS PROVIDED FOR A SECTION 3706 OF LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with SectiorL7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic. q Class tf Contractor's Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a Construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lenders Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) Or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not Intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner 1D verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, ialsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous malarial? ❑ Yes ❑ NO (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight Of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ............................. ..........."........................................................................ ...--......................................................................................................................................................................•........................................... 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Masa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of S00 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed 6..........................gas at standard temperature and pressure). .................................................................................................................................................................................................................................................................................................. 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. .. ........... .................................................. ............................................................................................................... .............................................................................................. .................................................................. 4 If an RMPP is presently required, hes Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No ....................................................................................................................................................................................................................................................................................... ............�-................................... 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this a plication agermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes p No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). . ..................................................................................................................................................................................................................................................................................................................................... ................. 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries Of a school? ❑ Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safely Code). ................................................................................................................... �..............................................................................................................................................-................... I.................. 7 If a permit lrom the South Coast Air quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ...................................................................................................................................................................................................................................................................................................................................... 8 (It fires", attach certificate of Compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. re a Owne (s) r Authorize pp Ira tDate CODE N. !N$Pf:CT1oN TYPE 12M INITIALS CODE t INSPECTION TYPE DATE INTQ16Li 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 04 Final Demolition 250 Final BuildinglOocupancy kaf (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92626 ELECTRICAL PERMIT Job Address: 3333 BRISTOL.ST Suite No 1622 Vicinity: 1622 Parcel Nunmber. 41250107 Applicant: BARTH,EDDIE $23.50 $0.00 Address: 140 LOMAS SANTA FE $0.00 0 $0.00 SUITE 200 Phone: 858-793-9104 $0.00 SOLANA BEACH, CA Zip 92075 Owner: SOUTH COAST PLAZA $0.00 0 Address 0 $0.00 0 $0.00 COSTA MESA CA' Phone: 0 '$0.00, 3315 FAIRVIEW ROAD Zip: 92626 Contractor: DICKINSON CAMERON CONSTRUCTION INC Address: 140.LOMAS SANTA FE $0.00 0 _ $0.00'' SUITE 200 Phone: 858-793-9104 $91.50 SOLANA BEACH, CA Zip: 92075 $0.00 0 ' License: 690239. ISSUE FEE Temp service test Res. a/c package New Res (1-2 units) New Res (3+units) Pool 1 Spa Lighting Fixts Recept Outlets Switches Non Res Appl Res Appl Service to 200a Service to 1000a Service over 1000a Motors to 1 hp Motors to 10hp Motors to 50hp Motors to 1 00h Motors over 100hp Communication drops Sub panel to 200a Pole Light Pk9 Sign Circuits Temp Pwr Pole Intermed Pole Status: ISSUED Applied: 01/26/2006 Issued: 01/26/2006 ISSUED BY: SCOPE OF PERMIT DEMOLISH EXISTING SPACE 1622, CONSTRUCT DEMISING WALL TO DIVIDE EXISTING SPACE INTO, TWO AND CREATE SPACE 1622 FOR FUTURE TENANTS. REF B05-02255 3 SUB PANELS AND 1 TRANSFORMER UP TO 45 KVA ry FEE SUMMARY, - COMMENTS I SPECIAL CONDITIONS NOTICE: The work authorized by this permit $hall comply with all applicable handicap access requirements under California statutes regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable cot required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this FOR INSPECTIONS CALL: (714) 754-5626 2446-46 (6100) all Quantity $23.50 $0.00 $0.00 Busway 1100 ft , $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 '$0.00, ,. $0.00...: 0, 'S0,00 0 $0.00 0 $0.00 0 _ $0.00'' 0 $0.00 ..` , ' 0 $91.50 3 $0.00 0 $0.00 0 $0.00 0 $0.00 0 COMMENTS I SPECIAL CONDITIONS NOTICE: The work authorized by this permit $hall comply with all applicable handicap access requirements under California statutes regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable cot required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this FOR INSPECTIONS CALL: (714) 754-5626 2446-46 (6100) all Quantity Temp Dist System ! Lighting $0.00 0 Busway 1100 ft , $0.00 0 Standing Section : $0.00 0 •' r . Misc Electrical Equipment $0.00 0 Transformers up to 1 kvalkw $0.00 0 .......... 1.,- up to 10 kvalkw $0.00 0 .................up to 50 kvalkw $73.80 3 .................up to 100 kvalkw $0.00 0 ..... ........over 100 kvalkw $0.00 0 Low Voltage Equipment $0.00 0 Law Volt Wiring System 1 Ckt $0.00 0 Misc. Conduit $0.00 0 Misc. Conductbr $0.00 0 Circus ( gen or ride) $0.00 0 Circus (meth ride or lights) $0.00 0 Christmas Tree Stand $0.00 0 Fireworks Stand $0.00 0 Other Electrical Fee $0.00 Investigation Fee $0.00 Plan Check Fee $0.00 , Reinspection Fee .$0.00 TOTAL CALCULATED FEES $188.80 COMMENTS I SPECIAL CONDITIONS NOTICE: The work authorized by this permit $hall comply with all applicable handicap access requirements under California statutes regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable cot required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this FOR INSPECTIONS CALL: (714) 754-5626 2446-46 (6100) all DECLARATIONS WORKERS' COMPENSATION DECLARATION: hereby affirm under penalty of perjury one of the following declarations: ❑ have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the ork far which this permit is issued. eve and wi11 maintain workers' oompensaticn insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. works �mpensatj n Insurance carrier and policy number are: �j J Carrie ��i�V II _ i`mbar: 7zt7 f � " section need not be Completed it the permrf is valued atone hundred dollars ($i00) or less.) \�' J1 ❑ I Certify that in the performanee of work for which IN is issued, I shall not employ any person in any manner so as to become subject to the workers' I of California agr that if I uld cc a subject to the workors' compensation provisions of Section 3700 of the Labor Code, I shall forthwith c y ith th se provisions. W AFNIN : FAILURE TO SECURE WORKERS' OWPENSATION COVERAGE 1S UNLAWFUL AND SHALL SUEJECT AN1=701P IMttA L PENALTI S AND CIVIL FINES llP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: Ihereby.Ihat I am licens urlder provisions of Chapter 9 (commencing with Section 7000) of Division 3 o1 the Business a rofessions Code, and my license is in full force, q Class q nature: CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance o1 the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which regwrOS a permit to construct, after, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as (hair sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Cade: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose o1 sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or Improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: „- Date: Owner ID verified by drivers license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California AdminWrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ...............................................................:.................................................................................................................................................................................................................................................................................. ............ 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous matorials7 ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ............................................................................................................................................................................................................................................................................................................................................................ 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 H an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑Yes ❑ No ...................................................... •.............................................. ...................................................................................................... - ........................................................................................................... 5 Does or will the applicant or pr©sent or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification from the South Coast Air Ouality Management District or from any other air pollution control district or agency? LJ Yes No (Section 65650.2 of the California Government Code requires that the requested information be furnished on applications for non-residanttal building permits). _..................... — --—.__...............................-----....................... -.............._.......-... _............... —............ _...................... _ 6 Wil! any part of the fatality to be constructed under this permit be within 1000 feat from the outer boundaries of a school? ❑ Yes ❑ No (If 'res", the facility must meet the requirement of Sections 25534 and 42303 of the Califomia Health and Safety Code). _.................._................._....................._....--.....,......................................._........__._.............................._.......__. ..................—.................... _............... _.............. --- ............. ... 7 If a ppermit from the South Cost Air Quality Management District or other air potlution control district or agency is required for the work which is the subject of this app)icatlon, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ........--•--•..............................................111................1......--- .................. ..... -----.-........._........................---................. _................ -............... 8 (if yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all slate laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances rotating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above -describe ro rty for inspection purposes. I to occupy or allow occupancy of any building authorized by this permit until final inspection. S' ure ega pit CODE It. INSPECTION a DAM IHTrTIALS CODE INSPECTION TYPE DATE 1NTITJALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 206 Final Plumbing 200 Final Re -Roof 210 Fina[ Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 • www.ci .lob Address: 3333 BRISTOL ST Suite: 1407 Vicinity: Parcel Number: 41250107 CITY OF COSTA MESA BUILDING DIVISION DEVELOPMENT SERVICES DEPARTMENT PERMIT Applicant: LOONEY, SHEILA Address: 5200 E HUNTER AV ANAHEIM, CA Owner: SOUTH COAST, PLAZA, Address COSTA MESA 3315 FAIRVIEW ROAD. Contractor: ALERT'FIRE PROTECTION INC Address: 5200 E HUNTER AV Zoning: PDC PDC Phone: (714)993-2822 Zip: 92807 Phone: Zip: 92626 NUMBER 00193 77 FAIR DRIVE, COSTA MESA, CA 92626 ISSUED BY: Status: ISSUED Applied: 09/1112003 Issued: 10/0212003 Phone: (714)993-2822 ANAHEIM, CA Zip: 92807 License: 316324' SCOPE OF PERMIT TENANT IMPROVEMENT FOR "MAX MARA". SCOPE OF WORK TO INCLUDE: REMOVAL OF DEMISING WALL BETWEEN 1403 (FORMERLY. FRED JOALLIER JEWELERS) NEW CEILING, NEW. PARTITION WALLS AND FLOORING. MAX MARA WILL BE,TAKING OVER SUITE 1403. REF: B03-01331, OVERHEAD FIRE SPRINKLERS FOR T. I. FEE SUMMARY Plan Check: $90.51 ` Calc Valuation: $6,400.00 Permit: $139.26 _ Claimed Valuation: $6,400.00 Other: $0.00 Total: $229.76 \ v i NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTION& In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all requlred Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446-46 (6100) a e WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' ensation surance carrier and policy number are: Is-op � Oq f Carrier: - Policy Number: O c� (This section need not be completed it f e permit is valued at one hundred dollars ($100) or less.) ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree 1 t i I sho became subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisions. Applicant Signature: Date: WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFULLAD SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under prow ions of Chapter 9 (co encing with Section 7000) of Division 3 of the Businesss; and Professions Code, and my license Is in full force and effect. Lic. Z Class M Contractor's Signature: Date: _ __/Z —0 • Z9 CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that thrrre is a construction leading agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lendees Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that i am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.$, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Cade: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sea 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a coniractor(s) license pursuant to thio Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: _ Date: Owner ID verified by driver', license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard, temperature and pressure). .................................................................................................................................................................................................. ...... .........................................PP................................ g P 9 y ❑ 2 Does or will thea applicant or resent or future building occupant need to file a registration form for acute) hazardous materials? ❑ Yes No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .......................................... I . , ..---........................................................................................................................................................................................................................................................................................................... 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. .. ...... _........................................................_.................................................................. -....................................................................... ............................ ....... ..........................._.................................................. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No .................................................................................................................................................................................................................................................................................................................................................................... 5 Does a or will the applicant or present or future building occupant require for the work which is the subject of this plication a ffrmit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes LJ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). - - ­­'I'll,................. ••....... ----...................................................... 6 Wiil any part of the facility to be constructed under this parmit be within 1000 fait from the outer boundaries of a school? ❑ ..es ❑ No (11 "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). ........................... .................. ...............................................-_----- ...........................................•-----------..................................................................................................................................... ---................................. 7 if a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Cade Section 42303 been made? ❑ Yes ❑ No .-----�.......................................................................................................................................................................................I..........................................................................................................................----------....................................... 8 (Ef jos", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: f certify under penalty of perjury that I have read this application and state that the information given is Correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described pr pe 4 inspe tion purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. -03 Signa e f Legal Ower(9) Date Arc And/Or Authorized Applicant f Date CODE A. INSPECTION TYPE DATE jNTRIALS CODE f INSPEgTION TYPE INTrMLS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Root 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention r 1 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building)Occupancy (714) 754.5273 • Fax (714) 754-4856 . www.ci.costa-mesa.jA1MLDING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Status: ISSUED Suite: 1407 Inspection: Applied: 08/05/2003 Vicinity: MAX MARA SUITE 1407 $2,856.24 Issued: 09/26/2003 Parcel Number: 41250107 Zoning: PDC PDC SETBACKS, Applicant: PATRICK IMBRIALE MAIN STRUCTURE Front 0-0 ISSUED BY: Address: Front, 0-0 Rear 0-0 Left 0-0 Right 0-0 PARKING Existing: 0 Required: 0 Proposed: - 0 Phone: 714-957-8250 Zip: i Owner: SOUTH COAST PLAZA Address ` COSTA MESA CA Phone:' 3315 FAIRVIEW ROAD, Zip: 92626 . Contractor: DEVELOPMENT SUPPORT SERVICES INC Address: 1515 W ALTON AV Phone: 714-957-8250 SANTA ANA, CA Zip: 92704 License:. 748446 -- Arch , Eng: Address: Address:. Phone: Phone: Zip: License: License: -- SCOPE OF PERMIT - - - — - TENANT IMPROVEMENT FOR'MAX MARA". SCOPE OF WORK TO INCLUDE: REMOVAL OF DEMISING WALL BETWEEN 1403 (FORMERLY FRED JOALLIER JEWELERS) NEW CEILING, NEW PARTITION WALLS AND FLOORING. MAX MARA WILL BE TAKING OVER SUITE 1403. FEE SUMMARY Plan Check: $388.99 Calc Valuation: $350,000.00 Permit: $2,393.75 Claim Valuation: $350,000.00 SMTP R6s: $0.00 SMIP Com: $73.50 Other: $0.00 Inspection: $0.00 Total: $2,856.24 PLANNING & ZONING SETBACKS, MAIN STRUCTURE Front 0-0 Rear 0-0 Left- 0-0 Right 0-0 ACCESSORY Front, 0-0 Rear 0-0 Left 0-0 Right 0-0 PARKING Existing: 0 Required: 0 Proposed: - 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12.21.92) EXPIRATION: This permit shall automatically expire and become void If work is not commenced within 180 days, or if work Is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754.5626 48-48 (8=) DECLARATIONS WORKERS' COMPENSATION pECLARATIQN: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the tabor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. My workers, fo°mpensarn Insurance carrier and policy number are: Carrier:. C[1yCrf(�t"i14` - 4/AbZf2mAl _ Policy Number: (This section need not be completed f1 the permit is valued atone hundred dollars ($100) or fess,) ❑ I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in any manner so as to become subject to the workers' compensation laws of Callf mia, and a a that If I s ould become subject to the workers' compensation provisions of Section 3700 of the Labor Code, i shall forthwith comply with these pro";I �� T�L Applicant Signature: ;rd fl�e�t D Date: _1�6_ WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE (5100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed j or pro'slons of Chapter 9 (commencing with Section 7000) of Division 3 of the Business d Professions Code, and my license Is In full force and effect. Llc. #! y`-t1.� . Class a r Contracloes Signature: _ _ v - _,, Date: CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lenders Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to Its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec. 71344, Business and Professions Code: The Contractors License Law does not appy to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not intended or offered for sale. It, however, the building or Improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). - ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth Into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thlrty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I witl not employ anyone to do work which would require a permit from the Division o1 Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 WIII the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2 Does or wiI! the applicant or present or future building occupant need to file a registration torr for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater then a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑Yes ❑ No .......---............. __ _ —.................................................. — ..._— S Does or will the applicant or present or future building occupant require for the work which is the subject of this application a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? Yes I No (Section 85850.2 of the California Government Code requires that the requested Information be tumished on applications for non-residential building permits). ........ ..... ........_....... _ ...... —_.._.._......... ------- — ----—........................................................ ................ 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). .......... —................... —........................................................................ _.— --------- _.. — 7 It a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by Califomia Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8 (If yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding hazardous Materials and Emissions. Signature: Data: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: 1 certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all stale laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for Inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. lgnat Of galOwner(s) Date —ake;� -And/Or Authorized Applicant Date' CODE t. INSPECTION TYPE 11U IfiTMAL CODE I INSPECTION TYPE 2AM jNTRIA$ 1$16 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Ro-Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 2D4 Final Demolition 250 Final Building/Occupancy (714) 754-5273 • Fax (714) 754-4856 " www`.c'.costa-mesa.BLflLDING PERMIT 77 FAIR DRIVE, COSTA MESA, CA 92626 Job Address: 3333 BRISTOL ST Status: ISSUED Suite: 1407 Applied: 09/02/2003 Vicinity: MAXMARA - SUITE 1407 Issued: 09/02/2003 Parcel Number: 41250107 Zoning: PDC PDC Applicant: IMBRIALE, PAT Address: 1515 W ALTON AV = " " t ISSUED BY: MCl/ Phone: 714-957-8250 - - SANTA ANA, CAS- Zip: 92704 \ Owner: SOUTH COAST PLAZA Address COSTA"MESA CAPhone:. v ,"3315 FAIRVIEW ROAD:-/ Zip: 92626 Contractor: ,DEVELOP/MENT•SUPPORT SERVICES INC Address: 1515 W ALTON AV \ .' Phone: 714-957-8250 , SANT"NA,CA \l •Zip: 92704 % License:-' 748446 Arch Eng: Address: Address: 'Phone: Phone: j Zip: License: License: SCOPE OF PERMIT ' INTERIOR DEMOLITION IN PREPARATION FOR FUTURE TENANT IMPROVEMENT FOR "MAXMARA". REF: B03-01331, FEE SUMMARY Plan Check: $0.00 J Calc Valuation: $15,000.00 .` Permit: $251.25 _ -_ - , _ Claim Valuation: -'$15,000.00 SMIP Res: $0.00 - ;SMiP Cam: $3.15 ' Other: In $0.00 Notal: $254.40 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work Is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446-46 (6=) PLANNING & ZONING SETBACKS MAIN STRUCTURE",Front 0-;0 Rear 0-0 Left 0-0 Right 0-0 ; ACCESSORY .\Front, 0-0 ; ' Rear __-0-0 Left 04 Righty :0- 0 PARKING Existing: '0 Requited: 0, Proposed: 0, NOTES: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work Is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446-46 (6=) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ��Ive veandwill maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 Of the Labor Code, for the performance of the workfor whichthis permit is Issued. and will maintain workers' compensation Insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. My workers' compensation Insurance carrier and policy number are: Carrier: Policy Number: (chis section need not be completed it the permit is valued at one hundred dollars ($100) or less.) ❑ I certify that In the performance of the work for whi h this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Californls, d agree at l should become subject to the workers' compensation provisions of Section of 1 Labor Code, I shalt forthwith compty with these pr to Applicant Signature: Date: WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($1 OD,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license Is in full force and effect. Llc. a Class a Contractor s Signature: Date: CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, Improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 8 (commencing with Section 7004) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors license Law does not apply to an owner of property who builds or Improves thereon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors Ucense Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title B, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ................................ ........................................................................................................ ....................... ................................ ........................ -.... -..................... __.................... .................. ......................... ..... 2 Does or w€ll the appl€cant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one lime has on hand a quantity of acutely hazardous materials equal to or greater then a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). -.............................. _._.............................................. ..................................................... .......................... ._.................... ................ ................................................._...I...................................... _................ -_.............. 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. .. .............. -..................... --.......................... _............ ..................... 4 1f anRMPP is presently required, has Section 25534 of the Celifom€a Health and Safety Code baen fully complied with? [I Yes ❑ No .. .................... ....... ...-..........................................................................._................. ..,............................................ ,.................................................................................................................. ........................................ . ................... 5 Does or will the applicant or present or future building occupant require for the work which Is the subject of this a plication aarm€l for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes I No (Section 65850.2 of the California Goverment Code requires that the requested information be furnished on applications for non-residential building permits). 6 WIII any part of the fac€iity to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'fres', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). .............. ................................. ............................. I -- ...............-............................................... ...,,.................... I— ............................ ..................................................................................................................................................................... 7 If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which Is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? [3 Yes [:1 No ....... ...........•--•--........................................................................................................... .............. ...................................................................................................................................................... _................................................. ........ B (If yes', attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above Is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the Information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. J SI at Of Legal Owner(s) — ate SET ,(/A 912J And/OrAuthorized Applicant ate CODE t. INSPECTION TYPE 2&U INIrFKLS G12DE INSPECTION TYPE IKOy,g 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final BuildinglOocupancy - ,, C'urrtinurxr.r Inspection rLlutcr-irrls Testin;, SOUTHWE ST"' ` Inspection & Testing, Inc. 10826 South Norwalk Bled.. Santa Fe Springs. CA 90670 (562) 941-2990 • (7 14) 526-8441 FAX (562) 946-0026 To Whom It May Concern: Enclosed you will find copies of Daily Inspection Reports and or Compressive Strength Testing Results for your jobsite . We have enclosed these copies for your records. If you feel you have received any reports in error please return them to us. Also, if you have any questions or comments, please do not hesitate to call us Thank you, Southwest Inspection & Testing South, :st Inspection and Testing, Inc. 10826 South Norwalk Blvd., Santa Fe Springs, CA 90670 (562) 941-2990 - (714) 526-8441 - Fax (562) 946-0026 REGISTERED INSPECTORS'S DAILY REPORT SWITJob No. Date -r`jE. q -23-x'3 TYPE OF INSPECTION REQUIRED ❑ Reinforced Concrete COStructurol Steel Assembly ❑ Post Tensioned Concrete ❑ Fire Proofing ❑ Reinforced Masonry ❑ Asphalt ❑ Quality Control ❑ Other Job Address City — Job Name Permit No. - C3 Issued By Type of Structure Architect Engineer Material Descriptlon (type, grade, source) uo kr _ ontroctor -Vr Inspector(s) Name Su contractor TESTS PERFORMED TYPE OF SAMPLE SLUMP QUANTITY IN SET ADDITIONAL REMARKS ON SAMPLES INSPECTION SUMMARY -- LOCATIONS OF WORK INSPECTED, TEST SAMPLES TAKEN, WORK REJECTED, JOB PROBLEMS, PROGRESS, REMARKS, ETC. INCLUDES INFORMATION ABOUT- AMOUNTS OF MATERIAL PLACED OR WORK PERFORMED, NUMBER, TYPE & [DENT- NO'S OF TEST SAMPLES TAKEN: STRUCT. CONNECTIONS (WELD MADE H.T. BOLTS TOROUED) CHECKED, ETC. L 1 �- Ct -© OC I u>a n CGI CERTIFICATION OF COMPLIANCE I HEREBY CEATIFYTHAT I HAVE OBSERVED TO THE BEST OF MY MOV&EDGE ALL OF THE ABOVE REPORTED WORK UNLESS OTHERWISE NOTED. I HAVE FOUND THIS WORK TO COMPLY 1VITH THE APPROVED PLANS. SPECIFICATIONSMAPPE 5EC ONS OF � OVERNING BUILDING LAWS. 1 SIG ATURE EGI TEREOI --TOR % 3 --L AWZ— SPECIALTY NO. AGENCY CONTINUED ON NEXT PAGE ❑ PAGE -3- OF ._1_- TIME IN TIME OUT I REG, HOURS O.T. HOURS I CYLINDERS QPM All inspections based on a minimum of 4 hours and over 4 hours - 8 hour minimum. In ad ition, any inspeo ion exte ding ast noon hour will be an 8 hour minimum Approved by , Project Superintenden WHITE - OFFICE COPY, CANARY - ACCOUNTING COPY, PINK - INSPECTOR'S COPY, GOLDENROD - JOB SITE COPY (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us 11 ELECTRICAL PERMIT Job Address: 3333 BRISTOL ST Suite No 1407 Vicinity: SPACE 1407 (MAX MARA) Parcel Nunmber: 41250107 Applicant: SPRINGLER, TONY Address: 700 E REDLANDS BL STE U187 Phone: 909-335-1500 REDLANDS, CA. Zip: 92373 Owner: SOUTH COAST PLAZA Address COSTA MESA CA Phone: 3315 FAIRVIEW.ROAD Zip: 92626 Contractor: T D S ELECTRIC Address: 700 E REDLANDS BL STE U187 Phone: 909-335-1500 REDLANDS, CA Zip: 92373 License: 535479 77 FAIR DRIVE, COSTA MESA, CA 92626 ISSUED BY: Status: ISSUED Applied: 10/01/2003 Issued: 10/01/2003 SCOPE OF PERMIT ELECTRICAL PERMIT IN CONJUNCTION WITH THE 3,767 S.F. TENANTIMPROVEMENT FOR -MAX MARA" IN SPACE 1407. SCOPE OF WORK TO INCLUDE: REMOVAL OF DEMISING WALL BETWEEN 1403 (FORMERLY FRED JOALLIER JEWELERS) NEW CEILING, NEW PARTITION WALLS AND FLOORING. 65 LIGHT FIXTURES, 16 OUTLETS, 6 SWITCHES REF: B03-01331 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomla statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or It work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply wilh all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result In the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446.46 (aroo) FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 Temp Dist System I Lighting $0.00 0 Temp service test $0.00 Busway 1100 ft $0.00 0 Res. a/c package $0.00 Standing Section $0.00 0 New Res (1-2 units) $0.00 0 Misc Electrical Equipment $0.00 0 New Res (3+units) $0.00 0 Transformers up to 1 kva/kw $0.00 0 Pool / Spa $0.00 0 ................up to 10 kvalkw $0.00 0 Lighting Fixts $54.85 65 .................up to 50 kvalkw $0.00 0 Recept Outlets $17.60 16 ..................up to 100 kvalkw $0.00 0 Switches $6.60 6 ..................over 100 kvalkw $0.00 0 Non Res Appl $0.00 0 Low Voltage Equipment $0.00 0 Res Appl $0.00 0 Low Volt Wiring System I Ckt $0.00 0 Service to 200a $0.00 0 Misc. Conduit $0.00 0 Service to 1000a $0.00 0 Misc. Conductor $0.00 0 Service over 1000a $0.00 0 Circus ( gen or ride) $0.00 0 Motors to 1 hp $0.00 0 Circus (meth ride or lights) $0.00 0 Motors to 10hp $0.00 0 Christmas Tree Stand $0.00 0 Motors to 50hp $0.00 0 Fireworks Stand ' $0.00 0 Motors to 100hp $0.00 0 'Other Electrical Fee $0.00 Motors over 100hp $0.00 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomla statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or It work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply wilh all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result In the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2446.46 (aroo) DECLARATIONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declar"ons: ❑ ! Jwve and will maintain a certificate of consent to sell-Insure for workers compensation, as provided for by section 3700 of the tabor Code, for the performance of the ork for which this permit Is issued. 1 have and will maintain workers' compensation insurance, as requirad by section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. My workers' compensation Insurance ca r and policy number are: % /�� Carrier: �f -� ; i1 Policy Number:1>_1 >_1 - C ',3 (This section need trot be comp! tad if the pemrlt is valued at one hundred dollars ($100) or lass.) ❑ I certify that in the performance of the work for which Ihi rmif Is Issued, I shall not employ any person in any manner so as to become subject to the workers' ou stoma subject to the workers' Compensation provisions of Section 3700 of the Labor Code, I shall forthwith compensation taws of California, and agree t comply with these prpvi;$i l Applicant Signature: Date: ' WARNING: FAILURE NSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOILARE (5100, I. IN TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3709 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter a (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license Is In full force and effect. Lic. p 4 C7 Class fr° G- —,/D Contractor's Signature: Date: CONSTRUCTION LENDING A CY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature: Date: OWNER-BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Coda: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she Is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a dull penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not Intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-builder will have the burden of proving that he or she did not build or improve for purpose of sale.). - ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature: _ _ Date: Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec, 341, Title 8, California Administrative Code). ❑ As owner-builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). ---..................... .._................. .........,.._........................... ---...-•-- 1........_..—..... _—W...... _ _ 2 Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? C3 Yes El No (Section 25533 of the California Health and Safety Code, with someexcepflons, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 If an RMPP is presently required, has Section 25534 of the California Health and Safety Coda been tutly complied with? ❑ Yes ❑ No _..................._ _.__......._...---•• _......__.W _.._.._ _ _ _ ................ —.................._............................................................ ---._...................................... _...... ...... _..... _................ D—.. 5 oes or will the applitant or present or future building occupant require for the work which is the subject of this a plication a ermit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? LJ Yes 1 No (Section 65850.2 of the California Government Coda requires that the requested Information be furnished on applications for non-residential building permits). _..............................._.__................__..............._.......................__ _................ _ ..................................._.......,................................................. _..............._.._._.... 6 Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if "yes', the facility must meet the requirement of Sections 2$534 and 42303 of the California Health and Safety Code). _..._............................ _.— _ ........ _...... _... _._..-•-----................................. _......... _ 7 if a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have ail of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No ........................ —._......._...... -......._._.— _............._ _.................................................................................,................................................._............ ..................__ ....._.. 8 (ff yes', attach Ceriiiicate of compliance from the appropriate air pollution control officerp. CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: Date: CERTIFICATE OF COMPILIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the Information given is correct. I agree 10 comply with all state laws and city ordinances relating to building construct€on, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. IOwne s Date An uthodzed Applicant ate gQpE !. Q� I CODE# INSPECTIONTYPE 263 INMALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-Roof 210 Final Electrical I i 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final BuildinglOccupancy (714) 754-5273 - Fax (714) 754-4856 - www,ci.costa-mesa.ca.us 77 FAIR DRIVE, COSTA MESA, CA 92625 Job Address: 3333 BRISTOL ST Suite No 1407 Vicinity: SPACE 1407 (MAX MARA) Parcel Number: 41250107 Applicant: COOTER, LYLE Address: Owner: SOUTH COAST PLAZA Address: COSTA MESA CA 3315 FAIRVIEW ROAD MECHANICAL PERMIT Phone: (714) 685-0077 ' Zip: Phone: Zip: 92626 Contractor: K AND S AIR CONDITIONING INC Address: 143 E MEATS AVE Phone: (714) 685-0077 ORANGE, CA Zip: 92865 License: 483431 Status: ISSUED Applied: 09/29/2003 Issued: 09/29/2003 ISSUED BY: ;Oil SCOPE OF PERMIT MECH PERMIT IN CONJUNCTION WITH THE 3,767 S.F. TENANT IMPROVEME=NT FOR "MAX MARA'. SCOPE OF WORK TO INCLUDE: REMOVAL OF DEMISING WALL BETWEEN 1403 (FORMERLY FRED JOALLIER JEWELERS), NEW CEILING, NEW PARTITION WALLS AND FLOORING. MAX MARA WILL BE TAKING OVER SUITE 1403. 2 REPAIR ALT COOLING/HEAT, 2 VAV BOXES REF: B03-01331 FEE SUMMARY Quantity Quantity ISSUE FEE $23.50 Repair 1 Alt Absorbtion Unit $0.00 0 Inst FAU <100 k BTU 50.00 0 Repair/ Alt Refrigeration Unit $0.00 0 Inst FAU >100 k BTU $0.00 0 Ventillation System $0.00 0 Repair/ Aft Cooling/Heat $27.40 2 Evaporative Cooler $0.00 0 Inst 1 Rep. Recess Wall Htr $0.00 0 Commercial Incinerator $0.00 0 Refrig Sys <100 k BTU $0.00 0 Domestic incinerator $0.00 0 Refrig Sys >100 k BTU $0.00 0 Compressors I Absorption Systems Gas Piping $0.00 0 Up to 3 hp 1 100 k BTU $0.00 0 Factory Fireplace $0.00 0 3 To 15 hp 1500 k BTU $0.00 0 Hood w/Mech Exhaust $0.00 '0 15 To 30 hp 11,000 k BTU $0.00 0 VAV Box $21.30 2 30 To 50 hp 1 1,750 k BTU $0.00 0 Vent Fan 1 Single Duct $0.00 0 Over 50 hp 1 Over 1,750 BTU $0.00 0 Appliance $0.00 0 Boilers Fire Dampers $0.00 0 Up to 3 hp $0.00 0 Smoke Dampers 50.00 0 3 To 15 hp $0.00 0 Inst or Relocate Appl Vent $0.00 0 15 to 30 hp $0.00 0 Air Handlers < 10000cfm $0.00 0 30 to 50 hp $0.00 0 Air Handlers > 10000cfm $0.00 0 Over 50 hp $0,00 0 Floor Furnace $0.00 0 Other Mechanical Fee Floor or Suspend Heater $0.00 0 Investigation Fee $0.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: This permit shall automatically expire and become void if work is not commenced within 180 days, or if work is suspended or abandoned for a period of 180 days. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. FOR INSPECTIONS CALL: (714) 754-5626 2448.46 (8100) DECLARATiONS WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the 1ollowlng declarations: ❑ 1 have and will maintain a certificate of consent to self-4nsure for workers' compensation, as provided for by section 3700 of the Labor Coda, for the performance of the work for which this permit Is issued. "I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' Compensation Insurance carrier and policy number are: + G Carrier. —� Policy Number: 1 7 (This section need not be completed if t e permit is valued at one hbhdr&d dollars ($100) or less.) ❑ I certify that in the performance of the work for which this permit is issued. I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Califomia, and agree that if I should become subject to the workors' compensation provisions of Seyt},on 3700 of the Mbar Code, I shall forthwith comply with these provisions. (/� Applicant Signature: Date: T �� WARNING: FAILURE TO SECURE WOPZFIV COMPENSATION OOVERAGE IS UNLAWFUL AND SHALL SUaJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARE ($500,000)• IN ADDITION TO'rHE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3700 OF THE LA60R CODE. INTEREST. AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under rcrolslons of Chapter 9 (commencing with Section 7000) of Division 3 of tho Business and Professions Code, and my license is in full farce and effect. Uc. a _ _ _ L{ ��{ 3 / Class a • C�� z—� „ _ _ Contractors Signature: Date: 2� CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lenders Name: Lenders Address: Signature: Date: OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5. Business and Professions Code: Any city or County which requires a permit Io Construct, after, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is lll�ensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure Is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such Improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or Improve for purpose of sale.). - El 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors Licynse Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature: Date: Owner ID verified by drivers license. ❑ Yes ❑ No Drivers License No. Expires: Verification of Ownership by (type of document, I.e. - property tax bill or dead): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet In depth into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, fafsework, or demolition or dismantling thereof, will be more than thirty-six (36) feel high. (Chap. 3.2, Grp 2. Art2, Sec. 341, Title 8, California Administrative Code), ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless Such person has a permit to do such work tram the division. Signature: Date: Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1 Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the Califomla Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Carta Mesa Fire Department by every business which has at any one lime during a reported year a quanilly of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet • of compressed gas at standard temperature and pressure). 2 Does or will the applicant or present or future building occupant need to fila a registration form for acutely hazardous materials? ❑ Ya _s' ❑ No (Section 25533 of the Califomla Health end Safety Coda, with some exceptions, requires registration with the Costs Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater then a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). .............. .. _._................ __. 3 Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4 if an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully compliod with? ❑ Yes ❑ No 5 Does or will the applicant or present or future building occupant require for the work which is the subject of this ay�l1plication aermit for Such construction or modification from the South Coast Air Ouality Management District or from any other air pollution control district or agency? U Yes ND (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-resldenfial building permits). 6 Will any part of the facilityto be constructed under this permit be within 1000 fast from the outer boundaries of a school? ❑ Yes ❑ No (11 'yes', the facility must meet the requirement of Sections 25534 and 42303 of the Callfomla Health and Safety Code). 7 If a permit from the South Coast Air quality Management Dlstrid or other air pollution Control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by Califomla Health and Safety Code Section 42303 been made? ❑ as ❑ No 8 (If 'yes", attach certificate of compliance from the appropriate air pollution control officer). _ CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to Comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature: _ Date: CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state lawg and city ordinances relating to building construction• and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature Of L"al Own s) Da And/Or Authoriz5owlicant 9 CODE 1, IHSPECTIONJ�rpPE 2M INTITIA CODE 1 INSPECTION TYPE u f 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re-RDoI 210 Final Electrical 201 Final BfocklReiaining Wail 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy M PROJECT ADDRESS: 3333 BRISTOL ST UNIT. 1407 OWNER'S NAME: C.J. SE.GERSTROM & SONS ADDRESS: 331.5 FAIRVIEW RD COSTA MESA CA 92626 RRCHIENGINEER: (714)546-0114 REO.NO.: ADDRESS: UNIT: PERMITTEE: PACIFIC WEST BUILDERS (714)496-4958 ADDRESS: 33041 CALLE AVIADOR C SAN JUAN CAP,ISTRANO CA 92675 LICENSED CONTRACTOR DECLAPATION: I hereby affirm Shat I am licensed under provisions of Chapter 9 (commencing with Section 70001 of Division 3 of the Business and Professions Code, and my license is in full force and eNecL CITY LIC.: 0454 16 STATE LIC.: 4 9 6 4 6 9 CLASS: BB Date:y4�/ - — Signature:�dk WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to sell -insure or a certificate of Workers' Compensation Insurance. or a cerblied copy thereof (Section 3800. Lap. C). j OLICY NO.: 8 0 0 17 3 61 EXP. DATE: 11/24/91 - COMPANY: 1/24/91COMPANY: TRANSAMERICA Certified copy is hereby lumished. M Certified copy is filed woe city Building Division. Date:N—? `-, Applicant: EXEMPTION FROM WORKERS' COMPENSATION DECLARATION: (This section need not be compteted if the pemlit is for one hundred (S1DD) Or less), I certify that in the performance of the work for which this permit is issued, 1 shall riot employ any person in any manner so as to become subject to the Workers' Compensation Laws of California. Date: - -- - - - Signature: NOTICE: If, alter making this declaration, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction [ending agency for the performance of the work tar which this permit is issued (Section 3097, Civ. Q. LENDER: IN PREPARATION FOR THE ADDRESS: rrPORT O' CALL" STORE. OWNER BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractors' State License Law far the following reason (Section 7031.5 Business and Professional Code: Any city of county which requires a permit 10 construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that helshe is licensed pursuant to the provisions of the Contractors' State License Law (Chapter 9 {commencing with Section 7DOO► of Division 3 of the Business and Piolessions Code) or that he/she is exempt therefrom and the basis for the alleged exemption, Any violation of Section 7031.5 by any applicant for a permit subjects the aplaNcant to a civil penalty of not more than five hundred dollars (5500). I, as owner of the property or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Section 7044, Business and Professional Code: The Contractors' State License Law does not apply to an owner of a property who builds or improves thereon, and who does such work himseWherself Or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however the building or 1 improvement is sold w hw one year of completion• the owner will have the burden at proving he/she did not build or improve for the purpose of sale). I, as owner OI the property, am extlusivelY contracting with licensed contractors to construct the project (Section 7044, Business ❑ and PrOfessirros Code: The Contractors' State License Law does not applyto an owner of property who builds or improves thereon and who Contracts for su6h projects with a contractor(s) license pursuant 10 the Contractors' State License Law), I am aware that proos of their worker's Compensation insurance shouid be provided to me. ❑ I am exempt under Section: B. & P, C. for this reason: Date: Owner: I do hereby certify that I am aware of and understand the requiremenls of Cahlornia Health and Safely Code Sections 25505, 25533, and 25534 and that I or any luiure building Occupalil will/will not (circle one) need to comply with said state codes and the requirements for a permit for construction or modilicatian from the Air Quality Management District. Residential construction applications are exempt from these provisions. Date: Applicant; I hereby certify that I have read this application and state that the above information is correct. I agree to comply with all city and County ordinances and state laws relating w building construction and hereby ouch rite representatives of this city to enter upon the above-mentioned property lot inspection purposes. Date: _ ` —?-/--Signature: of Driver's License on Social Secunty 0 1641,46 Whae—Building; Green—Coda Enforcement; Canary—Applicant; Pink—Revenue; Goldenrod—Assessor CITY OF COSTA M4SA - BUILDING PERMIT PERM NO: B 05156! PERMIT NO: 3 051561. PLAN CHECK NO: N GOVT: N SUPP: N CONSTRICTION TYPE: 1FR SP PERMIT TYPE: STR PURPOSE. DEM JOB DESCRIPTION ; DEMO -INTERIOR OF RETAIL SALES SP,=,CE SQ FT: CLAIM VALUE: 1,040,00 CALC-VALUE: 1,000,00 GROUP OCC; 3-2'• ! COMMENTS: THIS IS NOT A PERMIT FOR CONSTRUCTION! 14 x• iF iE * iE ,� �'• it• ff Mf- ie * at• # Mh #f i4 Y• K�{• * iF ii• iF � jf•'t i{+>E ff * � k of ,k * ii• iF � if• •1E r1E +F aE• +E ie ii• �• TS it of K � � � y(• � ii• !F !t• it• is• � +E +cat• iE � � � iF Vit• 3r a; a4 � �F �•. Z O N I N G S E T B A C K S R E Q U I R E M E N T S - MAIN BUILDING --•-------- ---------- ACCESSORY BUILDING --------- FRNT: FT IN REAR; FT IN FRNT: FT IN REAR: FT IN LEFT: FT IN RGHT: FT IN LEFT: FT IN RGHT; FT IN PARKING REQ• PROV: PARCEL: 41250102 ZNE; REF NO: PLANNING N TES> ;Y aE � f�F of lE f~ >t � iF ? :- 3t- iE d4 * ai• iF ?F jf• � 3iF � �F }c !t• � ?t- ae ae � * 3f iE * 3E 3c �t• i� iE aE #t• aF •1E 3t ?f• !t• Tt• �F i{• 4c 3c # fit• it iE iF aE � ?:• � iF * !t• aE iF �(-•b•''F fit• ii•'t- � �F de• it• � at af• D E V E L O P M E N T S E R V T C.E S R E Q it I R E M E r S ZONING APPROVED BY DATE: BUILDING APPROVED BY _ _ _ DATE: 'r / APPLICATION ISSUED BY:� DATE: }E #• IF -)i• iE iF IE• iF i(• fE• 1E •li• i( i4• it # it 9f' ik it• i(• !t•�3' n• • . . � it �ir {��� t""}'s t''f- ft• iE jf• k• 3R #�1{• i{•'i� ill -iii"` 3�it• r 3F 1r �l. ME if• #t it• aF kF }F � 3t• K+E 3c aF 1f !E # iF it �iE iF it MI• jE li• � 9{Tt• lf• aF aF TE �F If �i• -1E 9E �F -}i• ac • * � Y ;f• 9f• ?F if• ii• at• 1� �E• �E !% aE ti• ii• 1F 3r' •1F• fi• ?r Ji• if fit• �i- ik 3t• it• ii• fit• dF � ??• aF iF •Ff• LEGALIZATION:N F E E S U M M A R Y STRUCTURAL SEGMENT:Y BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SMIP/RES GRADING PERMIT 25.00 SMTP/NON-RES PIAN , 50 ISSUE FEE BUILDING -DIV-> PERMIT ISSUE PLAN -CHECK TOTAL; PAID DUE TOTALS ---- > 25.50 0.00 0.00 25.50' 25.50 1 .00 REVENUE DIVISION TOTALS-'-> COLLECTED; 25.50 OVER/SHORT: .00 BLDG PMT PLUMBING ELECTRIC MECHANIC FIRE SHIP/TOT GRADING PLAN -CHECK 25.00 ,So ?E i{ ?t it iF # +F 9E 3F 1E irF fS 3E If k 1 }• �t iE * iF it aE kF it is is !E ;: iE yE +E ?f 3F I N D I V I D U A L F E E B R E A K D O W N TYPE QTY D E S C R I P T I O N UNIT COST TOTAL COST NO FEES WERE SELECTED FOR THIS PERMIT 01 00084143-06094144 TCI ! .g DATE: Or/04/91 13:19 CONSTRUCTION AND PLANNING' APPROVALS Permit # Date Inspector P 1 SPA APPROVALS Permit # Date Inspector 1. Temporary Electrical Service or Pole l 52. Pool & Equipment Location 2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd, 54. Forms 4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6- Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE 7. Footings 58. Electrical Conduit-Undrgrnd. 8. Foundation 59. Gas Pipe, 0 Undrgrnd., Test 9. Water Pipe-Undrgrnd. = 60. Backwash Lines, P -Trap, © Undrgrnd. 10. Structural Floor System 61, APPROVAL TO DECK 11. Property Sewer Line & House Connection 62. Backwash & Receptor -Final .' 12. Sewer Cap '%, r• ;; 63. Heater & Vent -Final 13. Roof Drains w % 64. Plumbing System - Final 14. Rough Plumbing % 65. Electrical -Final 15, Rough Electrical -Conduit 66. Solar System -Final 16. Rough Electric Wiring 67. Fencing & Access Approval 17. Rough Wiring Sign 68, APPROVED FOR PLASTERING 18. Rough Electrical -T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit # 20. Rough Factory Fireplace 21. Ducts, in Structure 70. Underground Hydro 22, Ducts, Ventilating 71, Product Piping ❑ Gas ❑ Oil 23. Gas Pipe -Rough & Test 72. Underground Flush 24. Roof Framing 73. Undergrnd, Storage Tank 0 Gas 0 Oil 25. Roof Sheathing 74. Overhead Hydro 26. T -Bar Ceiling (Structural) & Monocoat 75. Dry Chemical 27. Frame and Flashing 76. Dry Standpipe 28. Lathing & Siding 77. FIXED SYSTEM FINAL 29. Insulation 78. FIRE PREY. FINAL 30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat 79. FINAL INSPECTION 32. Electrical Power Meter -Final 80. FOOD CERTIFICATE ISSUED 33. Final Electric - Notes: 34. Final Heating & Air Conditioning 35. Final Gas Pipe -Test 36. Hood or Canopy 37. Final Factory Fireplace ' 38. Final Plumbing 39. Water Service -Final .40. Gas Service -Final -41. Solar Domestic -Final 42, Backflow Preventer 43. Backflow Irrigation ' 44. Landscape Irrigation System 45. Sound Attenuation , 46. Handicap Regulations 47. FINAL STRUCTURE & BUILDING/ o 48. FINAL PLANNING .. 49. Electric Release to Edison 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY No Date „� - Applicant to fill in all spaces except those within heavy border lines and sign all appropriate declarations. _' _U2 51 CITY OF COSTA MESA CONST UCTION PERMIT IPE MIT NO. TRACT NO. LOT NO, UNIT NO. Project Address Applicant's Mallin ddress V - 1506M TYPE OF CONSTRUCTION _ ❑_ ❑DEMOLISH NEW ADD ALTERATION REPAIR' ❑OTHER - CONVERSION A.P. # ' _ -q' Zone Owne'r's,,.--- Phone DESCRIPTION OF WORK/USE OF BL'OG. l _. SMain Building:' ' _ Accessory Building: Address E + _ Z Arch/Eng. License No. TYPE OF PERMIT LJ GRADING FOUNDATION STRUCTURAL T Front O ❑ TENANT '❑ ELECTRICAL ❑ PLUMBING ❑ MECHANICAL B N Address 0 Rear `. Contractor's NameAWE Phonegg OTHER C Right N PROJECT DESCRIPTION SQ. FT, OCCUPANCY K _ G Address (mailing) CONSTRUCTION TYPE VALUATION $tIW,W ' _ $ I Left 1 City License No. g ZONE GRADINGCU.YDS. ACRESE. Ping. Ref . Parking Req./Provided R LICENSED CONTRACTOR DECLARATION _ I hereby affirm that I am licensed under provisions of Charter 9 (commencingRemarks: ` Planning Nates: M , with section 7000) of Division 3 of the Business and Professions Code, and T T my license is in fu }� fo a and effect. i 1 1 r i S Licens CI 1 r� icense o. Date - signature i PLUMBING FEES WORKERS' COMPENSATION DECLARgTIQN Bar Sink Showers ELECTRICAL +FEES ' I hereby affirm that I have a certificate of consent to self -insure or a certificate F of Workers' Compensation Insurance,, or a certified copy thereof (Section - s Backflow Preventer • -- Service Sink - '- - - - ' Automatic Washer Transformer ❑ 15-50 KIN 3800, Lab. C t1 15h + { I / I ❑ 50+ KW Policy No..49yx0��0T Company Backflow Irrigation Sewer Cap Construction Pole Sub. Certified copy is hereby furnished. Certi etl ff��py }sled with the city Bu ing i 'o .' at bs Sewer Connection- Cooking -Unit _ , ,Meter Cup to 100,amps - ±• Dat. 10-, "- k Applicant , ' EXEMPTION'F'ROM WORKERS' CQMPENSAT N DECLARATION arifier's Solar Collectors l Dishwasher. 4 • Meter Cover 100 amps 1_ (This section need not be completed if the permit Wfan cine hundred ($100) or + 1 ishwasher ! Solar Piping j Dryers [:]Gas, ❑Electric Sub Panel less). , I Certify that in the performance of the work for which this permit is issued, I shall' not employ any person in any manner so as t0 become subject to the , ' Drinking Fountains Solar Tank € Fan ' Motors 00-1 HP 01 Y� - 8 + ' Workers' CompensationLawsof California., - - Date Signature Floor Drains Swimming Pool MSpa F:A-U. Inc.Solar,❑9-15 HP ❑16-15+ C NOTICE: If, after making this declaration, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith Floor Sinks --• - Urinal --�--- Fixtures - - .Microwave - - comply with such provisions or this permit shall be deemed revoked. _ \ CONSTRUCTION LENDING AGENCY Gas Service Outlets . - Water C€OSet ` '- 'Device Boxes 'Pole Light ; I hereby affirm that there is a construction lending agency for the performance I of the work for, which this permit is issued _(Section 3097 Civ. Cj), •! Interceptors* ._ Water Heater - - •Outlets Range ` i Lender's Name V Lender's •Addressi _ Kitchen Sink '' ' i -s Water Service `- Switches: , Sign " OWNER BUILDER DECLARATION -- �~ I hereby affirm .that I am-exernpt from the Contractor's License Law (or the Lavatorie, Auto -Wash t' Garbage Disposal Standing Sections following reason (Section 7031.5'Businessand'Professlonal Code: Any city or 1 \county which requires a permit -to construct, alter, improve, demolish or repair P -Trap Laundry Trays Generator ❑0 5 KW ❑5-15 KW Trash Compactor t any structure, prior to its' issuance, also requires the applicant for such permit - to file a signed statement that he/she is licensed pursuant to the provisions of Roof Drains the Contractor's License Law (Chapter 9 (commencing with Section 7000) of € Division 3 of the Business and Professions Code) or that he/she is exempt -and - f f therefrom the basis for the alleged exemption. Any violation of Section , • 7031,5 by any applicant for a permit subjects the applicant -.to a• civil- - enalty of not more than five hundred dollars ($500). -employees - 'Reinspection Fee - $15 Issue Fee $ 3 - ' 1, as owner of the. property or my with wages as their sole intended - ' Reinspection Fee $15 Issue Fee' $ 3 compensation, will do the work, and the structure is not or offered for sale (Section 7044, Business and, Professional Code: The Contractor's '•' MECHANICAL' FEES ' License Law does not apply to an owner of a property who builds or improves "- thereon, and who, does such work himself/herseif or through his or her own' - Boller•+ Hood or Type I ❑ - DEVELOPMENT SERVICES REQUIREMENTS:' employees, provided that such improvements are not intended or offered for is com- Canopy Type I I ❑ Zoning Appraved By , ata sale. If, however, the building or improvement sold within one year of pletion, the owner will have the burden of proving he/she did not build or im- Duct - Under Giound Building Approved By Date prove for the purpose of sale). ❑ I, as owner of the property, am exclusively contracting with licensed con- Duct - Structural ' Refrigeration System 4• Application Issued $y + at tractors to construct the project(Section 7044, Business and Professions Code: does to an owner of who ' CID-1.00,00OBTU 11100,000 BTU The Contractor's License Law not apply property builds or improve$ thereon, and who contracts for such projects with -a. con-.- Duct - Ventilating SU ARY OF FEES license Contractor's License Law). I am aware that BUILDING PERMIT $ SMIP $ tractors) pursuant to'the EXhaUstSystem ❑ Multiple �• System Repair/Alteration proof of their Worker's Compensation insurance should be provided to me. PLAN CHECK $ A , PERMIT ' ❑ I am exempt under Section B. & P. C, for this reason Firepl/Fact. Bit. ICBO # Fire Dampers PLUMBING $ ISSUANCE $ Date Owner;. Heating System & ducting Registers PLAN CHECK 25% $ ENERGY P.C. $ € hereby certify that I have read this application. and state that the above ❑0-100,000 BTU ❑100;000BT' i ELECTRICAL $ GRADING $ information is correct. I agree to comply with all city and county ordinances f " MICROFILM 1 $ and state laws relating to building construction, and hereby authorize repre- sentatives of this city tenter' upon t above-mentioned prop rty for inspection purposes. H$1 PLAN CHECK 50% MECHANICAL $ $ - - TOTALFEE + $ 'Signature "'� Date �� FeeIssue Fee $ 3 PLAN CHECK 25% $ f DriversLicense or SS #Reinspection ' CMF 0865-46, rev. 10/84 White - Building; Canary - Applicant; Pink - Accounting; + Goldenrod - Assessor CONSTRUCTION AND'PLANNING APPROVALS Permit # Date , Inspector POOL & SPA APPROVALS Permit # Date Inspector 1. Temporary Electrical Service or Pole 52, Pool & Equipment Location 2. Soil Pipe-Undrgrnd. 53. Steel Reinforcement 3. Electrical Conduit Utility-Undrgrnd. 54. Forms- -4. Electrical Conduit-Undrgrnd. 55. Electrical Bonding 5. Steel Reinforeemeni' . 56. Rough Plumbing & Pressure Test 6• Electrical UFER Grnd. 57. APPROVAL TO COVER-GUNITE 7; Footings 58. Electrical Conduit-Undrgrnd. 8. Foundation 59. Gas Pipe, © Undrgrnd., Test 9. Water Pipe Undrgrnd: - .60. Backwash Lines, P -Trap, ❑ Undrgrnd. 10. Structural Floor System '� ,' 61. APPROVAL TO DECK t1). Property Sewer Line & House Connection 62. Backwash & Receptor -Final 12. Sewer Cap i 63. Heater & Vent -Final 13. Roof Drains 64. Plumbing System - Final 14. Rough Plumbing. 65. Electrical -Final 15. Rough Electrical -Conduit 66. Solar System Final 16. Rough Electric Wiring 67. Fencing & Access Approval 17. {lough Wiring Sign 68. APPROVED FOR PLASTERING 18. Rough Electrical -T Bar Ceiling 69, POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit # 20. Rough Factory Fireplace 21. Ducts, in Structure 70. Underground Hydro 22. Ducts, Ventilating 71. Product Piping ❑ Gas ❑ Oil 23. Gas Pipe -Rough & Test 72. Underground Flush 24. Roof Framing 73. Undergrnd. Storage Tank ❑ Gas © Oil 25. Roof Sheathing 74. Overhead Hydro 26. T -Bar Ceiling (Structural) & Monocoat 75. Dry Chemical 27. Frame and Flashing 76. Dry Standpipe 28. Lathing &Siding 77. FIXED SYSTEM FINAL 29. Insulation 78. FIRE PREV. FINAL ! " 30. Drywall Nailing HEALTH DEPT. REQUIREMENT .31. Plaster Brown Coat 79. FINAL INSPECTION 32. Electrical Power Meter -Final e 80. FOOD CERTIFICATE ISSUED 33, Final Electric Notes:, 34. Final Heating &•Air Conditioning 35. Final Gas Pipe -Test 36. Hood or Canopy 37. Final Factory Fireplace 38. Final Plumbing 39. Water Service Final 40. Gas Service -Final 41. Solar Domestic -Final 42, Backflow Preventer 43. Backflow Irrigation 44. Landscape Irrigation System 45. Sound Attenuation ' 46. Handicap'Regulations , 47. FINAL STRUCTURE & BUILDING . r 48. Special Requirements Completed. r 49. Electric Release to Edison r - 50. Gas Release to Southern California Gas Co r 51. CERTIFICATE.OF.00CUPANCY No. Date, _ K a CD Applicant to fill In all spaces except those within Ci�r�OF COSTA MMESA ONSTRUCTION PERMIT Y 'rojegt AddressJJ 26&maLCJzzE Applicant's Mailing Addressss �% D f/ Owner's Name &Whone) Address Arch/Eng. License No. Address Contractor's Name Phone. t(y Address (mailing) �,�+���7 lZLlJ c F City License Na. LICENSED CONTRACTOR DECLARATION I hereby affirm that 1 am licensed under provisions of Charter 9 (commencing with section 7000) of Division 3 of the Business and Professions Code, and my license is in full f e 1 fect. Licens Cla s ye ens Date Signature WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self -insure or a certificate ,f Workers' Compensation Insurance, or a certified copy thereof (Section 300, Lab. � F^C policy No- I LJ � Company ertified copy is hereby furnished. ert}fis�cajy� is h the city B ivisi Date n --o "82t Applicant EXEMPTION FROM WORKERS' COMPENSATION E0ECLARWATION (This section need not be completed if the permit is for one hundred ($100) or IessJ. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California. Date Signature NOTICE: If, after making this declaration, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY ' r I hereby affirm that there is a construction lending agency for the performance of the work for which .this permit is issued (Section 3097 Civ. C.) Lender's Name Lender's Address OWNER BUILDER UECLARATION 1 hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5 Business and Professional Code: Any city or county which requires a permit to construct, alter, improve, demolish or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he/she is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he/she i5 exempt therefrom and the basis for the alleged exemption. Any violation of Section '031.5 by any applicant for a permit subjects the applicant to a' civil enalty of not more than five hundred dollars ($500). a 1, as owner of the property or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Section 7044, Business and Professional Code: The Contractor's License Law does not apply to an owner of a property who builds or Improves thereon, and who does such work himself/herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the bull -ding or improvement is sold within one year of com- pletion, the owner will have the burden of proving he/she did not build or im- 5 rove for the purpose of sale). 1, as owner of the property, am exclusively contracting with licensed con- tractors to construct the project (Section 7044, Business and Professions Code! The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and _who contracts for such projects with a con- tractor(s) license -pursuant to the Contractor's License Law). 1 am aware that proof of their Worker's Compensation insurance should be provided to me. ❑ 1 am exempt under Section B. & P. C: for this reason Date Owner I hereby certify that•I have read this application and state that the above information Is correct. I agree to comply with all city and county ordinances and state laws rela ' o building constructio a d hereby authorize repre- sentatives of thi city to enter -mentioned pr erty for inspection purp Signature Drlvers' Li ense or S5 appropriator— TYPE ppropriat TYPE OF CONSTRUCTION LJ NEW L) ADL] !—` ALTERATION LJ REPAIR ❑ CONVERSION ❑ DEMOLISH ❑ OT� DESCF3lf�� WORK/USE OF BLOG.;�f�r%%O A.P. # S Main Building: E TYPE OF PERMII� L GRADING L FOUNDATION U STRUCTURAL 1:1 TENANT ELECTRICAL ❑ PLUMBING ❑ MECHANICAL ❑ ,OTHER T B A Front Rear PROJECT DESCRIPTION SQ. FT. OCCUPANCY CON STRUCTION TYPE VALUATION $ ZONE GRADING CU.YDS. ACRES C K . S Right Left Ping. Ref. # Remarks: AP7a Planning Notes: Boiler Duct . Under Ground Duct - Structural Duct - Ventilating Exhaust System ❑ Multiple ❑ Firepl/Fact. Bit. ICBO # Heating System & Ducting El 0.1 00,000 BTU ❑ 100,000 BT Reinspection Fee 1 $15 9F 0865-46, rev. 10/84 White . Building; Canary - Applicant; Pink - Accounting; Goldenrod - Assessor Hood or Type I ❑ Canopy Typeil ❑ Refrigeration System ❑0.100,000 BTU 1:1100,000 BTU System Repair/Alteration Fire Dampers Registers Issue Fee I -S 3 Automatic Washer Construction Pale Sub. Cooking Unit Dishwasher Dryers ❑Gas ❑Electric 1092 9/30/05 Accessory Building: Parking Req./Provided ELECTRICAL Fan F.A.U. Fixtures Device Boxes Outlets Switches Garbage Disposal Generator 00-5 KW ❑5-15 KW r , Reinspoction Fee $15 ='Mown TL Zone _ Transformer ❑ 15-50 KW ❑ 50+KW Meter LJ up to 100 amps Meter El over 100 amps Sub Panel Motors 00-1 HP ❑1%-8 Inc.Solar ❑9-15 HP 1116-15+ Microwave Pole Light Range Sign ! Standing Sections Trash Compactor Issue Fee FEES $ 3 Z 0 N I N G R E 0 M T S DEVELOPMENT SERVICES REQUIREMENTS: PLUMBING I FEES !. Bar Sink Showers Backflow Preventer Service Sink Backflow Irrigation Sewer Cap Bathtubs Sewer Connection Clarifiers Solar Collectors t Dishwasher Solar Piping Drinking Fountains Solar Tank Floor Drains Swimming Pool w/Spa Floor Sinks Urinal Gas Service Outlets Water Closet Interceptors Water Heater Kitchen Sink Water Service Lavatories , Auto -Wash P—Trap Laundry Trays Roof Drains $ ENERGY P.C. $ ELECTRICAL Reinspection Fee GRADING $15 Issue Fee $ 3 .PLAN CHECK 50% MECHANICAL FEES Boiler Duct . Under Ground Duct - Structural Duct - Ventilating Exhaust System ❑ Multiple ❑ Firepl/Fact. Bit. ICBO # Heating System & Ducting El 0.1 00,000 BTU ❑ 100,000 BT Reinspection Fee 1 $15 9F 0865-46, rev. 10/84 White . Building; Canary - Applicant; Pink - Accounting; Goldenrod - Assessor Hood or Type I ❑ Canopy Typeil ❑ Refrigeration System ❑0.100,000 BTU 1:1100,000 BTU System Repair/Alteration Fire Dampers Registers Issue Fee I -S 3 Automatic Washer Construction Pale Sub. Cooking Unit Dishwasher Dryers ❑Gas ❑Electric 1092 9/30/05 Accessory Building: Parking Req./Provided ELECTRICAL Fan F.A.U. Fixtures Device Boxes Outlets Switches Garbage Disposal Generator 00-5 KW ❑5-15 KW r , Reinspoction Fee $15 ='Mown TL Zone _ Transformer ❑ 15-50 KW ❑ 50+KW Meter LJ up to 100 amps Meter El over 100 amps Sub Panel Motors 00-1 HP ❑1%-8 Inc.Solar ❑9-15 HP 1116-15+ Microwave Pole Light Range Sign ! Standing Sections Trash Compactor Issue Fee FEES $ 3 Z 0 N I N G R E 0 M T S DEVELOPMENT SERVICES REQUIREMENTS: Zoning Approved By nate Building Approved ByDated Application Issued By (/L� _ Data -- / =ay SUMMARY OF FEES BUILDING PERMIT $ SMIP $ PLAN CHECK $ PERMIT PLUMBING $ ISSUANCE $ PLAN CHECK 25% $ ENERGY P.C. $ ELECTRICAL GRADING $ .PLAN CHECK 50% $ MICROFILM $ .MECHANICAL $, I TOTAL FEE $'�L'>Z±L� PLAN CHECK 25% $ CONSTRUCTION AND PLANNING PPROVALS Permit # Date Inspector PUO L 'A APPROVALS Permit # Date Inspector 1.'Temporary Electrical Service or Pole 52. Pool & Equipment Location i v2.,Soil Pipe-Undrgrnd. 53. Steel Reinforcement , 3. Electrical Conduit Utility-Undrgrnd. 54. Forms 4, Electrical Conduit- Undrgrnd, 55. Electrical Bonding 5. Steel Reinforcement 56. Rough Plumbing & Pressure Test 6. Electrical LIFER Grnd. 57. APPROVAL TO COVER -GUN ITE -7. Footings 58, Electrical Conduit-Undrgrnd, 8. Foundation 59. Gas Pipe, ❑ Undrgrnd., Test .9. Water Pipe-Undrgrnd, 60. Backwash Lines, P -Trap, ❑ Undrgrnd. 10. Structural Floor System 61. APPROVAL TO DECK 11. Property Sewer. Line & House Connection 62. Backwash & Receptor -Final 12. Sewer,Cap 63, Heater & Vent -Final 13. Roof Drains 64. Plumbing System - Final 14. Rough Plumbing 65. Electrical -Final 15. Rough Electrical -Conduit 66. Solar System -Final 16. Rough Electric Wiring , �% 67, Fencing & Access Approval 17, Rough Wiring Sign 68. APPROVED FOR PLASTERING 18: Rough Electrical -T Bar Ceiling 69. POOL/SPA SYSTEMS FINAL 19. Rough Heating & Air Conditioning FIRE DEPT. REQUIREMENT APPROVALS Permit# 20. -Rough-Factory Fireplace 21. Ducts, in Structure 70. Underground Hydro 22, Ducts, Ventilating 71. Product Piping 0 Gas 0 Oil 23. Gas Pipe -Rough & Test 72. Underground Flush 24. Roof Framing 73. Undergrnd. Storage Tank ❑ Gas 0 Oil �. 25. Roof Sheathing 74. Overhead Hydro a'6- T -Bar Ceiling (Structural) & Monocoat 75. Dry Chemical t27.- Frame and Flashing 76. Dry Standpipe �28. Lathing & Siding 77. FIXED SYSTEM FINAL 29. Insulation 78. FIRE PREY. FINAL 30. Drywall Nailing HEALTH DEPT. REQUIREMENT 31. Plaster Brown Coat 79. FINAL INSPECTION X32. Electrical Power Meter -Final 80, FOOD CERTIFICATE ISSUED 33. Final Electric JJ� Notes: fe 2c ,`G t f ` 34. Final Heating & Air Conditioning • i �� 35. Final Gas Pipe -Test 36. Hood or -Canopy G 37. Final Factory Fireplace 38. Final Plumbing 39. Water Service -Final 40. Gas Service -Final 41. Solar Domestic -Final 42. Backflow Preventer 43, Backflow Irrigation 44. Landscape Irrigation System 45, Sound Attenuation 46. Handicap Regulations ; 47. FINAL STRUCTURE & BUILDING 48. Special Requirements Completed 49. Electric Release to Edison 50. Gas Release to Southern California Gas Co 51. CERTIFICATE OF OCCUPANCY No. Date City of Costa Mesa Development Services Department Building Safety Division CERTIFICATE OF OCCUPANCY No. P. O. Bax 1200 Costa Mesa, California The Building located at 3333 Bristol St. Sp': #1407 has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group B2 Occupancy. Use of Building -o -4. i Legal Description 412-501-02 (See reverse side for Metes and Bounds) Building Permit No B51.632 Electrical Permit No.EMP51633 Plumbing Permit No, FMP51633 Mechanical Permit No. EMP51633 Number of apartments and/or guest rooms ISSUED TO: Port O'Call Pasadena 906 Granite Pasadena, CA Building Official Tony C' De Baca: by Date October 30, 1991 This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. CMF 1015-46 rev. 1/83 White - Owner,, Canary - Numerical File; Pink -'Bldg. Permit File of osta 200 esa F)evelopment Servicev""n' ivision of Building and Safety v � •y CERTIFICATE OF OCCUPANCY This certificate is issued pursuant tthe requiiemerits fof,�thepniform Building Cade, Section 308 adopted by the City of Costa Mesa certi s,that at -the time of its -issuance the building structure herein below described was inspected andiappr� e� r' occuparicy�asf\ollows: Building Address X333 BE SROL 6;T,3'4�T_. Bldg. Permit No. B7647.1., Use f'� 5 CLMMNG,STs--�- Group m Type' of Cons tions 1 -FR SO +Fire`Zone 1;� ` 1� Use Zone Cl -S bwner of Building C. Jai SIX�.STPPMS _ ` T ant MAm Address A�= r ' ''•T r B ; BUILDING OFFICIAL- tOny Date ARp=- TT, 10* 3996 REQUIRED TO BE POSTED IN A CONSPICOUS PLACE 0B 50 7149570903 PAGE 02 12I15f2004 _ --Y OF COSTA MESA, BUILDING SAFETY DIVI- POST IN .00ONSPICUOUS PLACE 06 ME JOB NOTICE Schedule inspection one workday in advance. To schedule inspections, Cali (714) 754-5626. Provide the following information: 1) Permit number, 2) Job address, 3) Inspection Item number, 4) Day and data you need the Inspection. adz 7 ,,'�h PERMITS EXPIRE 180 DAYS (6 MONTHS) FROM ISSUE OR LAST 114SPECTION ttem I STRUC7URAL CONSTRUCTION-• Date Inspector nem i POOL & SPA Rite Inspector 4 Footings 94 Pool & Equipment Local Mn 6 gab 96 SIW Reinforcement 8 Structural Floor 100 Electrical Bonding 11 Pre -Inspect Roof 102 Rough Plumb & Pressure Test 12 Roof Sheathing 104 Approval to Cover- Gunitc 14- T -Bar Ceiling -Structural 106 Elec Conduit • Underground 16 Shear Parcel 108 Gas Pipe/Underground Test 18 20 Frame & Flashing Lathing d Siding 0 110 aackwash Lines, P -Trap, Underground 22 Insulation 112 Approval to Deck 24 Drywall Nailing 116 Pool Plumbing System •Final 26 Plaster Brown Coat 118 Pool Electrical - Final 30 Pre -Grout 122 FencatgfAccessJAlatms �proval 33 Disabled Access 124 Approval for Plastering 66 Rough • Factory Fireplace 126 PodZpa Systems - Final 68 Sewer System 2175 f=inal CMSD Approval 72 Gas Pipe - Rough Test 1610 FIRE DEPARTMENT APPROVAL Overhd HydrolOvefid Rough 90 Gas Pipe Test- Final 1612 Dry Chemical 92 Water Service - Final 1614 Dry Standpipe 36 ELECTRICAL Wer Ground 1616 Final - Fixed System 38 44 Elec Conduit - Underground Rough E ! B3 Call (714)154,5626 for trio following: • Data trapeaw 46 Rough Elec. Conduit 200 Final Re•Raof 48 Elec T -Bar Ceiling 201 Final WocWRetaining wall 50' Elec Power Fetal 203 Final Sign 51 Temp Power Final 204 Final Demolition 206 Final Mechaniral 208 1 Final Plumbing 210 Final FJeCVICaI d PLUMBNO & MECHANICAL Call [114) 327.7400 for the following: 0" kavedor 52 Soll Pipe - Underground 212 Fnal Fire Prevention ff3 ` 54 Waley Pipe: -underground Call Vi 4) 734-5335 for the fallowing: Dam lav - 55 Underground Gas 214 Final Transportation 5v3. 62 Rough Plumbing Call (7141754-5671 for the to(towing: Data msptdw fi4 Rough Mechanical 216 Final Engineering Approval 66 Rough • Factory Fireplace Call (714) 7545307 for the following: Dat• utSpCCmr 68 Sewer System 2175 f=inal CMSD Approval 72 Gas Pipe - Rough Test Call (714) 7545245 for the follovdng: Date Inspector 90 Gas Pipe Test- Final 2201 Finat Planning Approval 92 Water Service - Final Call (714) 754-5626 for the following: Dar Ing 222 Final Site I NOTES: SEE REVERSE 250 Final BuidinglOccupancy 111 n e40 Usr.MSt CITY OF COSTA MESA BUILDIMG D1Y1SIOM } 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 - Fax (714) 754-4856 • www.costamesaca.go_v �. FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BX12-00145 PERMIT TYPE B_MISC STATUS: ISSUED APN: 41250107 DATE ISSUED: 04/27/2012 Zoning: PDC, ISSUED BY: JOB ADDRESS: 3333 2830 BRISTOL ST CM Suite/Unit: 2830 Vicinity: SPACE 2830 Primary Occ: Const Type: ?? SO. FT: 0 Valuation: $10,000.00 SCOPE OF WORK: INTERIOR LANDLORD WORK TO SPACE 2830. CONSTRUCTION OF A NEW DEMISING WALL WITHIN 112 COLUM BAYS TO BE ON CENTER WITH COLUMN GRID AND CONSTRUCTION OF NEW NEUTRAL PIER. NO ELECTRICAL INCLUDED IN THIS SCOPE OF WORK. NOTE: FINAL APPROVAL OF PERMIT SHALL NOT BE GRANTED UNTIL ACCESS TO DWELLING UNIT(S) IS PROVIDED FOR VERIFICATION OF SMOKE AND CARBON MONOXIDE ALARMS BY THE CITY INSPECTOR. SEE ATTACHMENT WIINSPECTION CARD - OWNER: SOUTH COAST PLAZA City/State: COSTA MESA, CA Phone: APPLICANT: NAGY, ZSOMBOR City/State: Phone: 714-427-0370 CONTRACTOR: RS HAGLUND CONSTRUCTION License No.412567 r. Address: 502 S'SANTA FEUnit: City/State: SANTA ANA, CA Zip Code: 92705 ARCHITECT: LANCE BROWN Phone 714-427-0370 ENGINEER: 210 Final Electrical Phone 212 Final Fire Prevention FEE SUMMARY Building Plan Check: Building Permit: Electrical Permit: SMIP Residential SMIP Commercial Bldg Std Admin Fund Address:: 3315 FAIRVIEW RD Unit Zip Code:92626 Address: Unit: Zip Code: Phone 714-550-9997 Cell: License No. C19698 License -No.. $117.81 $181.25 $0.00 $0.00 $2.10 $1.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. \ INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE E. INSPECTION TYPIN AL CODE 0 INSPECTION TYPE DATE INTMAL 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final BlocWRetaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Fina! Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy t3 _ .\ 3 ��:.. .r,...T •a;-- .. '~i%.'> };, ; r� �.. 1.',•!C\:.'rr. -i�r '�. �...r"'1.: 1*i.r.�4-.�.,_'_ }_'-•�.-,y„�i. y.: r� �ri'�'y_^�,\.� �......•. CI_ -Y OF 'COSTA Mr )A 11 Development Services, Division of Building and Safety CERTIFICATE OF -"OCCUPANCY This certificate is issued pursuant to the requirements of the Uniform Building Code, Section 308 adopted by the City of Costa Mesa certifies that at the time of its'issuance the build ingstrti' ure herein below described was inspected and approved for occupancy as follows: Building Address 3333 13A9, 01 St. , Sp..:g, 1208 �' , Bldi .,Permit Number B06-00413 w ; y Use Display/Sale 'Merchandi:se (3331 Group Type of Corrstructian Fi'�o' Use ZonepnC Owner of Building South Coast Plaza, Tenant §CAROLINA HERRERA 3315 Fairview Rd; Cosba Mesa, CA 2.6 2-6' >?. Address r 92."F Y.• 11 BUILDING OFFICIAL-Khanh Q., Nguyen,. C.B.O. `. Date 09/15/0,6 REQUIRED TO BE POSTED IN'A CASPICOUS PLACE CITY OF COSTA MESA �p BUILDING DIVISION Q > 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 - Fax(714)754-4856 www.ci.costa-mesa.ca.us F �.; FOR INSPECTIONS CALL: (714) 754-5628 PERMIT NUMBER: BX08-00149 PERMIT TYPE B_MISC STATUS: ISSUED ' APN: 41250107 DATE ISSUED: 07/21/2009 - Zoning: PDC, ISSUED BY: JOB ADDRESS: 3333 3010 BRISTOL ST CM Suite/Unit: 3010 Vicinity: CHRISTIAN LOUBOUTIN, SPACE 3010 Primary Occ: F Const Type :vv SQ. FT: 0 Valuation: $20,000.00 SCOPE OF WORK: INSTALLATION OF 7' HIGH MOSILE STORAGE RACKS FOR "CHRISTIAN LOUBOUTIN", SPACE 3010, REF#: BC08-00209 OWNER: SOUTH COAST, PLAZA Address:: 3315 FAIRVIEW'RID Unit City/State: COSTA MESA; CA Zip Code: 92626 Phone: APPLICANT: PAUL J RUFFING, AIA Address: 1101 DOVE STREET Unit: SUITE 140 City/State: NEWPORT BEACH, CA Zip Code: 92660 Phone: 949-660-8062 CONTRACTOR. HURST AND SIEBERT , License No. 622681 Address: 2377 SO EL CAMINO REAL Unit: SUITE •103 City/State: SAN CLEMENTE, CA Zip Code: 92672 Phone 949-361-0111 Cell: AkCHITECT: PAUL J BUFFING, AIA License No. C4264 ' Phone 949-660-8062 ENGINEER: PEYTON - TOMITA AND ASSOCIATES License No. 3304 Phone 714-245-4931 FEE SUMMARY Building Plan Check: $80.31 Building Permit: $321.25 Electrical Permit: $0.00 SMIP Residential $0.00 t J iii: SUITE SMIP Commercial $4.20 Bldg Std Admin Fund ?? TOTAL FEES $406.76 41 i1,ni'• SUITE. G i' - 'NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations.:(Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. ;INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE V. INSPECTION TYPE DATE INTITIALS CODE # INSPECTION TYPE DATE INTMALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final BlocklRetaining Wall 212 Final Fire Prevention _ 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign �� �. t 222 Final Site 250 Final Building/Occupancy 204' Final Demolition ` � `; -3 t WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. oil 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compengation Insurance carrier and policy numb r sedpn need not be completed d the penn+t Isis valued at one hundred Ooliars (Si 00) or>�J ❑ rtify that in the performance of the work for which this permit is issued. J shall not employ any person in any manner so as to become subject to the worke ' ' compensation laws of Qaornia, and agree that if I should becomes jec to L kers' c pens ion provisions of Section 3700 of the Labor h with c ply hese provisions. -o7lrC�� picant's ign re Da WARNING: FAILURE TO SECURE WORKERS' COMPAZ COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is i full force and effec . — 0 11 can c rs S' to CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a Construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for Such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors Licenge Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License taws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature Dale 3057-46 (3107) Owner ID verified by drive . license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Division of Industrial Safety Permit Number: Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Pian be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the Califomia Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7, If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If "yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY- I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by'Nis PgxTitArnlij final inspfIttion. Signa re of .ego vme j Date F rt l Andlor Auth nied_A� ant Dal CI- ,Y OF COSTA Mr 'A� Development Services, Division of Building and Safety C CERTIFICATE OF OCCUPANCY This certificate is issued pursuant to the requirements of the Uniform Building Code, Section 308 adopted by the City of Costa Mesa certifies that at the time of its issuance the building structure herein below described was inspected and approved for occupancy as follows: Building Address 3333 Bristol"•5t. `, frSte 30.0.9- Bldg. Permit.NumberBC07-00394 Use Clothing Retail (2,250 s.f.) M llwl XXXXXXXXX PDC Group Type of Construction Fire Zone Use Zone Owner of Building South Coast. Plaza Tenant OSCAR DE LA RENTA Address 3315 FikaBview. itd . , Costa Mes'a",, CA Ste B BUILDING OFFICIAL-Khanh Q. Nguyen, C.B.O.: ` Date:.. 03/17/08 REQUIRED TO BE POSTED IN A CONSPICUOUS PLACE CITY OF COSTA MESA BUILDING DIVISION Y 77 FAIR DRIVE, COSTA MESA, CA 92626 - (714) 754-5273 - Fax (714) 754-4856 • www.ci.costa-mesa.ra.us ` FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: E08-00046 PERMIT TYPE ELEC APN: 41249102 STATUS: ISSUED DATE ISSUED: 02/1212008 ISSUED BY: BJK JOB ADDRESS: 3333 3009 BRISTOL ST CM Suite/Unit: 3009 Vicinity: SUITE 30Cq OSCAR DE LA RENTA ' SCOPE OF WORK: 100A ELECTRICAL SERVICE FOR THE FUTURE "OSCAR DE LA RENTA" STORE IN SUITE ZM. NO OTHER WORK AUTHORIZED WITH THIS PERMIT. OWNER: SOUTH COAST PLAZA PHONE; APPLICANT: AM VANCE PHONE: 714-875-8021 CONTRACTOR: J M VANCE ELECTRIC - Address: 10203 NIGHTINGALE AVUnit: City/State: FOUNTAIN VALLEY, CA ZipCode: 92708 ELECTRICAL PERMIT FEES Electrical Plan Check Fee: Electrical Permit Fee: Reinspection Fee TOTAL FEES $27.00 $54.00 $0.00 $81.00 Address: 3315 FAIRVIEW AVE UnIt:MISC. CitylStatelZip: COSTA MESA, CA Address: 10203 NIGHTINGALE AV Unit: CitylStatelzZip: FOUNTAIN VALLEY, CA License No. 705273 PHONE: 714-875-8021 CELL; D NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE i 114SPPECTIDN TYPE DATE INTRIAL CDD£# INSPECTION TYPE DATE INTMAL 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final BlocklRetain-ing Wall 212 Final Fire Prevention 202 Final Factory Fin; Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy .C ITY OF COSTA MESA BUILDING DIVISION H77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 - Fax (714) 754-4856 • www.ci.costa-mesa.ca.us FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BX08-00044 PERMIT TYPE B_MISC STATUS: ISSUED APN: 41249107 DATE ISSUED: 02/13/2008 Zoning: PDC , ISSUED BY: CAC JOB ADDRESS: 3333 3009 BRISTOL ST -CM. _= =-' Suite/Unit: 3009 Vicinity: 3009 `PrimaryOcc:, Const Type :?? SQ. FT: 0 r Valuation: $800.00 SCOPE OF WORK: BC07-00394 SUITE 3009 FOR OSCAR DE LA RENTA"- NON ILLUMINATED STORE FRONT SIGN:;.,; :.. OWNER: SOUTH COASTPLAZA ; ,.N :r °' Address:: 3315 FAIRVhEW, RD Unit City/State: COSTA MESA, CA Zip Code: 92626 Phone: :E _ APPLICANT: ELIANA9 EIRON {_��.� . ,-Address: 7159 VINELAND AVE Unit: City/State: NORTH HOLLYWOOD, CA. Zip Code:.- 91605 - Phone: 818-982-0316 CONTRACTOR: AMERICAN NEONICS INC License No. 520989 Address: 7159 VINELAND AVE _ Unit: City/State: NORTH HOLLYWOOD, CA :.x,a w..-. Zip Code: 91605• _ _ _ ,Phone`:=x,.818-982-0316: Cell: 818-982-28257 ARCHITECT: License No. . Phone ENGINEER: License No: Phone NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE 0. INSPECTION TYPE DATE INTITIALS CODEC INSPECTION TYPE DATE INTITIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 2DFinal Factory Fire Place 220 Final Planning Approval 203 Final Sign 3—�1— e$ 222 Final Site Final Demolition 250 Final Building/Occupancy FEE SUMMARY Building Plan.Check: Building Permit: . " $32.65 Electrical Permit: r .. -$0.00 SMIP Residential ' SMIP Commercial !` ${}.001 $0.00TOTAL FEES ',;� _�• w ,_,.$53.87 -�� °' NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE 0. INSPECTION TYPE DATE INTITIALS CODEC INSPECTION TYPE DATE INTITIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 2DFinal Factory Fire Place 220 Final Planning Approval 203 Final Sign 3—�1— e$ 222 Final Site Final Demolition 250 Final Building/Occupancy WORKERS' COMPENSATION DECLARATION I hereby affirm under penally of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the pert rmance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by s ion 3700 of the Labor Code, for the performance of the work for which this permi ed. My workers' compensation Insurance carrier and policy n er are: C Carrier: t I need not De completed tithe perm+t is valued of one hundred datlars (fi00J a less.) P i ❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Coqe, I shall fortDkvith comply with these provisions. jF A lipnr re le WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and mr5els in full force and effect. Lie. # C _ 02 3 09 Con s lgnalure CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason {Sec. 7031.5, Business and'Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance. also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sate (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signalure 3057.46 (3107) Date Owner ID verified by drip, ,ice. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure. scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Date Division of industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feel of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 55850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'fres", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If 'yes", attach certificate of compliance from the appropriate air pollution control officer), CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. 1 agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature N Legal er(s) e Date CITY OF COSTA MESA BUILDING DIVISION } 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us �. FOR INSPECTIONS CALL: (714) 754-5626 F07-00369 FIRE SUPRESSION PERMIT .lob Address: 3333 BRISTOL ST .- . Status: ISSUED Suite: 3009 _ 201 Applied: 12/13/2007 Vicinity: Final Factory Fire Place 203 Final Sign Issued: 01/04/2008 Parcel Nunmber: 41249107 < ; Zoning: PDC PDC Applicant: Si IEILA'L'OONEY�r'.;,'` " Address: 5200 E HUNTER AV SUITE Phone: 714-993-2822 ANAHEIM, CA Zip: 92807 Owner. SOUTWCOASf PLAZA.. - - =r7-0369 Address 3315FAIRVIEW.RD •� �!_ - Phone: COSTA MESA;'CA Zip:. 92626 Contractor: ALERT FIRE PROTECTIONrINC Address: 5200 E HUNTER AV 'B YPhone: SUITE 7-14-993-2822 ANAHEIM, CA.'-',- . i Zip: 92807. License: 316324 = 12113!2C107 f1i)4 2008 SCOPE OF PERMIT ADD 10 OVERHEAD SPRINKLER HEADS AND RELOCATE 32 FOR "OSCAR DE LA RENW IN SPACE 3009, REF.: Br -07-00394' - FEE SUMMARY Plan Check: $81.41 Calc Valuation: $6,000.00 Permit: $125.25 Claimed Valuation: $6,000.00 Other: $0.00 Total: $206.66 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia statutes -.and; related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. - - -- — - INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. OC Ol 4. INSPECTION TYPE 1616 Fixed System Final Fire Prevention 1266 Pool Spa Final 200 Final Re -Root 201 Final Block/Retaining Wall 202 Final Factory Fire Place 203 Final Sign 204 Fina; Demolition j DATE � � � INTMALS +i CODE/ INSPECTION TYP 206 Final Mechanical 208 Final Plumbing 210 Final Electrical 212 Final Fire Prevention 220 Final Planning Approval 222 Final Site 250 Final Building/Occupancy DATE INTMAL !1O Y �� WORKERS' COMPENSATION DECLARATION: 49 Owner ID verified by ❑ No I hereby affirm under penalty of perjury one of the following declarations:Driver's;t icense'No. Expires: `(� Z - ElI have and will maintain a certificate of consent to self -Insure for workers' ''�ation of Ownership by (type of document, i.e. - property tax bill or deed): compensation, as provided for by section 3700 of the Labor Code, for the pe ormance of the work for which this permit is issued. �I have and will maintain workers' compensation insurance, as required by tion 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: 1 ry- y 7-� I Carrier: gVr1 _ 7 T N 1i- NS . e ' (This s -dm need not be auw#eted f the permit is valued atone hundred dollars (5100) or less.) Policy Number: 63 00000.? 75-071 ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subiect tjll e workers' compensation provisions of Section 3700 of the Labor Code, forth h corn with these provisions. 10 rAppiicant's Signature Date WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. 04 ntratl_or's Signature L.^_ate CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lenders Address: Signature OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature 305746 (3107) Date DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Date Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safely Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department, 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No S. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any pan of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (if 'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signatur r at Own ) Date -� -�_y g Andlor Authonzed Apptirant _ _Date 4r WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the e{rformance of the work for which this permit is issued. 6L.J\ I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workars' compensation Insurance carrier and policy numrrb ra a (This sedansedan neer t cat compreiedrQfhe permit isCvalued a! one hundred dol^la'r's�(Si00) or less.j ❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should becomes jecl to the rkers' comp sation provisions of Section 3700 of the Labo C sha f rthlvit om with these provisions. nature Owner ID verified by driver s license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Appljeanl's Signature Division of Industrial Safety Permit Number: Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION' WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE 1. Will the applicant or present or future building occupant need to file and IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL certify a Business Plan for emergency response to release or threatened PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS release of a hazardous material? ❑ Yes ❑ No ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS (Section 25505 of the California Health and Safety Code requires, with some PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND exceptions, that a Business Plan be filed with the Costa Mesa Fire ATTORNEY'S FEES. Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of LICENSED CONTRACTORS DECLARATION: 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas I hereby affirm that I am licensed under provisions of Chapter 9 (commencing at standard temperature and pressure). withSection7000) of Division 3 of the Business and Professions Code, and 2. Does or will the applicant or present or future building occupant need to file my��yrrnse is in full force and effect. a registration form for acutely hazardous materials? ❑ Yes ❑ No Li ae # (Section 25533 of the California Health and Safety Code, with some -/6U@xceptions, requires registration with the Costa Mesa Fire Department by 0/'each business which at any one time has on hand a quantity of acutely o rs Si ature hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard CONSTRUCTI N LENDING AGENCY: temperature and pressure). ❑ 1 hereby affirm that there is a construction lending agency for the 3. Does or will the applicant or present or future building occupant need to performance of the work for which this permit is issued. (Sec. 3097, Civil Code). prepare an RMPP (Risk Management and Prevention Program for acutely Lender's Name: hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Lender's Address: Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. Signature Date 4. If an RMPP is presently required, has Section 25534 of the California OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTOR$ to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature Date 3057-46 (3107) Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (It yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (if `yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inppection. Si t fe t galk _ Date 1n 19 Andlo �Auth .Apps Da CITY OF COSTA MESA BUILDING DIVISION F09-00025 s 77 FAIR DRIVE, COSTA MESA, CA 92626 - (714) 754-5273 - Fax (714) 754-4856 - www.ci.costa-mesa.ca.us r °.* FOR INSPECTIONS CALL: (714) 754-5626 License: 358795 SCOPE OF PERMIT Status: ISSUED Applied: 02/1112009 Issued: 02/18/2009 9 NEW SPRINKLER -HEADS IN CONJUNCTION WITH THE 866 SF SHELL CONSTRUCTION FOR FUTURE TI (NEW STRUCTURAL DECK, BEAMS, ETC) FOR "LOUIS VUITTON" ON THE 3RD LEVEL IN SUITE 3008, REF: BC08-00491 FEE SUMMARY Plan Check: $54.11 Calc Valuation: 52,500.00 Permit: $83.25 Claimed Valuation: $2,500.00 Other: $0.00 Total: $137.36 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE 0. INSPECTION TYPE DATE INTITIALS CODE O0 I-NSPECTION TYPE DATE INTITIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical r' 201 Final BlocklRelaining Wall 212 Final Fire Prevention ror� rf�'1 _ n L 1 v1 A 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy FIRE SUPRESSION PERMIT Job Address: 3333 BRISTOL ST Suite: 3008 Vicinity: SUITE 3008 LOUIS VUITTON . Parcel Nunmber: 41249107 .' Zoning: PDC,- 'PDC Applicant: WIEMANN, JOHN • Address: Phone: 626-332-7066 Zip. Owner: SOUTH COAST PLAZA Address 3315 FAIRVIEW RD ' Phone: COSTA MESA,.CA Zip: 92626 Contractor ALLREADY FIRE SPRINKLER'-;' Address: 818 N GRAND AV Phone: 626-913-6720 COVINA, CA Zip: 91724 License: 358795 SCOPE OF PERMIT Status: ISSUED Applied: 02/1112009 Issued: 02/18/2009 9 NEW SPRINKLER -HEADS IN CONJUNCTION WITH THE 866 SF SHELL CONSTRUCTION FOR FUTURE TI (NEW STRUCTURAL DECK, BEAMS, ETC) FOR "LOUIS VUITTON" ON THE 3RD LEVEL IN SUITE 3008, REF: BC08-00491 FEE SUMMARY Plan Check: $54.11 Calc Valuation: 52,500.00 Permit: $83.25 Claimed Valuation: $2,500.00 Other: $0.00 Total: $137.36 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE 0. INSPECTION TYPE DATE INTITIALS CODE O0 I-NSPECTION TYPE DATE INTITIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical r' 201 Final BlocklRelaining Wall 212 Final Fire Prevention ror� rf�'1 _ n L 1 v1 A 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy City of Costa Mesa Development Services Department Building Safety Division CERTIFICATE OF OCCUPANCY No. 0 0 0 6 9 0 P, O. Box 1200 Costa Mesa, California The Building located at 3333 Br:Lstol. Street #2874 d Gent1Pmn's Agreement Inas been inspected and found to comply with the provisions of all Ci*,y of Costa Mesa Ordinances applicable thereto for a Group 13^2 Occupancy. Os e of Building Irntesior Altexatlo3'i.s r Legal Description 140058-20 (See reverse side for Metes and Bounds) E-10020 Building Permit No. _AF -9971 „ _Electrical Permit No. BE -9971 Plumbing Permit No. Mechanical Permit No. Number of apartments and/or guest rooms , '0` ISSUED TO: Building Official by= /.� 3315 VA i^view RnEld, Ch—Sta MPS, CA IV Date / / AZ-*Ik / 7 0 T This Certificate of Occupancy SHALL BE posted in a conspicuous place on e premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. CMF 1015-46 rev. 1/83 White - Owner; Canary - Numerical Fite; Pink - Bldg. Permit File V, CITY OF COSTA MESA � Development Services, Division of Building and Safety CERTIFICATE -OF OCCUPANCY This certificate is issued pursuant to the requirements of the Uniform'BuiIdiiig Code, Section 308 adopted by the City of Costa Mesa certifies that at the time ofits issuance the building structure herein below described was inspected and approved for occupancy as follows: Building Address 3333 Srmst'o St. Ste 2874` _ Bldg Permit NumberB04-00235 Use Retail Group M Type of Construction qIv ER. rrar� ,Fire Zone Use Zone Owner of Building South„Coi�fibaPlaza tel_ v T_ errant 60k "Brothers” Address 3315 Fai riew��Rd. ^,\1Casta' Mesa, CA Pr �� � AWN A , Y BUILDING, OFFICIAL -Rick �,Bio" C.B.O.g -= � e ria Combination Inspector \ v (0) r- — x J ,:Dates REQUIRED TO BE POSTED INA CONSPICOUS PLACE CITY OF COSTA MESA r BUILDING DIVISION } 77 FAIR DRIVE, COSTA MESA, CA 92626 - (714) 754-5273 • Fax (714) 754-4856 - www.costamesaca.aov t- ".� FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BC11-00550 PERMIT TYPE: B_COMBO STATUS: ISSUED Sub Type: COM—ALT DATE ISSUED: 1211912011 ISSUED BY: JOB ADDRESS: 3333 3013 BRISTOL ST CM Suite/Unit: 3013 APN: 41249102 Zbning:PDC, , Vicinity: Primary Occ: Const Type: I -A SO. FT: 0 Valuation: $75,000.00 r SCOPE OF WORK: 520 SO FT TENANT IMPROVEMENT FOR "TORNEAU". SERVICE CENTER. NO NEW RESTROOMS BEING ADDED. 1 VAV BOX, 47 LIGHTING FIXTURES, 33 RECEPTACLES, 4 SWITCHES, 1 200 AMP SERVICE, 1 SINK, 1 TRAP PRIMER OWNER: SOUTH COAST PLAZA Phone: APPLICANT: MEDEL, MICHAEL Phone: 757-566-3032 CONTRACTOR: DAVID A NICE BUILDERS Phone: 757-566-3032 Cell: St ARCHITECT: ENGINEER: .1C , COMBINATION PERMIT FEE SUMMARY Building Plan Check: Building Fees: Electrical Fees: Mechanical Fees: Plumbing Fees: SMIP Residential: SMIP Commercial: Bldg Std Admin Fund TOTAL FEES: 'Refer to fee receipts for all fees oald for aroiect Address: 3315 FAIRVIEW AVE City/State/Zip: COSTA MESA, CA ,- Address: City/StatelzZip: Unit: MISC. Unit: License No. 709012 - Address: 4571 WARE CREEK RDUnit: City/State: WILLIAMSBURG, VA ZipCode 23188 License No. License No. $133.05 $818.75 $131.60 $34,15 $43.10 $0.00 $15.75 $3.00 $1,179.40 PHONE! PHONE: HOURS FOR CONSTRUCTION ACTIVITY: EFFECTIVE 3/18/2010 - PER CMMC Sec. 13-279 tL Monday thru Friday- 7:00 am thru 7:00 pm. Saturdays- 9:00 am thru 6:00 pm. Prohibited all hours - Sundays and the following Federal holidays: New Years Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day and Christmas Day S1. Ar Ef' NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord, No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. fWSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all rrequired inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. (✓I, WIDE A. INSPECTION TYPE DATE INTITIALS CODE 1 INSPECTION TYPE W ` E /r N A 1816 Fixed System Final Fire Prevention 206 Final Mechanical . `nq r12 -L •566 Pool Spa Final 208 Final Plumbing 200 Finaf Re -Roof 210 Final Electrical 261 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approva$ I203 Final Sign 222 Final Site .4- 204 Final Demolition 250 Final Building/Occupancy k City of Lova Mesa a+,Veopment B@ iRT[iY@{F 3u'4t"ng 5afety pv'5idn CERTIFICATE CRYIC(fiAYC Q F OCCUPANCY CCUPAVC1 N o. P, 4, 13ox 1200 Cast) Mesa, California The Building located at 3333 Briscal Street;, Space 3021 has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicabfe thereto for a Group b2 OCCU pane Y' Use sof Building Retail Legal DescripOon __-412- 01-02 (See reverse side for Metes ,and Boundsl Building Permit No B 54517 Etectrical Permit No.E54832_ _. Plumbing Permit No.2' 54033 Mechanical Permit No. M 54671, M 55827 Number of apartments , _,., anti/or guest rooms ISSUED TO: C. J. 5egerstxom 6 Sons g/� Space 3!�y 3021 Costa Mesa, CA 92626 Building Official Tony C'I3e Haea by Date Atlauat 10, 1992 This Certificate of Occupancy SHALL, BE posted in a conspicuous place on the premises and SHALL NOT SE removed except by the Building Official of the City of Costa Mesa under Sea. 307 (e) U.S.C. CMF 1015-A6 rv_v. 1/8,3 White - Owner: Candry - Numerical Fite; Pink - Sldg- Permit File Am CITY OF COSTA MESA BUILDING DIVISION i 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 www.ci.costa-mesa.ca.us t- FOR INSPECTIONS CALF_: (714) 754-5.626`. PERMIT NUMBE BC07-00319 PERMIT TYPE: B COMB02 STATUS: ISSUED Sub Type: COM—ALT DATE ISSUED: 1110812007 ISSUED BY:. RMD JOB ADDRESS: 33333011 BRISTOL, ST -dM SuitelUnit:; 3.011 APN: 41249102 %' Zoning:PDC, , - Final Re -Roof 201 Final Block/Retaining Wall Vicinity: SUITE 3011 ST JOHN KNITS, '•, `, - Primary Occ: Final Factory Fire Place ConstType- !-FR `•� ' ` SO. FT:' ' 3500 Valuation`:. $40,000.00 204 Final Demolition SCOPE OF WORK: 3500SF INTERIOR DEMO AND TI FOR "ST JOHN KNIT" IN SUITE 301,1.-ELEC, MECH, PLUMBING: 1 VAV BOX, 9 LIGHTS, 3 OUTLETS,`2 SWITCH, 4 COMMUNICATION DROPS. OWNER: SOUTH COAST PLAZA — - Address: 3315 FAIRVIEW AVE Unit: MISC. Phone: ;City/State/Zip: COSTA MESA, CA' APPLICANT: WATSON, DUSTY f s •n Address: 1' '' Unit: Phone: 714-662-703' City/StatelzZip: CONTRACTOR: WATSON CONSTRUCTION INC. `— ' License No. 705797 Phone: 714-662-7933: <t Address: 1260 LOGAN AVE Unit: UNIT B002 Cell: '� City/State: COSTA MESA, CA ZipCode 92626 ARCHITECT: JOHN BRYAN PRICE ' .. , License No.C30696- PHONE:949-716-8258 ENGINEER: License No. PHONE:'. COMBINTATION PERMIT FEE SUMMARY Building Plan Check: $88.28 Building Fees: $543.25 ` Electrical Fees: $43.30 Mechanical Fees: $34.15 Plumbing Fees: = $23.50 SMIP Residential:$0.00 '... SMIP Commercial: " • } $8.40 TOTAL FEES: $298.63 "Refer to fee receipts for at fees paid for project NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION, INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE I. iNSPE0014 TYPE 1616 Fixed System Final Fire Prevention 1266 Pool Spa Final 200 - Final Re -Roof 201 Final Block/Retaining Wall 202 Final Factory Fire Place 203 Final Sign 204 Final Demolition DATE ENTMA1.5 CODE INSPECTION TYPE 206 Final Mechanical 208 Final Plumbing 210 Final Electrical 212 Final Fire Prevention 220 Final Planning Approval 222 Final Site 250 Final Building/Occupancy all"/��L7r, 0 L{lif WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Can'ier,,• �I� ^ F,151 r (This sseUAn need not be completed d the permd is valued atone hundred dotlars ($ too) or fess.) Policy.Number. L `4n4�, f certify that in the performance of the work for which this permit is is ued I Shall not employ y erson in any manner so as to become subject to the rkers' co ansa on ws of California, and agree that if 1 should be m su ect tot wvo ensation provisions of Section 3700 of the a orda, I shall rth comply with these provisions. f y rarit's,Signature WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($1170,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: ereby affirm that I am licensed under provisions of Chapter 9 (commencing wvi Section 7000) of Division 3 of the Business and Professions Code, and my i nse is in full fort and effect. Ic' Class � �C-Irma-Fs Signature CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an -owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractors) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature 3057-46 (3167) Date Owner ID verified by driver's ,. tee. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property lax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feel in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Date Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be fumished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safely Code Section 42303 been made? ❑ Yes ❑ No 8. (If 'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that tft information given is correct. I agree to comply with all state laws and city r antes relating building construction, and authorize representatives of t e ity of G a sa to enter upon the above-described property for i sp tion pure . I gree not to occupy or allow occupancy of any building a th rizq(1 by this r t until final inspection. Owner(s) Das nppUrent � �f CITY OF COSTA MESA BUILDING DIVISION r 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 - www.Ci.costa-mesa.ca.us FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BC08-00358 PERMIT TYPE: B_COMBO Sub Type: COM—ALT JOB ADDRESS: 3333 3011 BRISTOL ST CM APN: 41249102 Zoning:PDC, , Vicinity: 3011 Const Type: I -A SQ. FT: 0 SCOPE OF WORK: INTERIOR STORE ALTERATIONS TO UNIT 3011. ST JOHN KNITS. 6 LIGHTS 1 ALT DUCT SYSTEM. ` OWNER: SOUTH COAST PLAZA Phone: APPLICANT: MERCER, BRIAN Phone: 714 476-0537 CONTRACTOR: BMC INC Phone: 951-789-9411 Cell: ARCHITECT: JOHN BRYAN PRICE ENGINEER: STATUS: FINALED DATE ISSUED: 08/14/2008 ISSUED BY: YH Suite/Uiiit: 3011 Primary Occ: M Valuation 'Address: 3315 FAIRVIEW AVE City/State/Zip: COSTA MESA, CA Address: City/State/7Zip: License No. 826373 Address: 20960 LAKERIDGE DRUnit: - City/State: PERRIS,CA License No.C30696 License No. COMBINATION PERMIT FEE SUMMARY Building Plan Check: $343.49 Building Fees: $2,113.75 Electrical Fees: $31.20 Mechanical Fees: $37.20 Plumbing Fees: $0.00 SMIP Residential, $0.00 SMTP Commercial: $63.00 TOTAL FEES: $2,651.65 "Refer to fee receipts for all fees paid for project $300,000.00 Unit: MISC. Unit: ZipCOde 92570 PHONE:949-716-8258 PHONE: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related _.regulations..lOrd_Nn_Si7-9R_s-1_�.7aa_o�t_� .:M DATE OF ISSUE OR DATE OF LAST INSPECTION. (� ender this permit to be considered legal, such work must comply with all applicable codes, and all IV obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. INTMALS CDD:! INSPECTIONS ItrmuLs 206 Final Mechanical tl • ' 208 Final Plumbing i 210 Final Electrical 212 Final Fire Prevention 220 Final Planning Approval 222 Final Site 250 Final Building/Occupancy CITY OF COSTA MESA NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE /. INSPECrON TYPE D/1T IN AL CODE R INSPE00111 TYPE DAjF, INTMALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy BUILDING DIVISION t 77 FAIR DRIVE, COSTA MESA, CA 92626 - (714) 754-5273 - Fax (714) 754-4856 - www.ci.costa-mesa.ca.us �. FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BX07-00199 PERMIT TYPE B_MISC STATUS: ISSUED APN: 41249102 DATE ISSUED: 1/105/2007 Zoning: PDC, ISSUED BY: RMD JOB ADDRESS: 3333 3011 BRISTOL ST CM `, Suite/Unit: 3011 Vicinity: SPACE 3011 Primary Occ: Const Type :?? SQ. FT: 0 Valuation: $30,000.00 S50PE OF WORK: NON-STRUCTURAL DEMO IN PREP FOR T.I. FOR "STYJOHN KNITS", SPACE 3011. REF#: , B 7-00319. OWNER: SOUTH COAST PLAZA Address:: 3315 FAIRVIEVn AVE Unit MISC. CitylState: COSTA MESA, CA Zip Code: 92626 Phone: APPLICANT: WATSON. DEBBIE Address: ' 1260 LOGAN AVE Unit: UNIT B002 City/State: COSTA MESA, CA Zip Code: 92626 Phone: 714-662-7933 CONTRACTOR: WATSON CONSTRUCTION INC.- License No. 705797 Address: 1260 LOGAN AVE Unit:- UNIT B002 CitylState: COSTA MESA, CA' Zip Code: 92626. Phone 714-662-7933 Cell: ARCHITECT: License, No. Phone ENGINEER: License No. Phone FEE SUMMARY Building Plan Check: $0.00 Building Permit: $442,25 Electrical Permit: $0.00 SMIP Residential,". $0.00' SMIP Commercial $0.00 $O.00TOTAL FEES $442,25 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE /. INSPECrON TYPE D/1T IN AL CODE R INSPE00111 TYPE DAjF, INTMALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 'W I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are; - Ca— rrler:. "Zrmv sect oa need nor be rigor/eteedrd the p&rw iiss vaaeed at one h x crew doears 01001 orlass ) Prolicy– ❑ 1 certify that in the performance of the work for which this permit is issued. I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Lab Code, I shall oNrthwith comply with these provisions. ,r/t_ I Applicant's Signature oto WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. tractor's Srg`nature CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($50D).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of properly who builds or improves thereon, and who does such work himself or herself or through his or her own employees. provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature Date 3057-46 (3107) Owner ID verified by driver's Driver's License No. ,e. ❑ Yes ❑ No Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty -sic (36) feet high, (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, Califomia Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Appi}cant's Signature Odle Division of industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the Califomia Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the Califomia Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 504 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the Califomia Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the Califomia Government Code requires that the requested information be fumished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the Califomia Health and Safely Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by Califomia Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (if 'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. 81g Lure of Legal ONmerfs / e If 9 'Gate Aal An _� I r _ . 3333 South Bristol SPACE #2618 f STUARDS FOR NM/STCATARRDS EUROPA Oj- N V-&ntA-- 64' __-44585 INT ALT $108,000 - i - 44695 FIRE SPRINK $2,500 - 45294 BOILER 1 _ E--16364 misc. ^48874,1=,`' = DM -ALT.. $100,000AN ., zmmmmmm�� - 40 -49873 FIRE SPRINK $1,590 _ #406 26-90 Tl. COSTA MESA BUILDING -SAFETY DEPARTMENT P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626 TA ATION FOR STRUCTURAL PERMIT For ILD AppNG licant to Fill in Completely —Use Ink BY DATE RECEIVED pATF�SSUED BUILDING ADDRESS ��-5) &'% R 33 �77 OWNER S t 1il�h� — V C -'U� OTC MAIL G� lADDRESS �[ t.w TEL.CT LOT BLOCKCITY C04; dAe NO.CONSTRUCTION D I ALTER REPAIB BRANCH ADDRESS ARCHITECT TEL. ADDRESS 11 CONTRACTOR G,i��yt C,Tg1 OWNS VALUE FIRE ZONE TYPE GR APPROVED i. BY DATE TEL Z1 CITY ZV1 �? �t NO. ZONE NO, OF PLANS USE OF NEW BUILDING YARDS APPROVED ACCESSORY BUILDING STATE CITY LIC. NO. 745C) Z7.5 LIC. NO. YARDS APPROVED MAIN BUILDING O. OF BLOGS (FROM C/L STREET) SIZE=NOW OF LOT ON LOT F13ONT FT. FT. FT. USE OF EXISTING SLOG. �{�0- Jam FT. Separate permits are required for L SIDE FT. FT. FT. electric, plumbing and heating work. REAR FT. USE OF BUILDING AND WORK TO BE PERFORMED DISTANCE BET. BET. MAIN & MAIN SLOGS. ACCESS. SLOGS. DROVED +r{ 5 rl V, 1-1 C.U.P. APPROVED QajE I hereby acknowledge that I have read this application and state that the above Information is correct and agree to comply with all laws regulating building construction, and I shall not employ any person .In violation of the workman's compensation laws of the State -Of California. t hereby certify that I am properly licensed as a contractor under the State of California Business and Professions Code, Division 3, Chapter 9, and that such licenses are In full force and effect, or 1 am exempt from the provisions of the State of California Business and Professions Code, Division 3, Chapter 9. yr Signature of Permittee _ _ CA_ - Authorized Agent SO. FT. THE AMOUNT SHOWN UNDER VALUATION IS FOR THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY. VALUATION PERMIT FEE $ Ov q ff�� PLAN CHECK $ 1 CI O $ �t� \ 1J� TAX b .56 TOTAL PAi D $ 'Z G q'O Q7_ - 45294 rCOS�A MESA"BUILDING-SAFETY DEPARTMENT' K3.80i{ 1200 COSTA MESA. CALIFORNIA 92626 For Applicant to Fill in Completely — JUse Ink OnlyBUILDING ADDRESS ��� �i r� ` 1 OWNER 7l//� l MAIL y/JJ ADDRES 3_3 33 /G/ ,} TEL. CITYjp` NO. CONSTRUCTION BRANCH ADDRESS ARCHITECT TEL. ADDRESS f''rA/ CONTRACTOf;?W 4C�1 ¢ 369-1 1/03/76 1'005�J TL APPLICATION FOR STRUCTURAL PERMIT REC ! Y PATE RECEIVED DA ISSUE 30 � Jl1D OyS,eS''pp-1Q PER lr N A.P. NO. F 'ji BUILDING ADDRESS TRACT LOT BLOCK, FIRE ZONE APPROVED DATE I Z j TEL �. NO.i / CITY ( f ZONE NO.OF PLANS USE OF NEW BUILDING YARDS APPROVED STATE ! J CITY eYARDS APPROVED LIC. NO. �yJ LIC. NO. MAIN BUILDING ACCESSORY BUILDING SIZE NO. OF B ,r IFROMC/LSTREET) g OF LOT NOW ON LOT FOONT FT. FT. USE OF _ TOTAL PAID $ a/ S 0 EXISTING BLDG. FT Separate permits are required for L SIDE FT. FT. FT. electric, plumbing and heating work. REAR FT. USE OF BUILDING AND WORK TO BE PERFORMED DISTANCE BET. BET. MAIN & MAIN BLDGS. ACCESS. SLOGS, VAR.. DATE C.V.P.. APPROVED 1�J r APPROVED I hereby acknowledge that 1 have read this application and state that the above information is correct and agree to comply with all laws regulating building construction, and I shall not employ any person in violation of the workman's compensation laws of the State of California. I hereby certify that I am properly licensed as a contractor under the Stateof California Business and Professions Code, Division 3, Chapter 9, and that such licenses are in full force and effect, or I am exempt from a prov[sions of the Stale of California Buslne and Prolesaions ivisl 3 h pte Signature o Perm Ittea Authorized Agen m i 0 SO. FT. a THE AMOUNT SHOWN UNDER VALUATION IS FOR M THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY. VALUATION PERMIT FEE S �D(' Kms— PLAN CHECK $ J ra o g LL TAX V _ TOTAL PAID $ a/ S 0 44644) SEP 22-77CN5AU01 1 06* ****40.10 COSTA MESA SUILDING-SAFETY DEPARTMENT P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626 APPLICATION FOR STRUCTURAL PERMIT 1G'.,. A�..1:..�... f., Cal ;_!`,......1„a,.t., tr__ a_t. �_t.. ......J,1,.,..aa... a.. a ua .,. yv..rN.......y —vac ■un wuy CEI D BY DATE RECEIVED DTE IS BUILDING ✓UJED W �` ADDRESS 0 ire" P OWNER hnp' A.P. NO, MAI L BUILDING ADDRESS3315 Fairview RCI• ADDRESS 41 1W16,t TEL. CITY Cp'sta Mesa NO. TRACT LOT BLOCK CONSTRUCTION NEW ADD ALTER REPAIR LENDER BRANCH OWNER ADDRESS V LUE ARCHITECT T -S S OR ENGINEER NEL. FIRE �} ADDRESS ZONE TYPE ZZCGROUP dL� CONTRACTOR SCOTT E. CAMPBELL CO. BYPROVED7780 LEI DATE r ADDRESS %673 Melrose Ave. TEL. Ze/% NO.OF PLANS USE OF NE BUILDING CITY 1,pg An eles 90046 No. 651 404 I 0/ STATE CITY LIC. NO. 160206 LEC. NO. 00807 YARDSAP PROVED YARD; A PROVED MAIN BUILDING ACCESSORY BUILDING SIZE NO.OF BLDGS. IFROM C/L STREET) OF LOT NOW ON LOT FRONT FT. FT. USE OF EXISTING BLDG. R. SIDE FT. Separate permits are required for L. SIDE FT. FT. electric, plumbing and heating work. ' REAR USE OF BUILDING AND WORK TO BE PERFORMED DISTANCE BET. BET, MAIN & In I fire sl2rinIsLars MAIN BLDGS. ACCESS. BLDGS. VAR. - DATE C.U.P. 46 APPROVED APPROVED Fly D&JE I hereby acknowledge that I have read this application and state that the above information is correct and agree to comply with all laws regulating building construction, and I shall not employ any person in violation of the workman's compensation laws of the State of California. I hereby certify the 1 am properly licensed as a contractor under SQ. FT. the State of C or is Business and Profe n Code, Division 3, Chapter 9, end such licenses are In fo a and effect, or I am exem [ the pislo of t to Califia Business THE AMOUNT SHOWN UNDER VALUATION IS FOR THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: VALUATION PERMIT FEE $ and Profe slo Code Ivislo 3 ha ter 9 Signature f Na F. PLAN CHECK $ CO m a Permktae TAX $ Authorized Agent TOTAL PAID $ ID W 44585 COSTA MESA BUILDING -SAFETY DEPARTMENT A.O. BOX 1200 COSTA MESA, CALIFORNIA 92626 For Applicant to Fill in Completely — Use Ink Only BUILDING Y DATE RECEIVED p T SSUED OJLe G_O ERMIT NO, 8 L 5 - 6j ADDRESS LOT ;(Z' W OWNER CC3-3ZJ �l�l] la (t -bS - k EN S f4C 1 MAIL ADDRESS �- fl` 6a o.148�j CIO CITY W y CITY NOL TEL. NO. S4ia'0114 CONSTRUCTION VALUE S E J�1 V YMAIIN LENDFR LIC.STATNO. -37314 O LIC. NO. BUILDINGARDS ACC98 RY BUILDING BRANCH (FROM C/L STREET) OF LOT NOW ON LOT ADDRESS USE OF ARCHITECT G �V EN`S TEL. 43'1'`l� SEP —1-77""00 0142* ***500.91 FM-S—A APJLi4Af10N FOR STRUCTURAL PERMIT REC A.P. NO. / Y DATE RECEIVED p T SSUED OJLe G_O ERMIT NO, BUILDING ADDRESS ST / %/! [ rt 10 TRACT LOT BLOCK W A CONTRACTOR P ADDRESS 5--%.r S• F W 0 CiL �- fl` 6a o.148�j ZONES j� NO. OF M PLANS USE OF NEW 8 I= OF �µl CITY NOL OWNER !'C[�/tom /&ggL"!e-�2 VALUE S E J�1 V r 3 � � I �C "+67 FIRE ZONE hkE, � �J ADDRESS to 3C} 1`� GROUP Li N ;e -C (LA"P rltl'•) APPROV D BY DATE + CONTRACTOR ADDRESS 5--%.r S• F W 0 CiL �- fl` 6a o.148�j ZONES j� NO. OF M PLANS USE OF NEW 8 I= OF �µl CITY NOL �^ W YMAIIN APPROVED ` LIC.STATNO. -37314 O LIC. NO. BUILDINGARDS ACC98 RY BUILDING SIZE NO. OF $LOGS. (FROM C/L STREET) OF LOT NOW ON LOT FRONT F USE OF EXISTING BLDG. R. 5F n FT Separate permits are required for L sID FT. electric, plumbing and heating work. REAR F FT. USE OF BU€LOING AND WORK TO BE PERFORMED DISTANCE BET. BET. MAIN & MAIN BLDGS. ACCESS. SLOGS. VAR. DATE C.U.P. + APPROVED APPROVED RY DATE 2// IZ2 I heraVY acknowledge that I have read this application and state that the above information is correct and agree to comply with all laws regulating building construction, and I shall not employ any person In violation of the workman's compensation laws of the State of California. I hereby certify that I am properly licensed as a contractor under SO. FT. the State of California Business and Professions Code, Division 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR Chapter 9, and that such licenses are In full force and effect, or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: am exempt from the provisions of the State of California Business Code Division 3, C S. VALUATION PERMIT FEE $ ' and Professlons plat Signature of �p � �_ PLAN CHECK $ Permittee , V—" - _ __� S TAX E Authorized Agent TOTAL PAID $ s' • -ZOSTA MESA BUILDING -SAFETY DEPARTMENT P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626 For Applicant to Fill in Completely — Use Ink Only BUILDING a� �y� ADDRESS � Y+40p x OWNER OR TENANT l�i luf 9SrUA$X0 F MAILING ADDRESS TEL. CITY NO. CONSTRUCTION BRANCH ADDRESS ARCHITECT—. TE ADDRESS L7i.CJ NFGKJ[�CZ[V1a7�. CONTRACTOR ADDRESS USE OF BUILDING AND WORK TO BE PERFORMED T101�• MRI�RMMAL PERMIT 11.11 TL 4 4.1PERMlT N° 488 7 A.P. NO. 11� TEL. CITY NO, STATE CITY LIC. NO. LIC. NO. SIZE SPACE NO. NO. OF BLDGS. OF LOT TR.NO. NOW ON LOT USE OF NEW AOD EXISTING BLDG. THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY. Separate permits are required for electric, plumbing and heating work. USE OF BUILDING AND WORK TO BE PERFORMED T101�• MRI�RMMAL PERMIT 11.11 TL 4 4.1PERMlT N° 488 7 A.P. NO. 11� O,S � /J NG ADDRESS DDRE55 UNIT SPACE NO. w TR.NO. LOT BLK. NEW AOD IALTERIREPAIR MOVING DEMOLISH OWNER - T —ISTU ► FF D UE usE 0 $ ZONEC� TYPE V -/j GROUP 1r•� APPROVED 4714? ? P O BY DATE / L. 7 APPROVED SETBACKS (FROMC/LSTREF-Ji � PLANNING ACTION RETAIL S&LAS : IMJ716euxv, Mrmax. I DATE 1 APPROVED I hereby acknowledge that I have read this application and state that the above information Is correct and agree to comply with all laws regulating building construction, and I shall not employ any person in violation of the workman's compensation laws of the State of California. I hereby certify that I am properly licensed as a contractor under the State of California Business and Professions Code, Division 3, Chapter 9, and that such licenses are in full force and effect, or I am exempt from the provisions of the State of California Business and Professions Cod Dlvision 3, Chapter 9. Signature of dyl Permittee or q f sib Authorized Agent Date d C i lS � 50. FT, w THE AMOUNT SHOWN UNDER VALUATION IS FOR m THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY. VALUATION PERMIT FEE $ Ln toe, PLAN CHECK S / c Sv oO TAX $ TOTAL PAID $ ►i . r r COSTA MESA BUILDING -SAFETY DEPARTMENT APPLICATION F6R19TRU6TUk1RLPERMIT-8 7e(10 P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626 TL RECEIVE BY L:::�='t 7 Li For Applicant to Fill in Completely — Use Ink Only BUILDING + /� = ADDRESS f C• A.P. NO. OWNER OR 4P6.4 BUILDING 7 ADDRESS 3 �1.� - tdi2 SE TENANT �� MAILING UNIT /�__ / — ADDRESS SPACE N NO. ��J (7 r"r TR.NO. LOT BLK. CITY oSTA- FSA NOL NEVI RDD ALTER REPAIR MOVING DEMOLISH CONSTRUCTION LENDER BRANCH OW NEA ADDRESS VALUE USE . $ ARCHITECTJ OG. TEL. -0 OR ENGINEER b ADDRESS 2 4X- Q ! ZONE TYPE GROUP APPROVED CONTRACTOR C P D BY DATE ADDRESS CITY TEL �9-✓C STATE CITY APPROVED SETBACKS Y LIC. NO. LIC. NO. ell, SIZE NO.OF BLDGS. (FROM C/L STREET) ++ _1AI fit - OF LOT NOW ON LOT FRONT FT. f D USE OF fL EXISTING BLDG Y R. SIDE FT. Separate permits are required for A L SIDE FT I" electric, plumbing and heating work. REAR FT. USE OF BUILDING AND WORK TO BE PERFORMED PLANNING ACTION . } . t DATE l APPROVED DAIE APPROVED I hereby acknowledge that I have read this application and state that the above Information is correct and agree to comply with all laws regulating building construction, and l shall not employ any person in violation of the workman's compensation laws of the State of California. I hereby certify that I am properly licensed as a contractor under SO. FT. the State of CaMornla Business and Protesslons Code, Division 3, THE AMOUNT SHOWN UNDER VALUATION 1S FOR Chapter 9, and that such licenses are in full force and effect, or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: am exempt from the provislons of the State of California Business VALUATION PERMIT and Professions CodaADivisi ,Chapter 9. FEE $ PLAN CHECK 4 Signatureiofi Permitted o Z ^� 5 TAX $ �~ Authorized Agent Date Z2 TOTAL PAID $ w� TL CITY OF COSTA MESA DEVELOPMENT SERVICESIBUILDING SAFETY Croon anrker_G cnu• Building Permit Certificate of Occupan ❑ Electrical Release Form ❑ Gas Release Form , Sanitation Fixture Fo ` Plumbing Permit #—� Mechanical Permit # Electrical Permit # Reinspection Permit # ❑ Health Department Approval ❑ Roofing Certification ❑ Insulation Certification ❑ Dry Chemical System Certification ❑ Flame Spread Certification I` Fire Sprinkler Certification i,_. Soils Certification ❑ Special Inspection Certification Other: All Required Documents In lu / lwcl O.K. to Approve C.O. Inspector O.K. to Release C.O. Building Official GMF 1046.30 .' ,.,lig-t..-'.-:fr-�: � i+-r-.-f..:tl+.--'NPS-`^w�.n, r,:.� n.,.�v-*.w^lratiw+^r•,s.:ti,�..Wa•Hv�!`(j +.r�.,.w:.;.jt,Y"^.. �—.�.,,w.,--^- -� 1 t tit of to-5ta Nesa Development Services, Division of Building and Safety CERTIFICATE OF OCCUPANCY This certificate is issued pursuant to they er q irements fo the Uniform Building Code, Section 308 r� I� adopted by the City of Costa Mesa ceftifiesrthat.at-thetiz�e ofats issuance the building structure herein it i � . � � �-- / ��ra�. below described was inspected andappr�oved;for:occupaney>asrf ws: nN8i r B 2 Building Address 3333 BRISTOL STREET DIl�IT Z6�Bldg. Permit No. -� Use 12ars'1 Group M Type`.of Gonstructio3n - �,YS♦P Fi�rlse,Zone � ' ,.� • } Use Zone !�Y ,.���'��• I` y •5` Owner of Building _C- Ja l Se$ei•sCroms, -- - Teriant "BO6$ :HUGO ROSS" 7 5 - Address'' 4'3315r NV By BUILDING OFFICIAL tOnp Lb,GNo„ver 20 996 Date z.., • (0)� REQUIRED TO BE POSTED A CONSPICOUS PLACE., t CI -� OF COSTA M1** Development Services, Division of Building and Safety %0*146 CERTIFICATE OF OCCUPANCY This certificate is issued pursuant to the requirements of the 2007 California Building Code, Section 110 adopted by the City of Costa Mesa certifies that at the time of its issuance the building structure herein below described was inspected and approved for occupancy as follows: Building Address 3333 3802 Bristol Street Bldg. Permit Number BC09-08453 Use Commercial Group A_Z 'Type of Construction r—A Fire Zone Use Zone PDC Owner of Building South Coast Plaza Tenant Capital Grille Address 3315 Fairview Road, -costa Mesa, CA 9252 4 By BUILDING OFFICIAL-Khanh Q. Nguyen_, C.B.O. 10-21-10 Date �1 REQUIRED TO BE POSTED IN A CONSPICUOUS PLACE CITY OF COSTA MESA BUILDING DIVISION > 77 FAIR DRIVE, COSTA MESA, CA 92626 - (714) 754-5273 • Fax (714) 7544856 - www.ci.costa-mesa.ca.us f FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: SB10-00046 PERMIT TYPE B_SIGN JOB ADDRESS: 3333r3802-BRISTOLTST C Vicinity: SQ. FT: 0 a STATUS: ISSUED DATE ISSUED: 07/0212010 ISSUED BY: Suite/Unit: 3802 Valuation: - $12,199.00 SCOPE OF WORK: CHANNEL LETTER BUILDING SIGNS FOR CAPITALE GRILLE AT SOUTH COAST PLAZA. 3 ILLUMINATED SIGNS AND 1 PLAQUE SIGN. OWNER: SOUTH COAST PLAZA PHONE: APPLICANT: BENSON, RICHARD PHONE: 818-974-5808 CONTRACTOR: AD ART Address: 1300 W SHAWUnit: SUITE31D City/Stale: FRESNO ,CA ZlpCode: 93711 ARCHITECT: ENGINEER: SIGN PERMIT FEE SUMMARY PLAN CHECK FEE: $145.11 HOURLY PC FEE: $0.00 PERMIT FEE: $223.25 ELECTRICAL FEE: $97.30 SMTP FEE: $2.56 OTHER: $0.00 INSPECTION: $0.00 BLDG STD ADMIN FUND $1.00 TOTAL FEE: $469.22 Address: 3315 FAIRVIEW RD Unit: CitylState/Zip: COSTA MESA, CA Address: Unit: City/State/zzip: License No. License No. License No. 826051 PHONE: 559-225-2138 CELL: PHONE: PHONE: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE i. INSPECTION TYPE PAM I"TIAL COoE1r INSPECTION TYPE DATE INTMAL5 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Etectrical 201 Final BlocklRetaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final SuildinglOccupancy 3 �3a►I"1�N�'�� WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and wi11 maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the erformance of the work for which this permit is issued. have and will maintain workers' compensation insurance, as required by n 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: 51 9STA T� vN,_5 (This section need not be complered d rhe permd u valued alone hundred do#ars (S100) or less) P umber. 1 �4UU8 �ZoaS ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisions. gnatnre �, WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 4 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. u6051��i5 �o�}SK}natere . CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder Wil have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an Owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature 3057-46(3/07) Date Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. • - - Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsewcirk, or demolition or dismantling thereof, will be more than thirty-six (36) feet high, (Chap. 3.2, Grp 2. Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Date Division of Industria( Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of [his application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be fumished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (if 'yes', attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature of Legal Owner(s) Date �9RRIL�d— CITY OF COSTA MESA O pM�sq BUILDING DIVISION t } 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 www.ci.costa-mesa.ca.us �. FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: E10-00220 PERMIT TYPE ELEC STATUS: ISSUED • 1 APN: 41249107 DATE ISSUED: 0911712010 ISSUED BY: KJB JOB ADDRESS: 3333 3802 BRISTOL ST CM Suite/Unit:. 3802 Vicinity: SUITE 3802 SCOPE OF WORK: REF: BC09-00463. "CAPITAL GRILLE" SUPPLEMENTAL ELECTRICAL PERMIT FOR INSTALLATION OF 12 LED LIGHT FIXTURES IN THE BAR AND DINING AREA. TITLE 24 TO BE PROVIDED ON JOB PER INSPECTOR. OWNER: SOUTH COAST PLAZA PHONE: APPLICANT: PAUL RAULERSON PHONE: 949-855-1892 CONTRACTOR: G N E ELECTRIC COMPANY INC Address: 19671 DESCARTESUnit: PHONE: 949-855-1892 City/State: FOOTHILL RANCH, CA ZipCode: 92610 . ELECTRICAL PERMIT FEES Electrical Plan Check Fee: $0.00 Electrical Permit Fee: $54.90 Reinspection Fee $0.00 TOTAL FEES $54.90 Address: 3315 FAIRVIEW RD Unit: City/State/Zip: COSTA MESA, CA Address: 19671 DESCARTES Unit: City/StatelzZip: FOOTHILL RANCH, CA - License No. el CELL: 502675 - NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all -applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. DE a INSPECTION TYPE 1616 Fixed System Final Fire Prevention 1266 Pool Spa Final 200 Final Re -Roof 201 Final Stock/Retaining Wall 202 Final Factory Fire Place 203 Final Sign 204 Final Demolition DATE INTITIALS CODE INSPECTION TYPE 206 Final Mechanical 208 Final Plumbing 210 Final Electrical 212 Final Fire Prevention 220 Final Planning Approval 222 Final Site 260 Final Building/Occupancy DATE INTMAL5 ,< lo-116-ICWa h r �•� CITY OF COSTA MESA 0 BUILDING DIVISION y 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 www.c[.costa-mesa.ra.us ".� FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BC09-00463 PERMIT TYPE: B_COMBO Sub Type: COM—ALT -STATUS: ISSUED DATE ISSUED: 03/09/2010 ISSUED BY: KJB JOB ADDRESS: 3333 3802 BRISTOL ST.CM­-_ sr.=�- - :, Suite/Unit: 3802 APN: 41249107 f> :. -Zoning: PDC , Vicinity: SUITE 3802 CAPITAL GRILLE= '_. , _ Primary'Occ: Const Type: I -A SQ: FT:,. , =103861,- ' .:`, Valuation: 2,200,000.00 SCOPE OF WORK: 9388 SF INTERIOR RESTAURANT TI & 998 SF TERRACE TI -FOR -"CAPITAL. GRILLE" IN SUITE 3802. DEMO OF CONCRETE SLAB AS NEEDED FOR CONSTRUCTION OF A NEW STAIRWAY & NEW CUSTOMER ELEVATOR; DEMO TERRACE & COVER. TI INCLUDES NEW ,'ELEVATOR & STAIRWAY, APPROX 550SF NEW FLOOR TO FILL EXISTING STAIR/BAR OPENING, NEW SOLID ROOF OVER EXISTING•998 SF TERRACE DINING -,-NEW 324SF COVERED ENTRY & RELATED SIDEWALK. ELEC: 414 LIGHTS, 80 OUTLETS,' 60.SWITCHES, 10'NON RES APP -L-,-1: SVS OVER 600V, 12 MOTORS TO.1 HP, 4. MOTORS TO 10HP, 18 COMM DROPS, 4 SUB PANELS, _ 20;TRANSF UP,T0,1'-KVAIKW,-3 TRANSF UP TO.50'KVA; MECH: 4 HOODS, 11 VAV BOXES;4 VENT FANS; PLUMBING: 1 -BACKFLOW, 2 COFFEE/ICE, 1. DISHWASHER, 14 FL DRAINS, 2 ROOF N= DRAINS, 1 EXPANSIOTANK, 1,GAS SVS, 2 BAR SINKS, 3 COMM SINKS, 17 FL SINKS, 1 -KitSINK, 1 SVS SINK, 2 TRAP PRIMERS, 2 URINALS; 1 VAC BREAKER;4 WASTENENT, 9 WATER CLOSETS, 1 -WATER HEATER, 1 WATER SVS, 1 WATER' SOFTENER. �~ OWNER: SOUTH COAST PLAZA; Address: 3315 FAIRVIEW RD Unit: Phone: CitylStatelZip:­ COSTA MESA, CA APPLICANT: ELMORE, TOMMY Address: Unit, Phone: 386-944-0470':: CitylStatelzZip: CONTRACTOR: HALEY CONSTRUCTION,INC License No. 683029 Phone: 386-944-0470 _` `. _ Address:` 900 ORANGE AVENUEUnif: Cell: CitylState: .,DA T' EACH, FL : ,' ZipCode 32114 ARCHITECT: ROBERT J HORNACEK. 'License No.C6605 PHONE:714 -832-1834 ENGINEER: License'No. PHONE: COMBINATION PERMIT FEE SUMMARY M Building Plan Check: $1,623:17_ Building Fees: Pool Spa Final Electrical Fees: $1,038.72 Mechanical Fees: $212.25 Plumbing Fees: $65320 SMIP Residential: $0.00 SMIP Commercial: $462.00 Bldg Std Admin Fund $88.00 TOTAL FEES: $14,066.09 "Refer to fee receipts for all fees oaid for orolect NOTICE: The �t h� sTper�rl l lk d �iihEAFiFPPPl,96FeWJAIN�o tcgfAEFOMMPel§�uAo%-PN[ifornia statutes and relate�J r6M9j*Mn�!r0&f& 792D �rtu � tgDy2)Saturdays- 9:00 am thru 6:00 pm. Prohibited all ours -Sundays and the following Federal holidays: EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE t• INSPECTIONTYPE 1616 Fixed System Final Fire Prevention 1266 Pool Spa Final 200 Final Re -Roof 264 Final Block/Retaining Wall 262 Final Factory Fire Place 203 Final Sign 204 Final Demolition DATE INTMALS CODE INSPECTION TYPE 206 Final Mechanical 208 Final Plumbing 210 Final Electrical 212 Final Fire Prevention 220 Final Planning Approval 222 Final Site 250 Final Building/Occupancy HATE INTITIALs Man. st IP1 ;.�� v �, :x•, w.. �I y. .r r.ti^ - ..� .,_�.L, .S. -!^ d* r^ � �.7 .r-u�Y,.. e.S.. �.., .,. - � , i, - x�. r� .,., Cl'Y OF COSTA M110L.A i .-.0000 Develoment Services, Division of Building and Safety CERTIFICATE OF OCCUPANCY This certificate is issued pursuant to the requirements of the 2007 California Building Code, Section 110 adopted by the City of Costa Mesa certifies that at the time of its issuance the building structure herein below described was inspected and approved for occupancy as follows: Building Address 3333 1207 'Bristol Street Use Commercial - Shoe Store BC10-00237 Bldg_ Permit Number Group MType of Construction I—A Fire Zone Use Zone FDC Owner of Building South Coast Plaza Tenant Jimmy Chop Address 3315 Fairview,, Rd. , 'Costa Mesa, CA 92626 By/K-9/20/10 K BUILDING OFFICIAL-Khanh Q. Nguyen, C.B.O. 9 / 20 / 10 Date V REQUIRED TO BE POSTED IN A CONSPICUOUS PLACE CITY OF COSTA MESA 0 BUILDING DIVISION y 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 - Fax (714) 754-4856 www.ci.costa-mesa:ca.us FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BC10-00237 PERMIT TYPE: B_COMBO STATUS: FINALED Sub Type: COM—ALT DATE ISSUED: 07115/2010 ISSUED BY: CAC JOB ADDRESS: 3333 1207 BRISTOL ST CM �:° 'Suite/Unit: 1207 APN: 41250107 Zoning`PDC, Vicinity: Primary.Occ: Const Type: I -A SQ. FT: 1243 ' Valuation: $375,000.00 SCOPE OF WORK: 1243 SQ FT TENANT IMPROVEMENT FOR "JIMMY CHOO": SCOPE OF WORK TO INCLUDE PARTITIONS, CEILING, MISC ELECTRICAL, PLUMBING AND MECHANICAL. 16 OUTLETS 7 SWITCHES 67 LIGHTS 6 COMMUNICATION DROPS 1 SIGN CIRCUIT 2 LOW VOLTAGE EQUIP. 1 LOW VOLTAGE WIRING SYSTEM: 1 VAV BOX'1 VENT FAN 1 SMOKE DAMPERS 1 ALT DUCT1 FLOOOR DRAIN .1'DRINKING FOUNTAIN 3 P TRAPS 1 EWER CONNECTION 1 TRAP PRIMER 2 WASTE AND VENT OWNER: SOUTH COAST PLAZA Address: 3315 FAIRVIEW RD Unit: Phone: �Crty/State/Zip: COSTA MESA, CA" . APPLICANT: RYAN, MARY Address: P O BOX 3749 Unit: Phone: 949-582-3735 City/StatelzZip: _ MISSION VIEJO, CA CONTRACTOR: SHRADER AND MARTINEZ . Phone: 928-282-755, ` Cell: 928-282-5009 , ARCHITECT: ATMOSPHERE DESIGN ENGINEER: COMBINATION PERMIT PEE SUMMARY License No. 511268 Address: 160 DRY CREEK RDUnit: City/State: SEDONA, AZ License No.31289 License No. Building Plan Check: '$411.74 ' Building Fees: $2,533.75. Electrical Fees: $197.71 . Mechanical Fees: $62.35,,,-, Plumbing Fees: $126.55 SMIP Residential: $0.00' SMIP Commercial: --:.$78.75 Bldg Std Admin Fund $15.00 ' TOTAL FEES: $3,425.85 ZipCode 86336 PHONE:914-244-1300 PHONE: "Refer to fee receipts for all fees paEd for project HOURS FOR CONSTRUCTION ACTIVITY: EFFECTIVE 3/1812010 - PER CMMC Sec. 13-279 Monday thru Friday- 7:00 am thru 7:00 pm. Saturdays- 9:00 am thru 6:00 pm. Prohibited all hours - Sundays and the following Federal holidays., New Years Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day and Christmas Day NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, g 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE $. INSPECTION TYPE 1616 Fixed System Final Fire Prevention 1266 Pool Spa Final 200 Final Re -Roof 201 Final B(ock/Retaining Wall 202 Final Factory Fire Place 203 Final Sign 204 Final Demolition DATE INTITIALS B air )C, 4 13NN CODE INSPECTION TYPE 206 Final Mechanical 208 Final Plumbing 210 Final Electrical 212 Final Fire Prevention 220 Final Planning Approval 222 Final Site 250 Final Building/Occupancy DATE INTITIALS CITY OF COSTA MESA o was BUILDING DIVISION J.77 FAIR DRIVE, COSTA MESA, CA 92626 - (714) 754-5273 - Fax (714) 754-4856 - www.ci.costa-mesa.ca.us } „ �. FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BX10-00185 PERMIT TYPE B MISC STATUS: ISSUED APN: 41250107 T DATE ISSUED: 08/23/2010 Zoning: PDC, ISSUED BY: KJB JOB ADDRESS: 33.33 1207 BRISTOL ST CM Suite/Unit: 1207 Vicinity:— Primary Occ: Const Type :?? SQ. FT: 0 Valuation: $1,250.00 ,I SCOPE OF WORK: k 1 ILLUMINATED SIGN AT SCP FOR "JIMMY CHOO., OWNER: SOUTH COAST PLAZA Address:: 3315 FAIRVIEW RD City/State: COSTA MESA, CA `, Zip Code: 92626 Phone: APPLICANT: GARY THOMPSON City/State: GLENDORA, CA Phone: 626-335-2887 CONTRACTOR: SIGN CONTRACTORS Address: 400 W FOOTHILL City/State: GLENDORA, CA Zip Code: 91741 ARCHITECT: Phone ENGINEER: Phone FEE SUMMARY Building Plan Check: Building Permit: Electrical Permit:, SMIP Residential SMIP Commercial Bldg Std Admin Fund TOTALFEES Address: 400 W FOOTHILL Zip' Code: 91741 License No. 740985 Phone 626-335-2887 $31.14 3 $47.90 $48.10 $0.00 $0.50 " $1.00 $128.64 License No. License No. Cell: Unit Unit: Unit: HOURS FOR CONSTRUCTION ACTIVITY: EFFECTIVE 3/18/2010 - PER CMMC Sec. 13-279 Monday thru Friday - 7:00 am thru 7:00 pm. Satrudays -9:00 am thru 6:00 pm. Prohibited all hours - Sundays and the following Federal Holidays: New Years Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day and Christmas Day NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE t. INSPECTION TYPE DATE INTMALS CODE # INSPECTION TYPE DATE INTn1AL 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Root 210 Final Electrical oZ ff 201 Final Block/Retaining Walt 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign G1. All c 222 Final Site 204 Final Demolition 250 Final BuildinglOccupancy WORKERS' COMPENSATION DECLARATION: , I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' co ensation, as provided for by section 3700 of the Labor Code, for the p ormance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by sectbn 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: (This secim need not he o np#1eled d the pe u vafted at one hundred dollars (5 100) or Mss.) ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workersmpensation provisions of Section 3700 of the Labor Gawlshall fort i comply with these provisions. s:s�tra e.�^-- � trtoete-�---• WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (S100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. 47— CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lenders Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ l am exempt under sec. Business and Professions Code for this reason: Signature Date 3057.46 (3107) Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Owners4 by (typeJof document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Division of Industrial Safety Permit Number: _ Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Pian be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weigh( of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will (he applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department, 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? []Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If "yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Lure of Legal s) Date /&W or. thorized P piicoAt__-� �� CI -Y OF COSTA Mr -A Development Services, Division of Building an&S�fety CERTIFICATE OF OCCUPANCY + This certificate is issued pursuant to the requirements of the Unif6rm. Building Code, Section 308 adopted by the City of Costa Mesa certifies that at the time "o'f its issuance the building structure herein below described was inspected and approved for occupancy as follows: Building Address 1333 Bri S- t-01 St. S.t.e 1615 Bldg., Perm,it NumberB06-01095 Use Design T1�,3 0 5 s f M V -:IF RI w. XXX XXX XX PDC Gfoup ,Type Ato—hstructiori '-Fire Zone Use Zone Owner of Building Address 3315 South, StPlaza Ten6iit::::::P,:ORSCHE DESIGN v.Fairview `.Rd'- Costa Mesa,' CA Y By' -Q BUILDING OFFICIAL-KhEinh-f Date ---07/05/07 1 -1 REQUIRED TO BE POSTED IN A CONSPICOUS PLACE CITY OF COSTA MESA BUILDING DIVISION f77 FAIR DRIVE, COSTA MESA, CA 92626 - (714) 754-5273 - Fax (714) 754-4856 • www.ci,costa-mesa.ca.us y. FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BC09-00364 PERMIT TYPE: B_COMBO STATUS: ISSUED Sub Type: COM—ALT DATE ISSUED: 09118/2009 ISSUED BY: RMD JOB ADDRESS: 3333 MACY BRISTOL_ ST CM Suite/Unit: MACY APN: 41249103 Zoning:PDC, , Vicinity: BASEMENT LEVEL, MENS DEPT Primary Occ: M Const Type: I -A SQ. FT: 0 Valuation: $12,000.00 SCOPE OF WORK: INSTALLATION OF A 10' X 12' PARTITION WALL INSIDE "MACY'S" LOCATED AT BASEMENT LEVEL, MENS DEPARTMENT. NO ELECTRICAL, NO OTHER WORK AUTHORIZED UNDER THIS PERMIT. OWNER: SOUTH COAST PLAZA BULLOCKS INC Address: REAL ESTATE DEPARTMENT Unit: CINCINNATI, OH Phone: City/State/Zip: 7 W SEVENTH ST APPLICANT: WILSON, KEITH Address: PO BOX 405 Phone: 415-257-0200 CitylStatelzZip: SAN ANSEIMO, CA CONTRACTOR: TRAINOR COMMERCIAL CONSTRUCTION INC License No. 453991 Phone: 415-259-0200 Address: 331 FAWN DRUnit: Cell: City/State: SAN ANSELMO, CA ARCHITECT: BARRY J GREENBERG ENGINEER: COMBINATION PERMIT FEE SUMMARY Building Plan Check: Building Fees: Electrical Fees: Mechanical Fees: Plumbing Fees: SMIP Residential: SMTP Commercial: Bldg Std Admin Fund TOTAL FEES: "Refer to fee receipts for all tees paid for project License No.0013002 License No. $136.01 $209.25 $0.00 $0.00 $0.00 $0.00 $2.52 $1.00 $348.78 Unit: : ZipCode 94979 PHONE:314-644-11234 PHONE: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE !. INSPECTION TMINTITIAL CODE t INSPECTION TYPE DATE INTITIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Roof 210 Final Electrical 201 Final BlocklRetaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final BuildinglOccupancy� WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy umbel ares Carrier: (This section need nor be oompJered d fhe pemrd is wafued ar one hundred dollars (S 7oi7j a kss ) PGTfc}rr.3 ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisions. q — Pt — N ARliwVs.5ignalme' rDate--, WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code. and my license is in full force and effect. Ltctc �'���•� ( C of ss� o�� ! yg f C�rractars Signature (,Darr---+�"` CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (5500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contraclor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature Date 3057-46 (3)07) Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend. will be made in connection with work authorized by this permit, and that no building structure. scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner-buitder, t will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Signature Date Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the Califomia Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Govemment Code requires that the requested information be fumished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (if 'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signalure Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. i agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature of Legal Owner(s) Date H"gtili]r.AuthQn�.9ppMca t r. CITY OF COSTA MESA BUILDING DIVISION } 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 - wvwv,ci.costa-mesa.ca.us �. FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BC08-00291 -- PERMIT TYPE: B_COMBO STATUS: ISSUED ' Sub Type: COM—ALT DATE ISSUED: 08/12/2008 ISSUED BY: RIVID JOB ADDRESS: 3333 MACY BRISTOL ST CM Suit6/1Unit:: MACY APN: 41249103 Zoning:PDC, Vicinity: MACY S `.- ,Primary OCC: A-2. Const Type: I -A l,.';! 'SQ: FT: 0 Valuation: $21,000.00 SCOPE OF WORK: 3,386 SF INTERIOR TI'AND EXTERIOR UPGRADES FOR "WOLFGANG PUCK" AT MACY'S. IMPROVEMENTS TO CONSIST OF EXTERIOR PAINTING, NEW COUNTERS, FINISHES, RESTROOM AND DINING AREA REMOD AND 5 LIGHT F1XT CHANGE OUT, NO CHANGE IN WATTAGE. NO WORK IN KITCHEN AREA. OWNER: SOUTH COAST PLAZA BULLOCKS INC Address: REAL ESTATE DEPARTMENT Unit: CINCINNATI, OH Phone: City/State/Zip: 7 W SEVENTH ST APPLICANT: SORUM, GREG , s Address: Unit: Phone: 714-527-8500 1. CitylStatelzZip: CONTRACTOR: ALAIN HIRSCH CONSTRUCTION CORP 'License No. 756267 Phone: 714-527-8500 ;;: , Address: 4431 CORPORATE CENTER DRUnIt: SUITE 123 Cell: City/State: LOS ALAMITOS, CA ZipCode 90720 ARCHITECT: TECTA ASSOCIATES,-,_ License No.S17636 PHONE:415.362-5857 XT 113 ENGINEER: License No. PHONE: COMBINTATION PERMIT FEE SUMMARY Building Plan Check: $217.91 Building Fees: • $335.25 Electrical Fees: $29.00 Mechanical Fees: $0.00 Plumbing Fees: $23.50 SMTP Residential: $0.00 SMTP Commercial: $4.41 TOTAL FEES: $610.07 "Refer to fee receipts for all fees paid for project NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this pe CODE t, INSPECIWN TYPE DAR INMAlS WDE J INSPECrON TYPE A IN L 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1j 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final BlocWRetaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 ' Final Demolition 250 Final Building/Occupancy WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the fallowing declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: -�Camr-d-er: . ., 16—PN%Z Fai lU n (This section need robe c rfrOvied d the pemM is vanred alone h, KkW dprars (S;00) or less.) 15ollcy Number: ❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the La Cod I shall forthwith comply with these provisions. io Appllcartt's Signature Dat WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic. #— -- 77 Class # va tractor's Signature to CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves .thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) ficense pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature 305746 S3107) Owner ID verified by driver's ticeh,_ J Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2. Art 2. Sec. 341, Title 8, Califomia Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Division of Industrial Safety Permit Number: Dale HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No {Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the Califomia Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the Califomia Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required. has Section 25534 of the Califomia Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the Califomia Government Code requires that the requested information be furnished on applications for non-residentiai building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if 'yes the facility must meet the requirement of Sections 25534 and 42303 of the Califomia Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by Califomia Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (if "yes", attach certificate of compliance from the appropriate air pollution control officer), CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state'laws and city ordinances regarding Hazardous Materials and Emissions. Signature Dale CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature of Legal Owner(s) pal Dale 1 r Ar6prAuthonzedApDlicant ale ,�. .-y..ry,..•Y,,,ry.,,y- -7T- tit? T - - tib of to'sta N esac Development Services, Division of Building and Safety CERTIFICATE OF OCCUPANCY This certificate is issued pursuant to,the'requirernent§ of -,the Uruforrn Building Code, Section 308 adopted by th'e?City of Costa Mesa ceriifies.that.at the time of its.issuance the building structure herein below described was inspected and=approved;for°occupancy,as>followS: Building Address Use Re tai] Group B--2 Type Owner of Building _ C J , Address 331.5 Fairview BUU DING OFFICIAL ton It "�/ ISTOL STREET UNIT 28aNffld . Permit No. B 72704 f'Construction I _ FR --&P Fire,Zone'k• °'. i Use Zone CIS 'SS STRUCTM — BATH egerstrom __ T � ARM WnRXs" Tenant ._�Ai[l._ -f _ _ - '?'+ V"Costa -CA oa8' .Mesa, -92 2 1 C 0' B i✓/� . Cf + \+�-Date ,November 15, 1995 REQUIRED TO BE POSTED IN A CONSPICOUS PLACE I¢z 0 � Cri'Y OF COSTA MLSA = Development Services, Division of Building and Safety CERTIFICATE.OF OCCUPANCY This certificate is issued pursuant to the requirements of the 2007 California Building Code, Section 110 adopted by the City of Costa Mesa certifies that at the time of its issuance the building structure herein below described was inspected and approved for occupancy as follows: BuiIdingAddress 3333 Bristol St #2867 Bldg: Permit Number BC12-00216 CITY OF COSTA MESA BUILDIMG D1VIS1OM 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 - www.costamesaca.gov FOR INSPECTIONS CALL: (714) 754-5626 fi PERMIT NUMBER: BC12-00294' PERMIT TYPE: B COMBO STATUS: 'ISSUED Sub Type: COM -ALT DATE ISSUED: 061.1 31212 ISSUED BY: 1L`//--'�Jlih JOB ADDRESS: 3333 2867 BRISTOL ST CM Suite/Unit: 2867 APN: 41250107 Zoning:PDC, , Vicinity: Const Type:l-A Primary Occ: SO. FT: 0 Valuation: t $13,200.00 SCOPE OF WORK:INSTALL MOBILE 10 FT HIGH SHELVING FOR A 1,876 SO FT T. I FOR "JOHNSTON-MURPHY, SPACE 2867. B C 12-00216 OWNER: SOUTH COAST PLAZA Address: 3315 FAIRVIEW RD Unit: Phone: City/State/Zip: COSTA MESA, CA APPLICANT: VARNER, JESSEE Address: Unit:: Phone: 612-803-3606 City/State/Zip: CONTRACTOR: RETAIL CONSTRUCTION SERVICES INC License No:542440 Phone: 651-704-8000 Address:11343 39TH ST N , Unit: dell: City/State: LAKE ELMO,� MNZipCode55042 ARCHITECT: License No. PHONE: ENGINEER: License No. PHONE: Ap COMBINATION PERMIT FEE SUMMARY r 1.1' CRXPIRATION: PERMIT EXPIRES 18o DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION, Building Plan Check: $38.55 Building Fees: $237.25 Electrical Fees: $0.00 %echanical Fees: $0.00 Plumbing Fees: $0.00 SMIP Residential; $0.00 60 P. Commercial: $2.77 Bldg -.Std Admin Fund $1.00 TOTAL FEES: $279.57 •'Akifei to fee receipts for ail fees nald for oroiect [1, ' HOURS FOR CONSTRUCTION ACTIVITY: EFFECTIVE 311812010 - PER CMMC Sec. 13-279 Monday thru Friday - 7:00 am thru 7:00 pm. Saturdays- 9:00 am thru 6:00 pm. Prohibited ail hours - Sundays and the following Federal holidays: c New Years Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day and Christmas Day bit, A: ,NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related 'regulations. (Ord. No. 92-28, § 1, 12-21-92) r 1.1' CRXPIRATION: PERMIT EXPIRES 18o DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION, WNSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all E4equired inspections and Final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. Elt k2OLL INSPECTION TYPE DAA, INTMALS CODE / INSPECTION TYPE Final Mechanical p/It a� 0616 Fixed System Final Fire Prevention 206 Si266 Pool Spa Final 208 Final Piumbing gq1�,rZ v 0 . 'Final Re -Roof 210 Final Electrical 40Lf 1 •[: 91 ; ; Final BlocklRetaining Wall 212 Final Fire Prevention ! Rd2 ', ' Final Factory Fire Place 220 Final Planning Approval _'_ (2 3 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy � CITY OF COSTA MESA �,ossn A'Fsq BUILDING DIVISION 77 FAIR DRIVE, COSTA MESA, CA 92626 - (714) 754-5273 • Fax (714) 754-4856 - www.costamesaca.aov FOR INSPECTIONS CALL: (714) 754-5626 'aMawns PERMIT TYPE APN: 41250107 Zoning: PDC, JOB ADDRESS: Vicinity: SO. FT: 0 B_MISC PERMIT NUMBER: BX12-00167 STATUS: ISSUED DATE ISSUED: 05/08/2012 ISSUED BY: KJB 3333 2867 BRISTOL ST CM Suite/Unit: 2867 Primary Occ: Const Type: ?? Valuation: $1,300.00 SCOPE OF WORK: ILLUMINATED CHANNEL LETTER SIGN FOR SCP. "JOHNSTON AND MURPHY". NOTE: FINAL APPROVAL OF PERMIT SHALL NOT BE GRANTED UNTIL ACCESS TO DWELLING UNIT(S) IS PROVIDED FOR VERIFICATION OF SMOKE AND CARBON MONOXIDE ALARMS BY THE CITY INSPECTOR. SEE ATTACHMENT WANSPECTION CARD _ OWNER: SOUTH COAST PLAZA City/State: COSTA MESA, CA Phone: APPLICANT: RECTOR, TONY City/State: /NSP€GIlON TYPE Qm I7IlDA Phone: 714-705-3249 PF Final Mechanical CONTRACTOR: ABSOLUTE SIGN INC L,icerise No.782551 Atldress: 4652 KATELLA AVEUnit: /State: LOS ALAMITOS, CA rp Code: 90720 V �. Final Re -Roof AyRCHITECT: Final Electrical ��one ENGINEER: Phone Final Block/Retaining Wall PJ+ Final Fire Prevention 01 FEE SUMMARY 04 Building Plan Check: C sl Building Permit. #;1i Electrical Permit: .. s• 204 SMIP Residential AF SMIP Commercial i> Bldg Std Admin Fund Ph Address:: 3315 FAIRVIEW RD Unit Zip Code:92626 Address: Unit: Zip Code: Phone 562-592-5838 $31.14 $47.90 $48.10 $0.00 $0.50 $1.00 License No. License No. Cetl:800-898-5444 TOTAL FEES $128.64 HOURS FOR CONSTRUCTION ACTIVITY: EFFECTIVE 3/1812010 - PER CMMC Sec. 13-279 thru Friday - 7:00 am thru 7:00 pm. Saturdays 4,00 am thru 6:00 pm. Prohibited all hours - Sundays and the following Federal Holidays: New Years Day. Memorial Day. Independence Day. Labor Day. Thanksaivina Dav and Christmas Dav ��(r!e!gulations. (Ord. No. 92-28, § 1, 12-21-92) *&PIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. !INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all Ar 'required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. ,,r, INSPECTION TYPE DATE INTMA fit: /NSP€GIlON TYPE Qm I7IlDA ., 616 Fixed System Final Fire Prevention 206 Final Mechanical ,> t .1286 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical sly -201 Final Block/Retaining Wall 212 Final Fire Prevention t,..: 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Signer 222 Final Site .. s• 204 Final Demolition 250 Final BuildinglOccupancy .li Fh WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: ` ` R f. Carrier: N (Tho sedw nerd r of be oompleled d the permitu valued atone hundred dollars (Stool or iess ) Policy Number: —7 034- (O 7_'t44o tV I certify that in the performance of the work for which this permit is issued. I shaif not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor _Qode, I slyforthwith comply with these provisions. ppiicant's Signature Date WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my licenseisin full force and effect. Lic. # _ f �2 �J�� I Class # C 1 2_ ntractor's Signature Date CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business anq Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sate.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this r(aason: Signature Date 3057.4e 13107) Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high, (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. if an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility.to be constructed under this permit be within 1000 feet from the outer boundaries of a school? []Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8, (If 'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penally of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. ��Zgnat tLegal Ownerfst ate 1 __ R6 Z tllor Authorized Applicant r5ate 0 • CITY OF COSTA MESA BUILDING DIVISION } 77 FAIR DRIVE, COSTA MESA, CA 92626 - (714) 754-5273 - Fax(714)754-4856 - www.costamesaca.cov °.� FOR INSPECTIONS CALL: (714) 754-5626 e PERMIT NUMBER: BX12-00137 PERMIT TYPE B_MISC STATUS: ISSUED APN: 41250107 DATE ISSUED: 04/2312012 Zoning: PDC, ISSUED BY: MDM JOB ADDRESS: 3333 2867 BRISTOL ST CM _ Suite/Unit: 2867 Vicinity: Primary Occ: Const Type :?? SO. FT: 0 Valuation: $2,000.00 SCOPE OF WORK: ' DEMO STORE FRONT AND NON-STRUCTURAL WALLS tzjVH-IN M U-9-1-111' r OWNER: SOUTH COAST PLAZA Address:: 3315 FAIRVIEW RD City/State: COSTA MESA, CA Zip Code: 92626 Phone: APPLICANT: TIM HAGEN City/State: CHANDLER, AZ Phone: 612,325-9587 CONTRACTOR: RETAIL CONSTRUCTION SERVICES INC Address: 11343 39TH ST N City/State: LAKE ELMO, MN Zip Code: 55042 ARCHITECT: Phone ENGINEER: Phone FEE SUMMARY Building Plan Check: Building Permit: Electrical Permit: SMIP Residential SMIP Commercial Bldg Std Admin Fund Address: 3393 E BLUEBIRD Zip Code: 85286 License No. 542440 Phone 651-704-9000 $45.01 $69.25 $0.00 . $0.00 $0.50 $1.00 License No. License No. Cell: Unit Unit: Unit: TOTAL FEES $115.76 HOURS FOR CONSTRUCTION ACTIVITY: EFFECTIVE 3/1812010 - PER CMMC Sec. 13-279 Monday thru Friday - 7:00 am thru 7:00 pm. Saturdays -9:00 am thru 6:00 pm. Prohibited all hours - Sundays and the following Federal Holidays: New Years Day, Memorial Day, Independence Day, Labor Day, Thanksgiving payand Christmas Day NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CORE IL INSPECTION TYPE 1616 Fixed System Final Fire Prevention 1266 Pool Spa Final 200 Final Re -Roof 201 Final Block/Retaining Wall 202 Final Factory Kite Place 203 Final Sign 204 Final Demolition P&TE INTMAL CODE x INSPECTION TYPE 206 Final Mechanical 208 Final Plumbing 210 Final Electrical 212 Final Fire Prevention 220 Final Planning Approval 222 Final Site 250 Final Building/Occupancy DATE INTITIAL • WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: f7hrs secborr neva nor be oprnpreted A the permit is valuedat one Hundred vaea+s (Si00) a cess-) Policy Number: ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Califomia, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Cod 1 shah fah comply with these provisions. 7' z3 rz licant's Signature Date WARN3N . FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. xLICENSED CONTRACTORS DECLARATION: hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. L'tc. # S y 2— yyU Class # C Ys Signature Date CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lenders Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 704A, Business and Professions Code: The contractors License Law does not appy to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature Date 3057-46 (3107) 40 Owner ID verified by driver's license. 0 Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person Is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (38) feet high, (Chap. 3.2, Grp 2, Art 2, Sec, 341, Title 8, Califomia Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Division of Industrial Safety Permit Number: Dale HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes [] No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions• requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. if an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes', the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If "yes', attach certificate of compliance from the appropriate air pollution control officer), CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. y Sf Cur of Legal Ownar(s) 'ArIjr Authorized Applicant Date y.7 3 • rZ Date City of Costa Mesa DevelopmePt Services Department CERTIFICATE OF OCCUPANCY No. 000633 Building Safety Division P, p, Box 1200 Costa Mesa, California The Building located at 1133 RR C f RPA(7 ;52R67 has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group ►--) Occupancy. Use of Building AMAIL SORE Legal Description $12-501--02 (See reverse side for Metes and Bounds) Building Permit No B-15132 Electrical Permit No. Plumbing Permit No. Mechanical Permit No. Number of apartments and/or quest %rooms ISSUED TO: Building Official. 1i i/�i1 i,RLVZZE CORPORAT1024 byt:a, 3333 BR STOL # 2667, COSTA iyiE.SA, CA. Date This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. CMF 1015-46 fev. 1/83 White - Owner; Canary - Numerical File; Pink • Bldg. Permit File City of Costa Mesa Development Services Department Building Safety Division CERTIFICATE OF OCCUPANCY No. P, O- Box 1200 f Costa Mesa, California The Building located at 3333 BRISTOL STREET; unit 2861 has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group B2 Occupancy. Use of Building RETAIL Legal Description 412-501--05 (See reverse side for Metes and Bounds) Building Permit No B 63044 Electrical Permit No. E 63246 Plumbing Permit No, P 63247 Mechanical Permit No. M A15111 Number of apartments and/or guest rooms Fire Prevention Permit No. P 63446 ISSUED TO: Building Official Ton C'De Baca C. J. SEGERSTROM 6 SONS ,'.,3333 FAIRVIEW ROAD by COSTA MESA, CA 92626 f Date August 27. 1993 This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa udder Sec. 307 (e) U.B.C. CMF 1015.46 rev, 1/83 White - Owner; Canary - Numerical File; Pink =Bldg. Permit File CITY OF COSTA MESA BUILDING DIVISION N77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 - Fax (714) 754-4856 • www.ci.costa-mesa.ca.us FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BC08-00499 PERMIT TYPE: B_COMBO STATUS: ISSUED Sub Type: COM—ALT DATEISSUED: 11/07/2008 -ISSUED BY: 1_1.JOB ADDRESS: 3333 2861 BRISTOL ST_CM_ `'` r.=Suitellinit:,'-,2861 APN: 41250107 <� ,` Zoning:PDC, r - Vicinity: 2861 f Primary Occ: 'M ConstType: I -A 1200'.w - Valuation: $150,000.00 SCOPE OF WORK: 1,200 SFINTERIOR'.TI FOR "PARADISE PEN" WITH 1 VAV BOX, 1 -VENT FAN, 501IGHT FIXTS, 9 OUTLETS, 6 SWITCHES, 1 SVC PANELIUP TO 200A; 1 MOTOR TO 1 HP, TCOMMUNICATION DROPJ1 TOILET;; OWNER: SOUTH COAST PLAZA Address!- W .3315 FAIRVIERD Unit: Phone:CitylStatelZip:-.';COSTA MESA, CA r APPLICANT: THOMAS, LLOYD o, _ "'.wa" "" Address: ``.' • - :;; i' Unit: Phone: 505-466-9930 City/StatelzZip: : ` ;t'. CONTRACTOR: THE STONE COMPANY GENERAL CONTRACTORS INC License No. 63.2054 ' Phone: 760-787-9700. Address:. _ 1721 MAIN STUnit: ` = i" STE 104 Celt: City/State: RAMONA, CA ZipCode 92065 ARCHITECT: MICHAEL BLACK = License N6.C25839 "u PHON>*;817 633-4200 ENGINEER:. License No. PHONE: COMBINATION PERMIT:FEE:SUMMARY Building Plan Check: ,y $206.99.; Building Fees: Electrical Fees: ` " $120.15 ' Mechanical Fees: $41.40; Plumbing Fees: "$33.30 ` f- SMIP Residential:r SMIP Commercial: TOTAL FEES: $1;70709 "Refer to fee receipts for all fees paid for project NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE 1I• INHM" 1616 Fixed System Final Fire Prevention 1266 Pool Spa Final 200 Final Re -Roof 201 Final SloWRetaining Wall 202 Final Factory Fire Place 203 Final Sign 204 Final Demolition UN INTMAl S CQQE INOCTION,TYPE DATE 01TIML5 206 Final Mechanical 20$ 210 Final Plumbing Final Electrical - ' 212 Final Fire Prevention 220 Final Planning Approval 222 Final Site 250 Final Buildingl0ccupancy WORKERS' COMPENSATION DECLARATION: hereby affirm under penalty of perjury one of the following declarations:.. ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: {This 'Mon need nor be pleted ,r the pe d is valued al one hundred dollars (3100) or less.) Poli IT 74 9G4 - Policy Number: _- ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of theAabor Code, I ` hall f with comply with these provisions. .�. (jl ����� Applicant's Signalure ' _Date WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and My license is in full force and effect. Li O _. Class # ContraclorsSignature _ Date CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code), Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that i am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or.through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). . ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature 3057-46(3707) Date Owner ID verified by driver -.,cense. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, wilt be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, Califomia Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Date Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the Califomia Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? []Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the Califomia Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the Califomia Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the Califomia Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by Califomia Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If "yes", attach certificate of compliance from the appropriate air pollution control officer). - CERTIFICATE OF COMPLIANCE: I"certify that under. penalty -of perjury the information given above is correct. I agree to comply,with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date ' CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signalur of a Date 7-0Fr Authorized Applicant t0ate WORKERS' COMPENSATION DECLARATION: hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: _ Carrier: /rJ/l�%� C.-AR/6� ,e,4A)n1:f_ (This section need rpt be rorrlpheted d the permd m shied at ane hundred "ars ($ 100) orfess-) Policy Number: C")3;�4 33G %Z 9 ❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the or Code, I sh I fort t comply with these provisions. /O-lv - �. Applicant's Signature Date --" WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic-# 61'32n� Class # Contractor's Signature - - Date CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects_ the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the -property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code:"The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors license Laws,), ❑ I am exempt under sec. Business and Professions Code for this reason: Signature 305746 (3107) Date Owner. ID verified by drive, - cense_ ❑ Yes []No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property taz bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feel high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code), ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Division of industrial Safety Permit Number: Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: t. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions. requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feel of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District'or from m any other air pollution control district or agency?, ❑ Yes ❑ No - (Section 65850.2 of the California Government Code requires that the requested information be fumished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If -yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by Califomia Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (if "yes", attach certificate of compliance from the appropriate air pollution control officer). ' . CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature ` Date - CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described • property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signat f Date tffor Auth6nzed Ap icant Date" City of Costa Mesa 1 L Development Services Department Building Safety Division CERTIFICATE OF OCCUPANCY No. P. O. Box 1200 + Costa Mesa, California The Building located at 3333 Bristol St. Sp. #3001 has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a'Group B-2' Occupancy. Use of Building restaurant Legal Description 412-501-02 (See reverse side for Metes and Bounds) IE56555 Building Permit.No B56472 Electrical Permit No. E56612 Plumbing Permit No. 55567 Mechanical Permit No. IM5654 O Number of apartments and/or guest rooms ISSUED TO: Building Official Tony C' De Baca C.J. 5egerstrom & Sons r'alrview xa. by ,._-...�...r Costa Mega, CA 92626 Date April 7, 1992 This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. CMF 1015-46 rev- 1/83 White - Owner; Canary - Numerical File; Pink - Bldg. Permit File WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: ❑ t have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. ❑ 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: `` (� Carrier: S +i+e- T [ <J c (This sedan need riot be completed /the permd isone hundred datar: (5700) or less) Policy Number. ❑ 1 certify that in the performance of the work for which [his permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisions. cffel2g�3 G .X _ _ 9 - Z q — 018 Applicant's Signallre I Date WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic: # 41 Z5 & -1 Class # q— 2:,q --a1p Contractor's Sogirwilfure Date CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Cade). Lender's Name: Lender's Address: Signasure nate OWNER -BUILDER DECLARATIONS: f hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation. WILL 00 THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not appy to an owner of property who builds or improves thereon; and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of•sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not appy to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: sognature 3057-46 (3107) Date Owner 1D verified by df. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i2. y property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, fa[sework, or demolition of dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Date Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? []Yes ❑ No (Section 25533 of the Califomia Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be fumished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if 'yes". the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (if 'yes", attach certificate of compliance tram the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to Comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature of Le at Owners) Date �P 9,-z4 --b$ And/or Aulhorizord Applicant Date CI�Y OF COSTA �MI �A Development -Services, Division of Building and Safety CERTIFICATE 'OF OCCUPANCY This certificate is issued pursuant to the requirements of the"Uniform Building Code, Section 308 adopted by the City of Costa Mesa certifies that at the time of its issuance the building structure herein below described was inspected and approved for occupancy as follows: r 3333 Br•i'St6�.1, St;. Ste: 30o0 BC07-00339 Building Address s Bldg.' Permit Number etail� Clo.thets3,.036 Use 1�-PR A XXXXXX PAG Group Type of Construction Fire Zone Use Zone South: Coast Plaza CANALL" Owner of Building Tenant Address 3315 Fairview Rd.,, Costa. Mesa, CA By BUILDING OFFICIAL-Mianh Q. Nguyen, .C.B.-O. Date 05/08/08 I REQUIRED TO BE POSTED IN A CONSPICUOUS PLACE CITY OF COSTA MESA BUILDING DIVISION t F07-00370 > 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca } FOR INSPECTIONS CALL: (714) 754-5526 FIRE SUPRESSION PERMIT .lob Address: 3333 BRISTOL ST Suite: 3000 ,,,:. .... ... Vicinity: Parcel Nunmber: 41249102 - Zoning: PDC PDC ' Applicant: WIEMANN, JOHN. Address: Owner: SOUTH COAST PLAZA Address 3315 FAIRVIEW AVE- MISC. COSTA MESA, CA Phone: 626-913-6720 Zip: Phone: Zip: 92626 Contractor: ALLREADY FIRE SPRINKLER . Address: 818 N,GRAND AV - - Phone 626-913-_6720 COVINA,")CA, • Zip. 91724 Licerise:. 358795 .SCOPE OF PERMIT INSTALLIRELOCATE 49 OVERREAD SPRINKLERS FOR "CANALI " IN,SPACE 3000. REF,: BC07-00339. FEE' SUMMARY Status: ISSUED Applied: 12117/2007 Issued: 03/04/2008 Plan Check: $117.81 Calc Valuation: $9,500.00 Permit: $18125 Claimed Valuation: $9,5oo.00 Other: $0.00 Total: $299.06 - NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LUST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE 0. INSPECTION TYPE OATS INTMALS CODE 0 INSPECTION TYPE DATE INTITIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical ` 201 Final BlocklRetaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final BuildinglOccupancy City of Costa Mesa Development Services Department Building Safety Division CERTIFICATE OF OCCUPANCY No. 000906 .P. O. Box 1200 Costa Mesa. California The Building located at 3333 BRISTOL MNA OFFICE has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group B-•2 Occupancy. Use of Building OFFICE Legal Description 412-501--02 (See reverse side for Metes and Bounds), Building Permit No: B-16415 Electrical Permit No. F-16655 Plumbing Permit No. P-1661fi Mechanical Permit No. Number of apartments ,aanndd/or guest rooms ISSUED TO: Building Official ��/ Jai . SO= COAST PLAZA — OFFICE bye 3333 BRIM UL. 00S`iA D'4E.SA. CA. 49 4-" t 19F5 Date This Certificate of Occupancy SHALL BE posted in a conspicuous place on the, remises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. v CMF 1015-46 rev. 1/83 White - Owner; Canary - Numerical File; Pink - Bldg. Permit File CONSTRUCTION AND PLANNI �� ����� ��,,••������ APPROVALS Permit # _LL-LXf0A Date Inspector POOL & SPA •APPROVALS � Permit # .y- Date Inspector 1. Temporary Electrical Service or Pole 43. Pool & Equipment Location Soil ipe-Un rgrn - 44. Steel Reinforcement - 3. Electrical Conduit Utility-Undrgrn 45. Forms- 4. Electrical Conduit-Undrgrn . 46. Electrical Bonding5_ Steel tee em orce I 47. Rough Plumbing &Pressure Test - - - -=----------- 6_ Electrical_UFER Grn._ 48. APPROVALTO COVER-GUNITE' - 7. Footings 49. Electrical Conduit-Undr rn' - 8. Foundation._ . _ - 50. Gas Pipe, ❑ Undr in, Test' 9. Water pipe-Undrg?n. _. __ - 51. Backwash .Lines P-Tra 'Q ndF rn'-'� - - _70. _Structural_F.Iooc:System. 52. APPROVAL TO DECK I .11. Property Sewer Line;& -.House Connection 53. - Backwash &Receptor-Final - - 12. Street Sewer Connection - 54: Heater & Vent-Final - .._ 13. Rough.Plumbing.55. Plum- 14. Rough Electric-Conduit - 56. Electrical-Final --' 15. Rough Electric-Wiring - - "-- 57. Solar System-Final - - 16: -Rough Heating & Air Conditioning - - encing &.Access-Approval 17.- Ducts; in Structure _ 9. APPROVED FOR PLASTERING,., - 1B. Ducts, Ventilating - - - - - -- . - _60. POOL/SPA SYSTEMS FINAL - - - ' 19. Gas'Pipe-Rough &Test f - - - 20: Roof Framing - - -- - 21: Roof Sheathing NOTES: ' 22. Frame and-Re-- iA- 23. Insulation-- - - - - 24. Lathing-& Siding- 25! Drywall Nailing i S_2 -a?3 c. f 26: Plaster Brown Coat - - - - /- • '/''n no' ' ',+':/-�'� ..l _:/ptr' / „t �'✓!-%' C ' - 27. Electrical Power-Meter-Final - - til + + 28. Final Electric _. - nT' a;%n "+ /'ii O r)A;:. ;'''� �' !.`•N`A`Y 1 29. - Final Heating &-Air Conditioning -- - - - C.S T"- t Alr:_5 c'_-%p.�• -�, s / '�' L, /I 30. Final Gas Pipe-Test - - - •-�fJ-•- Q-•il.G" f7 ;,+g.':r/�• O%' ,v v1+` -31. Final Plumbing 1.41, I 32. Water Service-Final - - - - -- _ _� "T' •'Y; r": .fi ; ';q- / .:+. ,%✓I7�� o!-"• iie'c4'c'*%r7Y -•33: Gas Service-Final -= _ /NAL Nf -7`_Yn ' 34. Solar Domestic-Final - _ _ /�+�L x'GP - - 35.- Landsca e Sorinkling System. - Lt • S l" L x ! 36. Sound Attenuation 37. Handicap Regulations --- - - - 38. FINAL STRUCTURE & BUILDING 39. Special Requirements Completed 40.. Electric Release to Edison 41. Gas Release to Southern California Gas Co. - 42. ' CERTIFICATE OF OCCUPANCY No Date - -" - ._ . N 1 City of Costa Mesa Building Safety Department Box1 P.O. Box 1200 CERTIFICATE OF OCCUPANCY ; ;a M5 Costa Mesa, California The Building located at 3333 Bristol St. G m_ra1'Office has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group M-7 Occupancy. Use of Building Tn+-c%ri nr Ali -Ara+ i rm &EP -,e— 12, 8 A Legal Description a A. R1An—fh,,?—,?n (See reverse side for Metes and Bounds) Building Permit No, R-7421 Electrical Permit No. n-2775 Plumbing Permit No. A+ -281d Number of apartments —n— and/or guest rooms -0- ISSUED TO: Building Official South Coast Plaza V. C. l�Cc Bui.ldirp Division Director Date Gj / � 1G �9�72 This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 306 (e) U.B.C. Form BU 34 Rev, 11/70 i CONSTRUCTION AND PLANNING s'�y Date Ins ector APPROVALS Permit # p POOL & SPA '- _ Date - In actor APPROVALS Permit.# [. � 1. Temporary Electrical Service or Pole 43.' Pool & Equipment COcation ' - - _ • - 2. Soil Pipe -Un rgrn- _ _ 44. Steel Reinforcement - - - - -- 3.. lectrical Conduit Utility-Undrgrn 45. Forms - - - - - 4. Electrical Conduit-Undrgrn _ _ 46. ondin Electrical Bonding-5. Steel tee m eorce _ _ 47. Rou h Plumbin & T st _ - - '• ' ' " • ' 6. Electrical UFER Grn 48. APPROVAL TO COVERGUNITE 7. ootings _ 49. Electrical Conduit-Undr rn 8. Foundation _ 50. . Gas Pi ❑ Undr rn Test .. ' -9. Water Pipe-Undrgrn _ 51.- Backwash Lines P - Trap- o r6 10. Structural. Floor System 52. APPROVAL TO DECK 11. Property Sewer Line & House Connection 53. Backwash & Receptor -Final - 12. Street Sewer Connection _ -- 54. Heater & Vent -Final - 13. Rough Plumbing - - - - 14. Rough Electric -Conduit .56. Electrical -Final 15. Rough Electric -Wiring - - "- -- 57. -SolaPSystem-FinSP- 16. Rough Heating & Air Conditioning - - -- ..Fencing & Access Approval ' 17. Ducts in Structure APPROVED FOR PLASTERING -18. Ducts, Ventilating 60. POOL/SPA SYSTEMS FINAL 19. Gas Pipe -Rough &Test _ 20. Roof Framing - 21: Roof.Sheathin NOTES: - " 22.,-.Frameand -Flashin 23' _ • Insulation=' =- 24. Lathin & Siding - 25: Drywall Nailing ' 26. Plaster Brown Coat - ,- 271 -Electrical Power Meter -Final ` 28: -Final Electric- -29: Final Heating & Air'Cdnditioning'•" 30.- Final Gas Pipe -Test. • 31.. Final Plumbing - - - - 32: -Water Service -Final. L 33. , Gas Service -Final 34. Solar Domestic -Final ' 35. Landscape Sprinkling System ' 36. Sound Attenuation - 37. Handicap Regulations - 38. FINAL STRUCTURE &BUI,LDING 39. Special Requirements Completed - 40. Electric Release to Edison - - 41. Gas Release to Southern California Gas Co. - '' •� 42. -- CERTIFICATE OF OCCUPANCY .NDate F C I 20520 COSTA MESA BUILDING-WETY DEPARTMENT f P. o. BQX 1200 COSTA MESA, CALIFORNIA 026" For Applicant ro Fill In CompleN1�( TYPE OR PRINTS MI -f #* BUILDING0_ 17:2 ..-.. JAN 31-67 001000* ****27.001 APPLICATION FOR PERMIT BUILDING For Office use Only ADDRESS .. RECEIFT NO. PERM Tpo 7i a COSTA MESA. CALIFORNIA fv � R[CQ �Y �Tt 11JIC[I'[p DA 1sgUR 7, - !/ OWNER BUILDING MAIL AD DR ADDR D FqRK C o" 35 ZONX Typt GROUP CITY ARCHITECT KILLIAT 1 TEL. BYPROV>TD ^R ENGINE N DAT>S ZONING kh�­ LONG C D KESS . . mos N No. usE of NEw � 5 PLANS 2 ■mto1NG �74� CONTRA R LICOAL DtECRIrrION ADDR A. P. NO. D S` - 017 CITY <� !' fJ 30" TO BOFAVK DE A ROVERH� G SHALL D$ iESB THAN Laic NO. p'� D 7 7 � EAVES SIZE HO. or BLDOe. ALLOWED (U. B. C. REQUIREMENT) OFLOT Now ON LOT YARDS APPROVED MAIN 13UILDING YARDS APPROVED CESSORY BUILDING USE Oi1•LQ 91,40. S O ! 6' �� FROM C/L 4mur ) GETBACK LINK FROM CENTER OF sTps1T REAR YAR FRONT FT. SID YAR I -Er, RIGHT R. DFr. DESCILIPTION OF WORK L. SID FT. • ALTERATION ADDITION REAR A FT. DISTANCE OCT. mi—r. M A REPAIR MOVING DEMOLI H MAIN BLDG$ CCESS. BLDGB. BUILDING NO. OF VAR.* DATE SIZE ROOMS STORE C. APPROVED EXTERIOR WALL ROOF APPROVICD Z-27-67 COVERING COVERINGDAT) UIS OF BUILDING AND WORKTO $I PIRFORMXD a a o Ifmy �.� �Gj104B E Ir SQ. FT. I NERISN ACKNOWLEDGE TKAT.1 HAVE RRAD THIS APPLIGT)ON THR AMOUNT SHOWN UDDER VALUATION 16 FOR TNR AND STATIC THAT THR ABOVIC JS CORRC= ANC AGRER To C4N. PURPOSR OF RSTASLISHING A PIRMIT FEE QNLY. FLY WITH ALL CITY ORDINANCR{ AND STATIC LAWS 11EGULATING VALUATION BUILDING CorimON. U BIGNATURLrpF r PERMIT FES PERM )TTI � / r AUTHORIZED AGRNT TOTAL PEQ 10 C- ,Y OF COSTA `--)'A Development Services, Division of Building and Safety J CERTIFICATE. OF-Q-CCUPANCY This certificate is issued pursuant to the requirements of the Unif6rm'BuiIding Code, Section 308 adopted by the City of Costa Mesa certifies that at the time of its issuance the building structure herein below described was inspected and approved for occupancy as follows: f -r 3• Building Address 3333 Bristol 'St." ate°`2889 Bldg,PiriiitNumber BC08-00092 Use Clothing Retail . (4 , 092 s f } M 1..A KXXXXXX PDC Group Type of Construction fire Zone Use Zone South Coas#< ,F,.1'aza HERMrs, Owner of Building Tenant Address 3315 Fairview R&..".Costa Mes'a,.. CA 92626 .7 BUILDING OFFICIAL-Khanh Q. Nguyen,,C.&-0..- ay' l Date 07/72 8 REQUIRED TO BE POSTED IN A CONSPICUOUS PLACE CITY OF COSTA MESA 00 BUILDING DIVISION f77 FAIR DRIVE, COSTA MESA, CA 92626 - (714) 754-5273 • Fax (714) 754-4856 - www.ci.costa-m a. s FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER BC08-00092 PERMIT TYPE: B_COMBO STATUS: ISSUED Sub Type: COM—ALT DATE ISSUED. 04/0712008 ISSUED BY: RMD JOB ADDRESS: 3333 2889 BRISTOL,ST CM-'. Suite/Unit:-,2889 APN: 41250107 '{y� r Zoning:PDC, - Vicinity: SUITE 2889 HERMES PrimaryOcc: M Const Type: �.. yp I -A .. , , ! SQ%FT: 4092 Valuation: $225,000.00 SCOPE OF WORK: 4092SF.INTER101Z STORE TI FOR A TEMPORARY LOCATION FOR"HERMES" IN -SUITE 2889. ELEC: 145 LIGHTS, 69 OUTLETS, 5 SWITCHES, 1 SVS TO 1000A, 1 SIGN CIRCUIT; MECH: 2 RE16AIR1ALT COOLING/HEAT, 3 VAV BOXES, PLUMBING: 1 DISHWASHER, 2 FLOO'R.DRAINS, 1 GAS OUTLET (1-4),3 P -TRAPS, 1 KITCHEN SINK, 2 TRAP PRIMERS, 2 WATE CLOSETS, 1 WATER.HEATER OWNER: SOUTH COAST PLAZA' , i Address: 3315 FAIRVIEW RD } Unit: Phone: ?�I City/State/Zip: COSTA MESA, CA s APPLICANT: MEDEL, MIKE °' Address: Unit: : Phone: 714-376-6632 CitylStatelzZip: 4 CONTRACTOR: DEVELOPMENT SUPPORT SERVICES -INC License No. 748446 Phone: 714-957-8250. Address: - 3187 AIRWAY AVEUniti UNIT G Cell: City/State: COSTA MESA, CA ZipCode 92626 ARCHITECT: PAUL J RUFFING, AIAf :',. License No.C4264 PHONE:949-660-8062 ENGINEER: L. License No. PHONE: COMBINTATION PERMIT FtESUMMARY Building Pian Check: $275.24 Building Fees: $1,693.75 Electrical Fees: `, . ., $301.02 Mechanical Fees: $82.85 Plumbing Fees: $147.25 SMIP Residential: $0.00 SMIP Commercial: $47.25- 47.25TOTAL TOTALFEES: $2,547.36 "Refer to tee receipts for all fees paid for projett NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under Califomia statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit, CAGE 1. INSPECTION TYPE RAS INTMA $ CODE IN5MCDON�E �I� I 1616 Fixed System Final Fire Prevention _ 206 Final Mechanical 1.71 09 1266 Pool Spa Final = 208 Final Plumbing P � -�- 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition _ 250 Final Building/Occupancy P/A. WORKERS' COMPENSATION DECLARATION. hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: /� f /t A'� n (AA-(— } Carrier: 5 A Ltd s V,,8 ` 0 U INS ' (7hrs satrArt Head not D� the permR is V c.J �valued f one undred dollars ($70t7) a less) Policy Number, 4 ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to th workers' compensation la of California, and agree that if I should beco a Subjec the workers' c Pe nsation provisions of Section 3700 of the La 1 11 f hwith co ly with these provisions. t-- 4.� Applicant's Signature _Date WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code. and my license is in full force andel ff Co tractor's Signature Date-' CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors license Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature 305746 (3107) Date Owner ID verified by driv. lc6 ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty -sic (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Division of Industrial Safety Permit Number: Dale HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). . 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If "yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct, I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for insp ction purposes. I agree not to upy or allow occupancy of any building authprized by this pNrmit until final inp ction. Si tur tJl al wner(s) � Da j{ Andlor Authonzed Applicant '-Date CITY OF COSTA MESA 9'" BUILDING DIVISION } 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us �•�' FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BC0400054 PERMIT TYPE: B_COMBO STATUS: ISSUED Sub Type: COM—ALT DATE ISSUED: 0212212008 -ISSUED BY: BJK JOB ADDRESS: 3333 2889 BRISTOL ST CM Suite/Unit: -'"2889 APN: 41250107 Zoning:PDC, , Vicinity: SUITE 2889 HERMES',,;�,, y Primary 0cc: M, Const Type: HT SO. FT:. 2000 Valuation:. $11,230.00 SCOPE OF WORK: 2000 INTERIOR STORE DEMOLITION IN SUITE 2889 FOR A TEMPORARY STORE FOR "HERMES," WORK INCLUDES REMOVAL OF SKIN ON WALLS & FLOORING; ALSO INCLUDES REMOVAL OF DISPLAY CASES. OWNER: SOUTH COAST PLAZA Address: •.3315 FAIRVIEW RD r Unit: Phone: City/State/Zip: COSTA MESA, CA APPLICANT: SNEDEN, KENT Address: 1081 ST REGIS PL Phone: 714-838-4112 CitylState/zZip: SANTA ANA, CA CONTRACTOR: SNEDEN AND BOWERS INC License No. Phone: 714-838-4112 Address: 1081 ST REGIS PLUniL- Celt: 714-350-2415 City/State: SANTA ANA, CA ARCHITECT: License No. ENGINEER: J License No. COMBINTATION PERM IT"FEE:SUMMARY, Building Plan Check: $136.01 , Building Fees: $209.25 Electrical Fees: $0.00 Mechanical Fees: $0.00 . Plumbing Fees: $0.00 SMIP Residential: $0.00 • , ; , •" . . SMIP Commercial: $2.36 TOTAL FEES: $347:62 —Refer to fee receipts for all fees paid for project Unit: 811856" ZipCode 92705 PHONE: PHONE: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply vtith all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE t• INSPECTION TYPE DATE INTMALS CODE # INSPECTION TYPEDA�1 IN1mAL5 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign _ 222 Final Site 204 Finale Demolition 250 Final Buildinglprcupancy WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' Compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. Xq I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this Permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: (This s&Wrleednot 6e cornpkied l me perim is vapbdal one hundred dolats ($100) or kss.) Policy Number: 213 — On- I 21 ]Z_ ❑ 1 certify t in the perform of he work for which this permit is issued, I sh of employ any rstm in arty manner so as to became subject tote ers' compensati laws of, alifomia, and agree that if I should A* e Obj#ct to the wo rs' rovisionsfJ �pf Sectio 3700 of Lab mole with th a orovisir3ns. T Date WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS {$100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTORS DECLARATION: 1 hereby affirm th t'f am licensed un derprovisions of Chapter 9 (commencing with Section 0) of Divisiop-3 of the usiness and Professions Code, and is in full force an¢ my tic effect. c. _ + w/ Class # v / , I IanUact Date CONSTRUCT19N LENDING AGENCY, ❑ 1 hereby k{trm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: t hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ l am exempt under sec. Business and Professions Code for this reason: Signature 3057-46 (3107) Date Owner 0 verified by drive, rise. 0 Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i,e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty -sic (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Tittle 8, California Administrative Code), ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Date Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration fort for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Goverment Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7, If a permit from the South Coast Air Ouality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (if 'yes*. attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF'COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is Correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mep to enter upon the above-described property for inspection urposes gree no t4 OCCQ y or allow occupancy of any building authorize y t ' ermit unti tnal inspection. Signalu er(sI Date a2 r7 r Aut ed{lpptiont Dale FEE SUMMARY Building Plan Check: $15.28_ • CITY OF COSTA MESA Electrical Permit: BUILDING DIVISION Q $0.00 Y 77 FAIR DIRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 • www.ci.00sta-mesa.ca.us uogo FOR INSPECTIONS CALL: (714) 754-5626 $1.00 PERMIT NUMBER: BX09-00130 PERMIT TYPE B MISC STATUS: ISSUED APN: 41250107 DATE ISSUED: 06!4012009 Zoning: PDC, ISSUED BY: RMD JOB ADDRESS: 3333 2889 BRISTOL ST CM - SuitelUnit: 2889 Vicinity: SPACE 2889Primary Occ: Const Type :?? SQ. FT: 0 Valuation: $500.00 SCOPE OF WORK: INSTALLATION OF A 6 Sl~ ILLUMINATED (1 SIGN CIRCUIT) WALL SIGN FOR "FACONNABLE"; SPACE 2889, OWNER: SOUTH COAST PLAZA Address:: 3315 FAIRVIEW RD City/State: COSTA MESA, CA Zip Code: 926.26 Phone: APPLICANT: DISK, EVA' Address: City/State: Zip Code: Phone: 619-438-8605 CONTRACTOR: GLOBAL LIGHTING AND SIGNS License No. 870582 Address: 29910 MURRIETA,HOT SPRINGS G104 City/State: MURRIETA, CA Zip Code: 92563 - Phone 800-723-4948" Cell: ARCHITECT: License No. Phone ENGINEER: License No. . Phone FEE SUMMARY Building Plan Check: $15.28_ Building Permit: $23.50 Electrical Permit: $48.10 SMIP residential $0.00 SMTP Commercial $0.50 Bldg Std Admin Fund $1.00 TOTAL FEES $88.38 Unit Unit: Unit: UNIT NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE t. INSPECTION TYPE DATE INTITIALS CODES INSPECTION TYPE DATE INTITIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Etectrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy r CITY OF COSTA MESA BUILDING DIVISION F77 FAIR DRIVE, COSTA MESA, CA 92626 - (714) 754-5273 • Fax (714) 754-4856 www.ci.costa-mesa.ca.us ? FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BC09-00096 PERMIT TYPE: B_COMBO Sub Type: COM—ALT JOB ADDRESS: 3333 2889 BRISTOL ST CM APN: 41250107 Zoning:PDC, , Vicinity: FACONNABLE, SPACE 2889 Const Type: I -A SQ. FT: 0 STATUS: ISSUED DATE ISSUED: 03/2612009 ISSUED BY: BJK Suite/Unit: .2889 Primary Occ: M SMIP Residential. Valuation: $18,000.00 SCOPE OF WORK: NON-STRUCRTURAL INTERIOR DEMO OF FIXTURES, WALLS, FINISHES AND -STORE FRONT IN PREPERATION FOR A T.f. FOR "FACONNABLE", SPACE. REF#: BC09-00088 OWNER: SOUTH COAST PLAZA Phone: APPLICANT: SHULER, DON Phone: 617-293-0379 Address: 3315 FAIRVIEW RD Unit: City/StatelZip: COSTA MESA, CA Address: City/State/zZip: CONTRACTOR: SHAWMUT DESIGN AND CONSTRUCTION License,No. 747583 Phone: 617-622-7000 Address: 560 HARRISON AVENUEUnit: Cell: City/State: BOSTON, MA 02118 ARCHITECT: ENGINEER: COMBINATION PERMIT FEE SUMMARY License No. License No. Building Plan Check: $190.61 Building Fees: $293.25 Electrical Fees: $0.00 Mechanical Fees: $0.00 Plumbing Fees: $0.00 SMIP Residential. $0.00 SMIP Commercial: $0:00 Bldg Std Admin Fund $1.00 TOTAL FEES: $484.86 —Refer to fee receipts for all fees paid for project Unit: ZipCode 02118 PHONE: PHONE: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE t, INSPECTION TYPE PEN INTMALS CODE INSPECTION TY DATENI Tn1AL5 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy •s CITY OF COSTA MESA BUILDING DIVISION 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us FOR INSPECTIONS CALL: (714) 754-5626 PERMIT TYPE: B_COMBO Sub Type: COM—ALT JOB ADDRESS: 3333 2889 BRISTOL ST CM APN: 41250107 Zoning:PDC, , Vicinity: FACONNABLE, SPACE 2889 Const Type: I -A SO. FT: 4359 PERMIT NUMBER: BC09-00088 STATUS: ISSUED DATE ISSUED: 04/30/2009 ISSUED BY: RMD Suite/Unit: 2889 Primary Occ: M Valuation: $800,000.00 SCOPE OF WORK: 4,359 SQ FT TENANT IMPROVEMENT FOR "FACONNABLE" SCOPE OF WORK TO INCLUDE: NEW STORE FRONT, INTERIOR REMODEL, NEW RESTROOMS. 1 VAV BOX, 3 AIR HANDLERS a 10K CFM, RELOCATE 2 SVC PANEL TO 200A, 1 VENT PAN, 285 LIGHT FIXTS, 2 FLOOR DRIANS, 1 DRINKING FOUNTAIN, 1 KITCHEN SINK, 1 SVC MOP SINK, 2 TRAP PRIMER, 2 WAHS BASINS, 2 WASTE AND VENT, 2 WATER CLOSETS, 1 WATER HEATER, 1 WATER PIPING INSTIREP, 1 WATER REPIPE. OWNER: SOUTH COAST PLAZA Phone: APPLICANT: ZIMMERMAN, JETHRO Phone: 617-839-9469 Address: 3315 FAIRVIEW RD City/State/Zip: COSTA MESA, CA Address: CitylState/zZip: CONTRACTOR: SHAWMUT DESIGN AND CONSTRUCTION License No. 747583 Phone: 617-622-7000 Address: 560 HARRISON AVENUEUnit: Cell: CitylState: BOSTON, MA 02118 ARCHITECT: GISH, JOHN ENGINEER: COMBINATION PERMIT FEE SUMMARY License No.C14052 License No. Building Plan Check: $757.05 Building Fees: $4,658.75 . Electrical Fees; $329.25 Mechanical Fees: $114.45 Plumbing Fees: $180.30 SMIP Residential: $0.00 SMIP Commercial: $168.00 Bldg Std Admin Fund $32.00 TOTAL FEES: $6,239.80 "Refer to fee receipts for all fees paid for project Unit: Unit: : ZipCode 02118 PHONE:206-623-4646 PHONE: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord, No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: in order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. GOOF :, JN_ �SPECTION TYPE 1616 Fixed Syst@m Final Fire Prevention 1266 Pool Spa Final 200 Final Re -Roof 201 Final Block/Retaining Wall 202 Final Factory Fire Place 203 Final Sign 204 Final Demolition QAU IN Al OM INSPECDjO.NME 206 Final Mechanical 208 Final Plumbing 210 Final Electrical 212 Final Fire Prevention 220 Final Planning Approval 222 Final Site 250 Final Building10ccupancy r spm N CITY OF COSTA MESA o W_ Q1 BUILDING DIVISION i 77 FAIR DRIVE, COSTA MESA, CA 92626 - (714) 754-5273 • Fax (714) 754-4856 - www.ci.00sta-mesa.ca.us r ".�FOR INSPECTIONS CALL: (714) 754-5626 k PERMIT NUMBER: BX09-00121 PERMIT TYPE B_MISC STATUS: ISSUED APN: 41250107 DATE ISSUED: 07/21/2009 Zoning: PDC, ISSUED BY: JOB ADDRESS: 3333 2889 BRISTOL ST CM Suite/Unit: 2889 Vicinity: SUITE 2889 FOR FACONNA13LE Primary Dec: Const Type :?? SO. FT: 0 Valuation: $6,000.00 SCOPE OF WORK: FOUR 9 FT HIGH X 12 FT MOBILE SHELVING UNITS IN THE STORAGE ROOM IN CONJUNCTION WITH THE INTERIOR STORE TI FOR "FACONNABLE" IN SUITE 2889 . REF: BC09-00088 OWNER: SOUTH COAST PLAZA City/State: COSTA MESA, CA Phone: APPLICANT: KEVIN BEHNKE City/State: BOSTON, MA 02118 Phone: 617-504-3079 CONTRACTOR: _Address: i Cty/State: Zip Code: ARCHITECT: Phone ENGINEER: Phone Address:: 3315 FAIRVIEW RD Unit Zip Code: 92626 Address: 560 HARRISON AVENUE Unit: Zip Code: 02118 21 SHAWMUT DESIGN AND CONSTRUCTION 560 HARRISON AVENUE $OSTON, MA 02118 02118 License No. 747583 Unit: Phone 617-622-7000 Cell: License No. ROLF ARMSTORNG License No. C61726 541-389-9659 FEE SUMMARY ':OR STORE Building Plan Check: $81.41 Building Permit: $125.25 Unit Electrical Permit: $0.00 SMIP Residential $0.00 SMIP Commercial $0.00 Bldg Std Admin Fund $1.00 Unit: TOTAL FEES $207.66 E d: 'NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28. § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In or0er for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections :and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration"of this"permil. CODE II INSPECTION TYPE DAR INTMALCODE / INSPECTION TYPE DAFT INTMAL5 .1616 Fixed System Fimel Fire Prevention 206 Final Mechanical 1266 Pool Spa t=int 208 Finat Plumbing 20o Final Re -Root 210 Final Electrical 201 Final Block/Retairting Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Oernolition 250 Finat Building/Occupancy L �e I.'"iI WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy number are: Carrier;, f Th)s sedfon need not aom Sed I the/pwennt its vaakmd of meehhundmd dollars S 100) 00etss.) Policy Number: ��� y yZ / 3� f 7/'J' q � ❑ I certi that in the performance of the work for which this permit is issued, I s II not employ any p on in any manner so as to become subject to the rkers' comp alio aws of Califo a, and agree that if k should beco subject o e rs' compen ton provisions of Section 3700 of th a o C , s to th with these provisions. -7-moi -01 Applicant ,use � Date --.... - _ _-� L__::. . WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SkALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (51 00,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. rc� r 2 C—_CG55 #• is ►/Jl "z u�ttor's Signature �iJate CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Profession4 Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (S500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under Sec. Business and Profession% Code for this reason: Signature Date 3057-46 (3)07) Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property lax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Division of Industrial Safety Permit Number. Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department, 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'fres", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7, If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 6. (If "yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions, &0noture Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances rely " g to building construction, and authorize representatives of the City of 96sta Mesa to enter upon the above-described property for inspecton pyrposes, I agree not tq)!Sccupy or allow occupancy of any building r st to �r( Applicant Date/,/ City of Costa Mesa Development Services Department Building Safety Division CERTIFICATE OF OCCUPANCY No. 000715 P. O. Box 1200 Costa Mesa, California J The Building located at 3333 r3RTIri0-1, SPACE 42883A has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group_ 0=2 Occupancy. Use of Building S`I RCICII`d Legal Description 412--501»02 (See reverse side for Metes and Bounds) Building Permit No P—Iq;d4 Electrical Permit No. Plumbing Permit No. Mechanical Permit No. Number of apartments and/or guest/ rooms ISSUED TO: Building Official - � by r�Jir s�,f� 31-4-43'3 /2/ f�RT�rIY1i. �?;t�i'iz1 rncrfn I�tF:'_Cb C'A Date [� I/�t �9e. This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. CMF 1015.46 rev. 1/83 White - Owner; Canary - Numerical File; Pink - Bldg. Permit File Development. Services, Division of Building and Safety CERTIFICATE OF OCCUPANCY This certificate is issued pursuant t�th; regtnrements of,,th��niform Building Code, Section 308 adopted by the City of Costa Mesa certifies�that'at-the time of4ts.issuance the building structure herein rr i r r...^�--:.._=w.. below described was inspected and�a<pprovedfor-occup-ancyasIUIIUWb :, - 3333/IZ"S `TOLQST 7�B8I H68330 Building Address � Bldg. Permit No. Use S-2 I �z i:�l�= 1PR 3P ,��� C1_8 Group ype,,of Construction Fire Zone X33; {• Use Zone 4��i? X32 �,� ASA-ESTI Owner of Building C•J•'30GER9'iROM 8-SOMS Tenant ME Address 3315FAIRVSW _ C70BTA MAiCA 92626 �. By BUILDING OFFICIAL- 0n'p C".! e ��aGQ �� l/ , `� � °�<.'�'�•.=. Date REQUIRED TO BE �,F WARY 24, PLACE CITY', OF COSTA MESA Development Services, Division of Building and Safety nmnwn� CERTIFICATE --OF OCCUPANCY This certificate is issued pfirsuant to the requirements :of theUnifq'rm Building Code, Section 308 adopted by the City issuance em of Costa Mesa certifies -that at the time of \\__��eti�e._b_Nildi -sifuc6re h`eii below described was inspected and approved for occupancy as follows - Building Address 3333 Brisiol"Stieet, Suite 2881, Bldg. -Permit Number B02-01861 Use Display Sale /Me rchandis4;j Group M Type of Constructiciii-r w -,-;u Fire'Z6ne South '.Coast, -Plaza Owner of Building ant 3315 Fairview%koadN Address \ Costa) Mesa, CA - 92626 Use Zone v, za­ rerr BUILDING OFFICIAL -Rick A,,Browhj-,.C.B'.0.' �Dat6" REQUIRED TO BE POSTED IN A- CONSPICOUS PLACE . "`' :'1'M1 ..--"''i+� v'.'titi_...;,,rc�. Y �E. •—r+'•:n,. ti- '^�1.�� � r ' -..'��_ lr.^. -• ....`•"4-..-r„;d�t 1.-ri.' t -`'-r i4'r _ - CIr' Y OF COSTA MFA -,,'A C Development Services, Division of Building and Safety I=I CERTIFICATE OF OCCUPANCY This certificate is issued pursuant to the requirements of the Uniform Building Code, Section 308 adopted by the City of Costa Mesa certifies that at the time of its issuance the building structure hereinbelow described was inspected and approved for occupancy as follows: Building Address 33 33 1 Bristol _St. Ste 2879 BIdg'.Permit Number B06-01379 Use Dismay/Sale Merchandise (1156 sf) Group M _ Type of Construction South Coast Plaza 1-FRirZYbn Owner of Building 3315 Fairview Rd., Costa Mesa; CA Address BUILDING OFFICIAL-Khanh Q. Nguyen, C.B.O. Use Zone PDC. Tenant, JOHNSTON & MURPHY 9 2 62,6 Wt W, ^9' 1 Date 09/21'/06 REQUIRED TO BE POSTED IN A CONSPICOUS PLACE Cid j Costa Mesa A Aar, . f Development Services, Division of Building and Safety CERTIFICATE OF OCCUPANCY This certificate is issued pursuant to�the�requiremenfs of7 they niforrn Building Code, Section 308 adopted by the City of Costa Mesa certifies,thatme of its issuance the building structure herein below described was inspected and�a}�pro ved�for�occupancy�as:foliows� Building Address 3333 BRISTOL'-, STttkkT SUITE 2873�W ��Mdg. Permit No. B$8-01660 Use RETAIL 1i'�n l` � N `✓ r `� a 2 N0, �:1 Group M Type,of,Con structic6 _I _FR Firi�'Zonel� Use Zone PDC Owner of Building CJ SEGSERSTROM & SONS— -Tenant EMG; i, OLUFSBI i Address3315airView Rbg4,- o to e --9-'2/626— l / 7 �� `�':° Date 4()v 12, I2, 1 RICK )rk RRS JCBO - BUILDING OFFICIAL REQUIRED TO BE POSTEDIN A CONSPICOUS PLACE N /WORKERS'COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: +q, Carrier: zi' GL — f C - i `�.14A (2 4 ; CO (This section need not be mmplered A the permit is valued at one hundred dorlars (5100) or less.) Policy Number: C, Z_ 1`i 7 cy(a6 El I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Lair Code, I shall forthwithicomp)i rith these provisions. Applicant's Signature-�� Date WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL. FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PF20VIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND FEES, LICENSED CONTRACTORS DECLARATION: �ATTORNEY'8 l hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. '1 Lic. #1 3 Class o Conirac[s Signature Date CONSTRUCTION LENDING AGENCY: ❑ t hereby affirm that there is a construction Lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: L(-nder's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): Q I, as owner of the property, or my employees with wages as their sole` compensation, WiLL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature 3057-46 (3707) Date Ir Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feel high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Division of Industrial Safety Permit Number: &ate HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to fife and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure), 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No S. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the Califomia.Govemment Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (if "yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I a fee not to occupy or allow occupancy of any building authod d by this per d unt f final spection. ® C� Z c r'Z Signature o Legal Owner(s) Date And7or Authorized Applicant Date -qx141A<*-1r CITY OF COSTAMESA r _,00F Development Services, Division of Building and Safety N%Wal� CUP TYPIC ATF OF nCCT TPA j`--JCV This certificate is issued pursuant to 6 itsis issuance the buildi 64�rwireme:nts of theiUnifo-r Building Code, Section 308 adopted by the City of Costa Mesa certifies that at the time i n re herein below described was inspected and approved for occupancy as follo Building Address 3 -3 3 3 .2 813 ,; Br3is t 0 1 S -t''. Bldg.'Permit Number B06-00059 V Use Merchandise Group M Tof Cohstruction LL;' Use Zone PDC pe C 11 1114 G Tenant OwnerofBuilding South od!s�� P T' Address 3315 FairviewN-6t-a-- Mesa, CA 92626 no, . . . ........ - w BUILDING OFFICIAL-Khanh 9 N'' en py.. . ..... . -22-06 Date -�5 REQUIRED TO BE POSTED IN A CONSPICOUS PLACE I = I M �-rnl�'�y�'.�.,.�i - ]rtrr r•,fs+s.-:.�a�lY'�^!'.'L+:�.`X'.^ .. f�"�iv��'1-r��L�... �..r r� .�.�..-�� y � ..t - � .�'l i'F, try.'�,�. .�nrt�r .�, � - CIr, i OF COSTA ME A W. __,OoP Development Services, Division of Building and Safety CERTIFICATE'OFOCCUPANCY This certificate is issued pursuant to the requireme ts-of the Uniform Building Code, Section 308 adopted by the City of Costa Mesa certifies that at the time of its issuance thebuilding structure hereiri=below described was inspected and approved for occupancy as follows: Building Address 3333'`Brxs:.to1,.,.St. Sp. 2645 ,^ Bldg Permit Number S06-012$'7 Accessori%1 s/retai,1 a Ilse L1 1625.. Group `"t Type of C.( I Owner of Building South C o r Address 3 315 F a -i ry 6;W.xl By, BUILDING OFFICIAL-Khanh Q. Nguyen; C B.O , t Date >f, 11/14/06 REQUIRED TO BE POSTED INA CONSPICOUS PLACE .� • - .•^ v��.,.r.^L•+•-„:,,_ �'.-.r:++..^+”"'w'n,-rY-''7w', tris..rw. y..�..'.,�-...�. -k.+.! +^•..�'_'F„*.4i�W'. '- .�„"``'nh,.�'++`f""'-rn.'vti:.�...,,s+.irn-.'r-+. of Gonia .TAmp, I Development Services Division of Building and Safety klwa� 1 CERTIFICATE OF OCCUPANCY :This certificate is issued pursuant t�therequiremetits of �the`Uniform Building Code, Section 308 adopted by the City of Costa Mesa certii s:that_at-tl�e time of its -issuance the building structure herein below described was inspected a andTa'ppr�ove&for occupancy as. follows: 3333 HhtOLAHREET SPACE 2$OS �A S $1247 Building Address fff� Bldg. Permit No. Use Retail I, 1 Group M Type gf,6fistructi6n�� 1? I -FR -Sp Fire,Zone,�', � � Use Zone M-9 w •i .�`� !JW '1 o.�Ttl•.P:.�f�. S;3e.��� I r ,tip Owner of Building C J _ Se4erstrom +Tenant " - " Address .* ',_- --=71 - F r� .. C By BUILDING OFFICIAL-ItOttp.'be �3aca., rye � � az Date ,`March 4, 1997 REQUIRED TO BE POSTED IN -A CONSPICOUS PLACE =I � • Ail yr r 0 6 q of to-sta 21) Development Services, Division of Building and Safety -CERTIFICATE OF OCCUPANCY This certificate is issued pursuant to j e?requiren adopted byiithe City of Costq Mesa certif[6-t A_ai-tl below desahbed was inspected and rappr'ove"d=fo occ Building Address Use ur•ylubs /,It Ic-a Ar f i Group B Type, of Cons Owner of Building C. J. Seizered Address 3333 BRISTOL IS RRET, 3n I -FR Fire form Building Code, Section 308 .ance the building structure herein 's: ,N\gBld . Permit No. B 82903 Use Zone C1 -S t: r x ,, �� M ��_(`-Nk g z�/ BUILDING OFFICIAL- ptOn/ 14W %%� I ...ins; Y; ���fj C bate June 2 , 1997 REQUIRED TO BE POSTED INA CONSPICOUS PLACE rrw ... r � '1" 4 }� . i' .^JI"" r.r :w .� .�' Y;�, v ��r'�..��r...��.y.w'vrw..4s. ::-.+`^•'�"' - � r, . r i 0� r X70[^ V Or VOF COSTA Mr1 �..J Development Services, Division of Building and Safety CERTIFICATE OF OCCUPANCY This certificate is issued pursuant to the requirements of the 2007 California Building Code, Section 110 adopted by the City of Costa Mesa certifies that at the time of its issuance the building structure herein below described was inspected and approved foroccupancy as follows: Building Address 3333 2$20' Bristol 'Street BI dg. PermitNumber$C09-00439 Use Tenant Improvement -Commercial. Mi -A . Group Type of Construction Fire Zone South Coast. Plaza' Wi6t Seal Owner of Building Tenant Address 3315 Fairview3_..Road.,.. Costa Mesa, " CA 9262:6 f Use Zone PDC By BUILDING OFFICIAL-Khanh Q'Nguyen; � Date 9-13-10 REQUIRED TO BE POSTED IN A CONSPICUOUS PLACE 0 CITY OF COSTA MESA ry "' BUILDING DIVISION p i 77 FAIR DRIVE, COSTA MESA. CA 92626 • (714) 754-5273 • Fax (714) 754-4856 - www.ci.costa-mesa.ca.us r ". FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BC09-00439 PERMIT TYPE: B_COMI30 STATUS: ISSUED Sub Type: COM—ALT DATE ISSUED: 12/28/2009 ISSUED BY: RMD .JOB ADDRESS: f [JJ -3 O'BRISTOL1ST CSuite/Unit: 2820 APN: 41250107 oning:PDC, , Vicinity: WET SEAL, SPACI~ 3807 Primary Occ: Const Type: IZ8 1A SQ. FT: 3807 Valuation: .$75,000.00 SCOPE OF WORK: 3,807 SF INTERIOR TI FOR "WET SEAL", SPACE 2820. RECONFIGURATION OF SALES AREA, FITTING ROOMS, STOCK AREA, CONSTRUCTION OF A NEW RESTROOM. STORE FRONT TO REMAIN. 1 ALTER/REPAIR COOLING/HEAT, 3 VAV BOX, 1 VENT FAN, 38 LIGHT FIXT, 1 OUTLET, 1 SWITCH, 1 WASH BASIN, 1 WATER CLOSET, WATER PIPING. OWNER: SOUTH COAST PLAZA' Phone: APPLICANT: NGUYEN, ANDREW Phone: 714-685-0775 CONTRACTOR: CEDARS ENTERPRISES Phone: 714-685-0775 Cell: ARCHITECT: GOGLIA, FREDERICK ENGINEER: COMBINATION PERMIT FEE SUMMARY Address: 3315 FAIRVIEW RD City/State/Zip: COSTA MESA, CA Address: CitylState/zZip: License No. 650785 Address: 18757 TURFWAY PARKUnit: CitylState: YORBA LINDA, CA License No.C20788 License No. Building Plan Check: $133.05 Building Fees: $818.75 Electrical Fees: $60.84 Mechanical Fees: $76.40 Plumbing Fees: $52.90 SMIP Residential: $0.00 SMIP Commercial: $15.75 Bldg Std Admin Fund $3.00 TOTAL FEES: $1,160.69 "Refer to fee receipts for all fees paid for project Unit: Unit: : ZipCode 92886 PHONE: 314-42B-3500 PHONE: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE 0 INSPECTION TYPE 1616 Fixed System Final Fire Prevention 1266 Pool Spa Final 200 Final Re -Roof 201 Final BlocklRetaining Wali 202 Final Factory Frre Place 203 Final Sign 204 Final Demolition DATE INTMALS CODES INSPECTION TYPE 206 Final Mechanical 208 Final Plumbing 210 Final Electrical 212 Final Fire Prevention 220 Final Planning Approval 222 Final Site 250 Final Building/Occupancy GATT IM'nnALS X RaQ� &J WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a cerlificale of consent to self -insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier; (This section need not he completed dthe permit is valued at one hundred dollars f$100) or less.) Policy Number: ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor CoA I shall forthwith comply with these provisions. Applicant's Signature Dbte WARNING:- FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic. # 078S --Class # F Contractor's Signature �r ate CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec, 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that unger penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ ), as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). C] I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ t am exempt under sec. Business and Professions Code for this reason: Owner ID verified by driver s license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than Thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, t will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Dale Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the Califomia Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If 'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penally of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection, ature f Legal Owners} Slgna,ture Date 3057x6 (3707} Andlar Authorized Applicant Date Dat WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: (Thus section meed not be p7mpletpd d the pern)r is valued at one hundred darars (3100) or tess.) Policy Number: r -- I certify that in the performance of the work for which this permit is issued. I shall not employ any person in any manner so as to become subject to the workers' compensation lacus of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of bor Code, I sha rthwith comply with these provisions Applicant's Signature D it - Z:5WRNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL, SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. _ Lic: # Class # /0 Contractor's Signature le CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that th@re is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Cocle: Any city or county which requires a permit to construct, alter, improve, demotish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature 3057-46 43107) Date Owner ID verified by driver *license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsewcirk, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, Califomia Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, a$ noted above, unless such person has a permit to do such work from the division. Applicant's Signature Date Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code), 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If 'yes". attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORLZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection: Signature of LAO s D to r lho6zed Applicant `"�Da CIT- `OF COSTA MEQ' Development Services, Division of Building and Safety CERTIFICATE' OF OCCUPANCY This certificate is issued pursuant to the requirements of the Uniform Building Code, Section 308 adopted by the City of Costa Mesa certifies thatat the time of its issuance the building structure herein below described was inspected and approved for occupancy as follows: Building Address 33:33 Bristol St: _Ste 2819 Bldg., Permit Number 806-02003 Use Retail Clothing .",.' ,(7•,•980 a. f7. ) Group M Type of,Construction I"FR' ' Use Zone PDC South C6st P,1'a za H AND M Owner of Building Tenant Address 3315 Fairvieir ,'Rd. , Costa. Mesa;' CA 9262 BUILDING OFFICIAL-Khanh-Q..Nguyen, C.B.O. Date 03/28/0 REQUIRED TO BE POSTED IN A CONSPICOUS PLACE ...L. . .., -'_^^ .--.-.. . - +. i.•�r....ur..,..'w....•--.•..��.a-.....r...+.it+.�+-+..VRn"'�.ren+....e+aY.-..r-►•+^v..:,...-+-.,„n„Mir„yyr`,vim-y;�„'r.r.r.,---•a..-�� 44A of tosta')'M" 'a 7L.�Development Services, Division of Building and Safety CERTIFICATE OF OCCUPANCY This certificate is issued pursuant to the f4equirem'en, s.� of�,the�Uniform Building Code, Section 308 adopted by the City of Costa Mesa certifies that -at the tirn"f its issuance the building structure herein below, described was inspected and pprove rsoccupancy<as:f j s:� Building Address 3333 BRISTOL? STREET UNIT: 2819 RF.TATT. Bldg. Permit No. B 77302 Use - Group M _ __ Typeof,Construction _T -VR Fire`ZoneUse Zone C-1 S Owner of Building C J SEGERSTROM & SONS— =Tenant -Ail Address By . ���y�`��� l.. l`_�_ � f,/'1 ^\1 I fes• 1 BUILDING OFFICIAL-taft it' -V 134ea: �C'� Date" my 2, 1996 - REQUIRED TO BE POSTffNWCONSPICOUS PLACE CjtAro f Costa 2Y) esa Development Services, Division of Building and Safety CERTIFICATE OF OCCUPANCY This certificate is issued pursuant to tYie requtre-merits of the Uniform Building Code, Section 308 r, i !L adopted by the City of Costa Mesa certif ke that at -=the time 6f4ts,issuance the building structure herein below described was inspected and,,<app ov&- r occupaney,as f�ll s: 3333 Brist�" 'ol(~\,Sit .2849 �aNB82857 Building Address Perrrut No. Use 5904 sq. ft. T.I.-Jf'a A 1wworth_s_tudio Group M Type�of•Constr�ruuction I—FRSP Fire,Zone r Use Zone C1 %U as rz:_NPM0 1'f!i:-�;b Owner of Building CJ Se dia rom and "Sons Tenant tiw tudio stn .: Address'0AA osta Mama ' _ By ry BUII.DING•OFFICIAL �On'p t�]De B'acQ, ACT BUILDING OFFI TALC- Burt Morgan'' ; T4\ v' ' Date n �� sP�temher 22, 1997 REQUIRED TO BE. POSTD-A CONSPICOUS PLACE _F AV NIL- I CITY OF COSTA MESA r! Development Services, Division of Building and Safety CERTIFICATEOF-0-CCUPANCY This certificate is issued pursuant to the requiremen of the Uiiif6rm Bdi]ding Code, Section 308 adopted by the City \� structure of -its g of Costa Mesa certifies that at the time of below described was inspected and approved for occupancy as foil ows* Building Address 3333 B i6� 1/��' '0 Suite 2849 r ,Street, Slui Idg., er itNumber B03-02158 j, Display Use /Szil:-e MeLh �--F Group M Type of Construction, 7,oJR ne Use Zone Owner of Building South Coas"t VJPlaza' Tt "BAT, - AND BODY WORKS" 7z/ Address 3315 Fairview `Roa:d,+,Costa Mesa, CA `52626 BUILDING OFFICIAL-KiCk /2004 REQUIRED TO BE POSTED'IN-A CONSPICOUS PLACE City of Costa Mesa Development Services Department O©r+�Q Building Safety Division CERTIFICATE OF OCCUPANCY No. P. 4. Box 1200 Costa Mesa, California The Building located at 11,41 C- Rr1st41 Street. Snace 2849 has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group R2 Occupancy. Use of Building Retail Legal Description 412-501-02 (See reverse side for Metes and Bounds/ Building Permit No, R 39W] ___,Electrical Permit No. E 39814 Plumbing Permit No. `ire PIlevention Permit No. F 39920 Mechanical Permit No. Number of apartments and/or guest rooms ISSUED TO: r - .7. gftmr_ st'om & Sons 3315 Fairview Road r-;iatta Mesa, CA 92626 Building Official George Friston by .7 _ Date Detober 31, 1969 This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. !'CMF 1015-46 rev. 1/83 White - Owner; Canary - Numerical File; Pink - Bldg. Permit File WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the lin mance of the work for which this permit is issued. ve and will maintain workers' compensation insurance, as required by 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: IA4 C, (This section need not be completed if the permit is valued at one hundred dollars (S 100) or less-} umber.W 4-7 — �-,rID d 8- 9 (O() — 0( `t" ❑ I certify that in the performance of the work for which this permit is issued. I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the La ode, I shall efthwith corn with these provisions. ttlure ,�9eress-,,., WARNING: URE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES A$ PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. 7 C0NSTRIIC N LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 70311.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-buitder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature Date 305746 (3107) Owner ID verified by driver's license. ❑ Yes ❑ No Driver's License No, Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Division of Industrial Safety Permit Number: Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or wilt the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the Califomia Health and Safety Code), 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If 'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Dale CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature of Legal Owneris)te Da _ WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. CRhave and will maintain workers' compensation insurance, as required by tion 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy are: {This section need not be a6mptefed d the pennrt is valued atone hundred dollars ($100) or less.) Polis N m er: W d 2 ill 1 61! h aSIP, / ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with these provisions. AP �a� nt'S $� afure e WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing withtion 7000) of Division 3 of the Business and Professions Code, and i tse is in full force and effect. �� (lCic. # / 74-1 y,% Ct I ss # Cori signature fe CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Profession% Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature 3057-46 (3107) Date Owner ID verified by driver s license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Date Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be fled with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If 'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signatur ofL al Owner(sl Date Anafor ori Applicant ate f CITY OF COSTA MESA BUILDING DIVISION s 77 FAIR DRIVE, COSTA MESA, CA 92626 - (714) 754-5273 - Fax (714) 754-4856 - www.ci.costa-mesa.ca.us t �.� FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BX10-00090 PERMIT TYPE B MISC STATUS: ISSUED APN: 41250107 DATE ISSUED: 05/2112010 Zoning: PDC, ISSUED BY: RMD JOB ADDRESS: 3333 2840 BRISTOL ST CM Suite/Unit: 2840 Vicinity: STORE FRONT Primary Occ: Const Type :?? SQ. FT: 13 Valuation: $1,850.00 SCOPE OF WORK: INSTALLATION OF A NEW 13 SF ILLUMINATED STORE FRONT SIGN FOR 'BANANA REPUBLIC', SPACE 2840 WITH 1 SIGN CIRCUIT. COMPLIANCE FORMS ATTACHED TO JOB CARD AND CITY PERMIT. OWNER: SOUTH COAST PLAZA City/State: COSTA MESA, CA Phone: APPLICANT: DUDDEY, BOBBIE City/State: Phone: 951-471-8419 CONTRACTOR: EMPIRE SIGN Address: 22816 COVE VIEW ST City/State: CANYON LAKE, CA Zip Code: 92587 ARCHITECT: Phone ENGINEER: Phone FEE SUMMARY Building Plan Check: Building Permit: Electrical Permit: SMIP Residential SMIP Commercial Bldg Std Admin f=und Address:: 3315 FAIRVIEW RD Unit Zip Code: 92626 Address: Zip Code: License No. 833106 Phone 951-471-8419 $43.03 $66.20 $48.10 $0.00 $0.50 $11.00 License No. License No. Cell: Unit: Unit: TOTAL FEES $158.83 HOURS FOR CONSTRUCTION ACTIVITY: EFFECTIVE 3/1812010 - PER CMMC Sec. 13-279 Monday thru Friday - 7:00 am thru 7:00 pm. Satrudays -9:00 am thru 6:00 pm. Prohibited all hours - Sundays and the following Federal Holidays: New Years Day, Memorial Day, Independence Day, labor Day, Thanksgiving Day and Christmas Day NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE /. INSPECrON TYPE DATE INTITIALS CODE R INSPECTION TYPE GATE INTMALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign b Z4 4 l O 222 Final Site 204 Final Demolition 250 Final BuildinglOccupancy Jtp of Costa 2r,.,�a Development Services, Division of Building and Safety CERTIFICATE OF OCCUPANCY This certificate is issued 'pursuant to the requirements of` t,ftyniform Building Code, Section 308 adopted by the City of Costa Mesa certifies:that at the ride of its issuance the building structure herein below described was inspected and,app���or-'occupancy Building Address Use RETAIL I3,/:BRISTO1rSTREET SPACE- NO. 28: Group MType, of Construction I -FR Fire Zo ;} Owner of Building C .I S13GERSTROM �^------ Jy)Te`nant Address 3315 FAIRPIEWrROAD. COSTA DESA;-CAi92G26" Permit No. B99-00920 Use Zone DKNY, f JEANS RIC> BR{i3rlI1; CTOR CLIPT CBO �PI \1 j- r�. By f / Irl BUILDING OFFICIAL-'";�� U Date 9 28-99 .i REQUIRED TO BE POSTED'IN-A CONSPICOUS PLACE .�i.- CIr Y OF COSTA MLA (2 _,00Development Services, Division of Building and Safety C CERTIFICNATE` CSF; OCCUPANCY This certificate is issued pursuant to the requirements of the Uniform Building Code, Section 308 adopted by.the City of Costa Mesa certifies that at the time of its issuance the building structure herein below described was inspected and approved for occupancy as follows: �Building Address 3 3 3 3` B r i.s to 2 St. S.t'e 2860- •Bldg:. Permit Number B07-00225 Use Cosmetics Use �(727g. fj' r, M ,,.• ;"•3� ` � FR� `�;,r.�. -. i.{ '-W . • . XXX3CX'X� PDC Group Type ofrConstructian Fire Zone Use Zone South Coaa ''laz1 MpDNLTgBROWN COSMETICS Tenant Owner of Building F. 3315 Fairview :Rd:. , Costa Mesa, CA 92626' Address �-- BUILDING OFFICIAL-Khanh'.IQ"' ' yen C.B.O. ., Date,06/13 REQUIRED TO BE POSTED IN A CONSPICOUS PLACE =I i City of Costa Mesa Development Services Department Building Safety Division CERTIFICATE OF OCCUPANCY No. 002755 P. O. Box 1200 Costa Mesa, California The Building located at, 33.33 RriiRtal ShrcwM-, Gt, w 9,851; _ has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group tai Occupancy. Use of Building ,aWAMIr-v f- rEa Legal Description 417—vj(V4-02 (See reverse side for Metes and Bounds) Building Permit No B 336316 E(ectricai Permit No. E 33750 Plumbing Permit No. F 34098 Mechanical Permit No. M 33507 Number of apartments and/or guest rooms ISSUED TO: C.J. Segerstt:om & Sons 3315 Fairview .Road Costa Mesa, CA 92626 Building Official Wiit_i.jam T. Howard by Date TAis Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. CMF 1015-46 rev. 1/83 White - Owner; Canary - Numerical File; Pink - Bldg. Permit File Cr,'( OF COSTA MESA BUILDING DIVISION o. F 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: SB11-00011 PERMIT TYPE B_SIGN STATUS: ISSUED DATE ISSUED: 02/0712011 ISSUED BY: RMD JOB ADDRESS: 3333 28855 BRISTOQST'C�M� Suite/Unit: 2855 Vicinity: So. FT: 0 Valuation: $2,850.00 SCOPE OF WORK: INSTALLATION OF (1) 8 S.F. INTERNALLY ILLUMINATED CHANNEL LETTERS LOCATED AT EXTERIOR OF MALL AND (1) STORE FRONT ILLUMINATED WALL SIGN FOR "PAPYRUS", SPACE 2855.2 SIGN CIRCUITS. OWNER: SOUTH COAST PLAZA PHONE: APPLICANT: DUDDEY, BOBBY PHONE: 951-471-8419 CONTRACTOR: EMPIRE SIGN Address: 22816 COVE VIEW STUnit: CitylState: CANYON LAKE, CA ZipCode: 92587 ARCHITECT: ENGINEER: SIGN PERMIT FEE SUMMARY PLAN CHECK FEE: $54.11 HOURLY PC FEE: $0.00 PERMIT FEE: $83.25 ELECTRICAL FEE: $72.70 SMIP FEE: $0.60 OTHER: $0.00 INSPECTION: $0.00 BLDG STD ADMIN FUND $1.00 TOTAL FEE: $211.66 Address: 3315 FAIRVIEW RO Unit: CitylState/Zip: COSTA MESA, CA Address: 22816 COVE VIEW STREET Unit: City/StatelzZip: CANYON LAKE, CA License No. License No. License No. 833106 PHONE: 951-471-8419 CELL: PHONE: PHONE: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE i IRSPECTION TYPE DATE INTmALS CODE = INSPECTION TYPE 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign X3 -)_q -(I 64 r"- - — 222 Final Site 204 Final Demolition 250 Final Building/Occupancy DATE INTITIAL CITY OF COSTA MESA BUILDING DIVISION r 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 - www.ci.costa-mesa.ca.us �. FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BC11-00036 PERMIT TYPE: B_COMBO STATUS: ISSUED Sub Type: COM—ALT DATE ISSUED: 03102/2011 ISSUED BY: RIVID JOB ADDRESS: ,333�3,2a55,BLRIS- OL ST CM_, Suite/Unit: 2855 APN: 41250107 Zoning:PDC, , Vicinity: PAPYRUS Primary Occ: Const Type: ll -8 SO. FT: 1890" Valuation: $165,000.00 SCOPE OF WORK: 1,890 SF INTERIOR TI FOR "PAPYRUS", SPACE 2855. WORK TO INCLUDE THE REMOVAL OF NON -LOAD BEARING WALLS, CEILING, STORE FRONT WITH THE RECONSTRUCTION OF NON -LOAD BEARING WALLS TO RECONFIGURE REAR OFFICE AREAS, NEW CEILING, STORE FRONT, SALES AREA AND FINISHES. CHANGE OUT OF EXISTING THERMOSTAT, 40 . LIGHT FIXT, 10 OUTLETS, 12 SWITCHES, 1 SVC TO 200. OWNER: SOUTH COAST PLAZA Address: 3315 FAIRVIEW RD Unit: Phone: City/State/Zip: COSTA MESA, CA APPLICANT: CREST, DWAYNE Address: Unit: Phone: 949-735-2230 City/StatelzZip: CONTRACTOR: HARDESTY AND ASSOCIATES INC License No, 634021 Phone: 949-735-2230 Address: 500 E BALBOA BLVDUnIt: Cell: City/State: NEWPORT BEACH, CA ZipCode 92065 ARCHITECT: GREGORY SHOE License No.C24595 PHONE: 210-408-1860 ENGINEER: License No. PHONE: COMBINATION PERMIT FEE SUMMARY Building Plan Check: $220.64 Building Fees: $1,357.75 Electrical Fees: $114.80 Mechanical Fees: $37.20 . Plumbing Fees: $0.00 SMIP Residential: $0.00 SMIP Commercial: $34.65 Bldg Std Admin Fund $7.00 TOTAL FEES: $1,772.04 "Refer to fee receipts for all fees paid for project HOURS FOR CONSTRUCTION ACTIVITY: EFFECTIVE 3/1812010 - PER CMMC Sec. 13-279 Monday thru Friday - 7:00 am thru 7:00 pm. Saturdays -9:00 am thru 6:00 pm. Prohibited all hours -Sundays and the following Federal holidays: New Years Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day and Christmas Day NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION, t INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all equired inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. lPE P. INSPECTION TYPE DATE INTITIALS CODE X INSPECTION TYPE DATE INTMAL f IIt 6 Fixed System Final Fire Prevention 206 Final Mechanical 6 Poo$ Spa Final 208 Fina$ Plumbing Final Re -Roof 210 Final Electrical Final BlockiRetaining Wall 212 Final Fire Prevention Final Factory Fire Place 220 Final Planning Approval Final Sign 222 Final Site Final Demolition 250 Final BuddinglOccupancy 3 w3 F I WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. . ❑ f have and win maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this Permit is issued. My workers' compensation Insurance carrier and policy number are: C r t'4 TLr"Tit t zCdhdG_ (Trus secron need not be rxxnyered d the pe rm is oval Medd of mde hwrdredorars (s rood or ress.) PC.–P . Number: 2(2 S c-& Q _ R-1–certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor I shall torthwit ply with these provis' ns. 2 -s-Signature � C WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code. and my license is in full force and effect. [ # - O ciM e Z jl _ nature CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the p@rformance of the work for which this permit is issued, (Sec. 3097, Civil Code). Londer's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demofish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): Q I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and (he structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for safe. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). Owner ID verified by driver .. acense. ❑ Yes ❑ No Drivdr's License No. Expires: Verification of Ownership by (type of document, i.e. • property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsewark, or demolition or dismantling (hereof, will be more than thirty -sac (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, l will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Division of Industrial Safety Permit Number: Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous materiat? ❑ Yes El No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be tiled with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the Califomia Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department, 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits), 6. Will any part of the facility to be constructed under this permit be within 1000 feet from (he outer boundaries of a school? ❑ Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safely Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If Nes", attach certificate of compliance from the appropriate air pollution conlrol officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and [3 h, as owner of the property, am EXCLUSIVELY CONTRACTING WITH city ordinances regarding Hazardous Materials and Emissions, LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of Signature bate property who builds or improves thereon, and who contracts for such project with CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I a contractor(s) license pursuant to the Contractors License Laws.), certify under penalty of perjury that I have read this application and state that EJ f am exempt under sec. the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of Business and Professions Code for this reason: the City of Costa Mesa to enter upon the above-described property for inspection purposes. I'agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. n re of Legal m ale Signature Date t 3457-45 {31(57) 'titin tl Applrro"' —' l 1 CITY OF COSTA MESA BUILDIMG DIVISION i 77 FAIR DRIVE, COSTA MESA, CA 92626 - (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us h u ` FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BC09-00440 PERMIT TYPE: B_COMBO STATUS:• ISSUED Sub Type: COM—ALT DATE ISSUED: 01/05/2010 ISSUED BY: KJB JOB ADDRESS: 3333 2623 BRISTOL ST CM Suite/Unit: 2623 APN: 41250107 Zoning:PDC, , 1 Vicinity: SPACE 2623 Primary Occ: Const Type: I -A SQ. FT: 5010 Valuation: $800,000.00 SCOPE OF WORK: 5,010 SF INTERIOR TI FOR "PRADA", SPACE 2623. WORK TO INCLUDE THE REMOVAL_ OF A DEMISING WALL IN ORDER TO CONSOLIDATE 2 SPACES INTO 1, RELOCATE RESTROOM, CONSTRUCTION OF A NEW STOREFRONT ENTRY, NEW FITTING ROOMS, OFFICE, RECONFIGURE SALES AREA. ELECTRICAL, MECHANICAL AND PLUMBING WORK. MECHANICAL TO INCLUDE: 3 VAV BOXES, 1 ALT. DUCT SYSTEM, 1 VENT FAN TO SINGLE DUCT. ELECTRICAL TO INCLUDE:1029 LIGHTS, 32 OUTLETS, 3 SWITCHES, 1 SERVICE TO 400 AMP, 3 SUBPANELS, 3 MOTORS TO 1 HP, 1 LOW VOLTAGE EQUIP, 1 COMMUNICATION DROP. PLUMBING TO INCLUDE: 1 COMMERCIAL SINK, 1 TOILET, 1 TRAP PRIMER, 1 WAS H_ -I.fir3 . BASIN, 1 FLOOR DRAIN.. OWNER: SOUTH COAST PLAZA Phone; APPLICANT: PEREIRA, CASE Phone: 562-243-7007 CONTRACTOR: PWI BUILDERS Phone: 480-461-0777 Cell: ARCHITECT: ENGINEER: COMBINATION PERMIT FEE SUMMARY Address: 3315 FAIRVIEW RD City/State/Zip: COSTA MESA, CA n Address: City/StatelzZip: License No. 816987 Address: 155 W MAIN STREETUnit: CitylState: MESA, AZ License No. License No. Building Plan Check: $757.05 Building Fees: $4,658.75 Electrical Fees: $1,003.23 Mechanical Fees: $76.40 Plumbing Fees: $97.15 SMIP Residential: $0.00 SMIP Commercial: $168.00 Bidg Std Admin Fund $32.00 TOTAL FEES: $6,792.58 .•Refer to fee receipts for all fees paid for project Unit: Unit: ZipCode 85201 PHONE: :r4 PHONE: /k -v1 I tzVt`} I ?2 •I:�. 1 '%f'r-s{.hU Ilt; NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related je �gulations. (Ord. No. 92-28, § 1. 12-21-92) ,EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE !. IN PECK TION TYPE DATE INiMALS CODE a IN PECTI N TYP D I�Niyf AADS, Q 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Fina! Electrical 201 • Final Block/Retaining Wall 212 Final Fire Prevention 1 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 264 WS h. 'lr Final Demolition • 250 Final Building/Occupancy S�aq �i}�+ hl%�L) ' e . r CITY 6F COSu MESA BUILDING DIVISION *� 77 FAIR DRIVE, COSTA MESA, CA 92626 (714)754-5273 •Fax (714) 754-4856 www.ci.costa-mesa.ca.us FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER. BC07-00225 PERMIT TYPE: B_COMBO STATUS: ISSUED Sub Type: COM—ALT DATE ISSUED: 11/05/2007 ISSUED BY: BJK JOB ADDRESS: 3333 2623 BRISTOL ST CM Suite/Unlit: ` 2623 APN: 41250107 Zoning:PDC, , Vicinity: BURBERRY Primary Occ: Const Type: I -FR !' SQ. FT:: ' 0 , . Valuation.!, $50,000.00 SCOPE OF WORK: INTERIOR T.I. FOR "BURBERRY", SPACE 2623 TO ADD A FULL HEIGHT NON -LOAD BEARING WALL, CHANGE OUT AND ADD NEW CABINET FINISHES. NO ELECTRICAL, MECHANICAL AND, PLUMBING WORK. OWNER: SOUTH COAST PLAZA Address: Unit: COSTA MESA CA Phone: City/State0p: 3315 FAIRVIEW ROAD APPLICANT: LILLIE, DON Address: Unit: Phone: 617-839-3073 CitylStatelzZip: . CONTRACTOR: SHAWMUT DESIGN AND CONSTRUCTION License No. 747583 Phone: 617-622-7000; Address: . 560 HARRISON AVENUE.Unit: Cell: City/Stale: BOSTON, MA.02118 ZipCode ARCHITECT: BARTELUCE ARCHITECTS AND ASSOCIATES License N6.C26233 PHON E:212-691-7200 ENGINEER: ,' License No. PHONE: COMBINTATION PERMIT FEE SUMMARY Building Plan Check: $104.69 Building Fees: $644.25 Electrical Fees: $0.00 Mechanical Fees: $0.00 Plumbing Fees: $0.00 SMTP Residential: $0.00 , SMIP Commercial: $10.50 TOTAL FEES: $759.44 "Refer to fee receipts for all fees paid for project NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE 1. INSKOONM DATE INIMAL CODEC INSPE it NTYPQA�1 INTMAL 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 206 Final Plumbing '200 Find! Re -Roof 210 Final Eleclrica!P/ 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site l 204 Final Demolition 250 Final Building[Occupancy l i r _ WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers compensation, as provided for by section 3700 of the Labor Code, for the perfo ance of the work for which this permit is issued. 7have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: JpV,r �nnwe rpp /� Carder: _ (This section need riot be completed I the PC~ is van ed at ane hundd/ rr�ed dollars WOO) orless.) Policy Number: ❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if i should becomeq subject to the workerk' compensation provisions of Section 3700 of the Lab\ Code. I shalArthwi A comply with these provisions. icant1k Signature Date WARNINGk F LURE T(a SECURE WORKERS' COMPENSATION COVERAGE IS UNLA Uj AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AMD CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my licen a is in full force and effect, Lic. # 7475 J Class # tt S 0`7 XCNtraclokk Signature Date CONSTRUSZFIpN LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve. demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing wilh Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).►: ❑ 1, as owner of the property, or my employees with wages as their sate compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature Date 305746 (3107) • . O ,ner ID verified by drive. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Date Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? [:]Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Govemment Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. 1f a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of [his application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If 'yes', attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. . nature o! Legal er( A 1.r A h ri - p4cant Date 497 t CITY CIP COSTA MESA BUILDING DIVISION 10 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 www.ci.costa-mesa.ca. �. ` s FOR INSPECTIONS CALL: (714) 754-5626 F07-00358 �rmqft � FIRE SUPRESSION PERMIT .lob Address: 3333 BRISTOL ST Status: ISSUED Suite: 2623 rT ���� Applied: 12/03/2007 Vicinity: SUITE 2623 BURBERRY.' Issued: 1 210 312 00 7 Parcel Nunmber: 41250107 Final Plumbing 200 Final Re -Roof 210 Final E$ectrical 201 Final Block/Retaining Wall Applicant: APODACA,DENNIS - _'° 202 Address: ., ,. 130 HIGHLAND AVE Final Planning Approval 203 Phone: •` 714-680-5174 222 Final Site 204 Final Demolition 250 FULLERTON,.CAr ` Zip: :,92832 Owner: SOUTH -COAST PLAZA Address � t COSTA MESA CA Phone: 3315 FAIRVIEW ROAD Zip: 92626 . Contractor: R.T SHELTON - - Address: 130 HIGHLAND'AVE. , FULLERTON CA ' Zip. 92832.' ' • License: 869383,_ SCOPE'OF PERMIT _ 1 OVERHEAD FIRE SPRINKLER FOR "BURBERRY. REF: BC07-00225: INTERIOR 7.1. FOR'"BURBERRY ;SPACE 2623 TO ADD A FULL HEIGHT NON -LOAD BEARING WALL, CHANGE OUT'AND'ADO NEW CABINET FINISHES. NO ELECTRICAL, MECHANICAL AND PLUMBING WORK: FEE'SUMMARY Plan Check: Permit: Other: Total: $25.19 - $38.75 - $0.00 $63.94 Calc Valuation: $1,000.00:.'; Claimed Valuation: si,000.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. -- INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE f. INSPECTION TYPE DATE INRTIALS CODE / INSPECTION TYPE DATE INTMAL 1616 ' Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final E$ectrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy L_ 5 WORKERS' COMPENSATION DECLARATION: 40 I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. EJ-1—have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier. A 1R+ (This section need not be complretedd Y the permitis valuedal one �hufndred dollars (8100) or less-) Policy Number: LA) Cl- J l ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if i should become subject to the workers' compensation provisions of Section 3700 of e abor Code. I shall forthwith comply with these provisions. J—'_'ZZ�Ap ,cant's Signature Date WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. � vv I _ 96 S3 R, 3 Class # �! Contractor's Signasure Date CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sate (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature 305746 (3107) Owner ID verified by drive El Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feel in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Date Division of Industrial Safely Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? [)Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code), 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If "yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature of Legal Owner(s) DaEe IVf// Ane uthonzee Applicant Date /2 -3-07 Date CITY OF COSTA MESA Development Services, Division of Building and Safety CERTIFICATE -OF _OCCUPANCY This certificate is issued pursuant to the requirements of-thebniform•Buildrng Code, Section 308 adopted by the City of Costa Mesa certifies that at the time.of.its issuance,the.building structure herein below described was inspected and approved foroccupancy as follows: o=: rl Building Address 3333 �Brr'i stoZ Str. #2623-.BIdk.0ermitNumber 3303-00804 Retail Use ---- - - Group M Owner of Building Address 3315 1 Type e of Cons South;Coa's}t Fairview�R"a `o \`; BUILDING OFFICIAL -Rick ucnon g•�u �zE,,. �a,�,r�re'�or PlazaTena `Costa mesa-;- CA vn C.B.O. ,-E& Use Zone j ,:; ,r ' > nt "BURBERRY" 926 � r C/, ; li Ee_tx 1 of of Inspection a �1/ i li REQUIRED TO BE POSTED -INV A CONSPICOUS PLACE I%PrE 37865 Z . aC) I- Z Za o� am J � J (n a W M J M J � L} � Z�W CL W LI Z J 0 M Z J W Ll] O = Z � LLI ::)O F_ Z CL U J CL CL a 0 z 0 V I— ( z ?_2-71.PA10 *YY **6q-73 COSTA MESA BUILDING -SAFETY DEPARTMENT P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626 APPLICATION FOR BUILDING PERMIT For Applicant to Fill in Completely RE�CExi ED BY DATE R CE DiJyTE ISSUED 't _1W C�� J "� ADOFIEBUILDISS 3333 Bristol St a FF �^ �7 PERMIT NO. -'L�SZ» n-7 OWNER A.P. NO. 4 �v BUILDING MAIL ADDFRESS 3315 Fairviewr s 3333 Bristol Street tai % t CITY Costa Mesa NO`."546-0110 TRACT LOT BLOCK CONSTRUCTION W AD PMOVING LENDER BRANCH OWNER ADDFI ESS VALUE ARCHITECT r O ass TEL xrc�iu e a N — /� S $ .00 OR ENGINEER FIRE 7 ADbFIESS 7440 N. Figueroa, L.A. 90041 ZONE Y P EGROUP CONTRACTOR d APPROVE BY / DATE—':) ADDFIEs C,-A4TEZONE_ 5 JNO.OF USE OF PLANS BUILDING EWjN CITY NOL¢ .. ll STATE CITY �} L1 C. NO. �2a LIC. NO.� h YARDS APPROVED YARDS APPROVED MAIN BUILDING ACCESSORY BUILDING SIZE NO. OF BLDGS. OF LOT in existing bldg. I NOW ON LOT (FROM C/LSTREET) RONT FT. USE OF EXISTING BLDG, retail 5ales FL SIDE FT.. ft. NO. OF ODG. 2 1 NEW f900 S • ROOMS STORIES L. SIDE FT. EXTERIOR WALL COVERING None ROOF COVERING Existinq REAR FT. FT. USE OF BUILDING AND WORK TO BE PERFORMED DISTANCE BET. BET. MAIN & MAIN SLOGS. ACCESS. BLDGS. # 7 retail7 sales—installation of store VAR,* DATE C.U.P.+ APPROVED front and merchandising fixtures APPROVED " RY I hereby acknowledge that I have read this application and state that rhe above information is correct and agree to comply with all lows regulating building construction, and I shall not employ .r any person in violation of the workman's compensation laws of the State of California. TAX I hereby certify that I am properly licensed as a contractor under SO. FT. the State of California Business and Professions Code, Divisicn 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR Chapter 9, and that such licenses are in full force and effect, or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY; am exempt from t1 a provisions of tate State of California Business VALUATION and Professions Cnae Division 3, Chapter 9. ` PERMIT FEE $ Signature of � Permittee L.—...__.$ lo " PLAN CHECK $ Authorized Agent TOTAL FEE $ to tD 0 i m Go N m E V` COSTA MESA BUILDING -SAFETY DEPARTMENT P.O. BOX 12DO COSTA MESA, CALIFORNIA 92626 FOR or Applicant to Fill in Com letely i� �j�/ / O[ 2.Z �7_� CITY CONSTRUCTION LENDER BRANCH ADDRESS ARCHITECT OR ENGINEER TEL. NO. TEL. NO, ADDRESS TE ISSUED CONTRACTOR YARDS APPROVED MAIN BUILDING ADDRESS (FROM C/L STREET) FRONT FT. A.P. NO. TEL. CITY NO. STATE CITY LIC. NO. LIC. NO. SIZE NO. OF BLDGS. OF LOT NOW ON LOT USE OF w EXISTING SLOG. SIZE OF NO. OF NEW BLDG, ROOMS STORIE: EXTERIOR WALL ROOF COVERING COVERING USE OF BUILDING AND WORK TO BE PERFORMED I hereby acknowledge that I have read this application and state that the above information is correct and agree to comply with all laws regulating building construction, and I shall not employ any parson In violation of the workman's compensation laws of the State of California. I hereby certify that I am properly licensed as a contractor under the State of California Business and Professions Code, Dlv(slcn 3r Chapter 9, and that such licenses are in full force and effect, or I am exempt from the provisions of the State of California Business and Professions Cnde, Division 3, Chapter 9. Signature of Permittee Authorized Agent PAIL LIAR —5-7t4c;;,. 00 1 1 APPLICATION FOR BUILDING PERMIT RECEIVED BY DATE RECEIV!1LU TE ISSUED USE OF NEW BUILDING YARDS APPROVED MAIN BUILDING YARDS APPROVED ACCESSORY BUILDIN (FROM C/L STREET) FRONT FT. A.P. NO. FT BUILDINGADQRESS FT. REAR FT. FT. DISTANCE BET. MAIN BLDGS. BET. MAIN & ACCESS, BLDGS. TRACT DATE APPROVED LBLOCK w A MOVING W01 -15d OWNERS FIRE ZONE APPROVED DATE ZONE NO. OF PLANS USE OF NEW BUILDING YARDS APPROVED MAIN BUILDING YARDS APPROVED ACCESSORY BUILDIN (FROM C/L STREET) FRONT FT. FT. FT L SIDEFT. FT. REAR FT. FT. DISTANCE BET. MAIN BLDGS. BET. MAIN & ACCESS, BLDGS. VAR,+ C.U.P. + DATE APPROVED APPROVED m SO. FT. o THE AMOUNTSHOWN UNDER VALUATION IS FOR THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: VALUATION z-(% s? PERMIT FEE S � 7 $ a PLAN CHECK $ E TOTAL FEE $ } la�-r --Iv- g 9_ cq�p>,g CITY OF COSTA MESA DEVELOPMENT SERVICES/131-11 LDING SAFETY RECORD PA -KA FOR: / STREET ADDRESS � WORKKDO�NEE� ,per-,, !� B ' 'ng Permit # C}✓ /G/� (ICY;,f Certificate of Occupancy ❑ Electrical Release Form ❑ Gas Release Form Sanitation Fixture Form ❑Pl Ing Permit # Mechanical Permit 0-10ectrical Permit ❑ Reinspection Permit # ❑ Health Department Approval ❑ Roofing Certification ❑ Insulation Certification ❑ Dry Chemical System Certification ❑ Flame Spread Certification ❑ Fire Sprinkler Certification ❑ Soils Certification E-1 Special Inspection Certification kr---Other: ,3 �P All Required Documents Included Clerk O.K. to Approve C.O. Inspector O.K. to Release C.O. Building Official CMF 1045.30 City of Costa Mesa _ Development Services Department Building Safety Division , CERTIFICATE OF OCCUPANCY No2 i P. O. Box 1200 Costa Mesa, California The Building located at 3333 Bristol Street, Space 2623 has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group R2 Occupancy. Use of Building Retail Legal Description 412-501-02 (See reverse side for Metes and Bounds) BE40324' 5 BE 40324 Building Permit No, P '49610 Electrical Permit No. E 39677 Plumbing Permit No, Mechanical Permit No M 39844 Number of apartments Fire Prevention Permit No.,F 39786 ISSUED TO: C.J. Seaerstrom & Sons 3333 Bristol St. Space 2623 C!osta Mssa, CA 92626 and/or guest rooms Building Official - C,?OrQe Edmiston �• / rte, by Date October 26, 1989 Thie Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. CMF 1015-46 rev. 1/83 ' White - Owner; Canary - Numerical File: Pink - Bldg. Permit File PC#1557-94 A CITY OF COSTA MESA DEVELOPMENT SERVICES/BUILDING SAFETY RECORD PACKAGE FOR: 3333 BRISTOL STREET UNIT 2623 PARCEL #412-501-07 B-2 TSTREET ADDRESS RETAIL STORE "BURBERRY'S" STORE EXP. WORK DONE 13 Building Permit # B67515 0 Certificate of Occupancy ❑ Electrical Release Form ❑ Gas Release Form Sanitation Fixture Form L— Plumbing Permit # Mechanical Permit # Mfi7fi49 Electrical Permit # R67699 ❑ Reinspection Permit # ❑ Health Department Approval ❑ Roofing Certification ❑ Insulation Certification ❑ Dry Chemical System Certification ❑ Flame Spread Certification ❑ Fire Sprinkler Certification Soils Certification ❑ Special Inspection Certification U Other: F67749 All Required Documents Included 4411 O.K. to Approve C.O. Cle Inspector O.K. to Release C.O. Building Official GMF 2046-30 City of Costa Mesa ` Development Services Department CERTIFICATE OF OCCUPANCY No. Building Safety Division 10 P. O. Box 1200 Costa Mesa, California The Building located at 3333 BRISTOL STREET UNIT 2623 has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group B-2 Occupancy. Use of Building RETAIL "BURBERRYS" Legal Description 412.501--07 (See reverse side for Metes and Bounds) Building Permit No $67515 Electrical Permit No. E67689 Plumbing Permit No, P Mechanical Permit No. M67642 Number of apartments and/or guest rooms Fire Prevention Permit No. F67749 ISSUED TO: Building Official ONY C'DE BACA C.J. SEGERSTROM 6 SONS 3315 FAIRVIEW ROAD by �. COSTA MESA CA 92626 Date This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. CMF 1015-46 rev. 1/83 White - Owner; Canary - Numerical File; Pink - Bldg. Permit File i 1• 3333 South-Bristol SPACE #2617 _ .•- COURRECES {,YI -BE1729 3/ INT ALT $20,000. - s/ ss PC 605-345 f - E17407 MISC Al�/Af5 2617 B049311 unit 2617 ! t PC# 06065-90 S -- P49376 tT it 2617 M049394µ ���7 -- REF: B49311 E049565 BEE': BP-49311 unit 2617 Unit 2617 F 49666 pC#6200-90 S r t i I CITY OF COSTA MESA DEVELOPMENT SERVICESIBUILDING SAFETY RECORD PACKAGE FOR:i --U3,3 Vis' K ET ADDRESS WORK DONE Eld Building Permit Ek Certificate of Occupancy W QQ/OSS ❑ Electrical Release Form,//L ❑ Cas Release FormAc�/¢ Sanitation Fixture Form.rJ,4 ❑ Plumbing Permit # ❑Mechanical Permit # 2/Electrical Permit#4jL�� ❑ Reinspection Permit # ❑ Health Department Approval ❑ Roofing Certification ❑ Insulation Certification ❑ Dry Chemical System Certification ❑ Flame Spread Certification r Fire Sprinkler Certification L Soils Certification ❑ ' Special Inspection Certification ❑ Other: All Required Documents Included Clerk O.K. to Approve C.O. Inspector O.K. to Release C.O. Building Official CMF 1046-30 City of Costa [Mesa 'Dewelapment Services Department Building Safety Division CERTIFICATE OF OCCUPANCY No. O U b L ,) P. Q, Box 1200 Costa Mesa, California The Building located at 1331nUr��rrriT Or� Qt37tr'�'_ 4•7F7'7 _ _ - • - . has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group z Qccupancy. Use of Building r-+tvnnrr nxr"e- Legal Description 41 rsr+ "T ISee reverse side for Metes and Bounds} Building Permit No. *7+�qg Electrical Permit No. ri ?,--n '+-1 Plurplaing Permit No, Mechanical Permit No. Number of apartments and/or guest rooms ISSUED TO: Building Official � 4. • r -7e, by - 3333 3 33 { ST. , 42612. MgMr}mss C. Rate 2 12s- les -- This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 ie} U.B.C. CMF 1015.46 rev. 1/83 White - Owner; Canary - Numerical File; Pink - aldg. Permit Fife CITY OF COSTA MESA MvELOP.JENT SERVICESBUILDING SAFETY RECORD PACK E FOR: z STREET ADDRESS .� / WORK DONEE 4�4 Building Permit # ` ❑ Certificate of Occupancy ❑ Electrical Release Form ❑ Gas Release Form r-- Sanitation Fixture Form PE mbing Permit i echanical Permit Electrical Permit ❑ Reinspection Permit # ❑ Health Department Approval ❑ Roofing Certification ❑ Insulation Certification ❑ Dry Chemical System Certification ❑ Flame Spread Certification ❑ Fire Sprinkler Certification L Soils Certification ❑ Special Inspection Certification ❑ Other: All Required Documents Included / Clerk O.K. to Approve C.O. Inspector Q.K. to Release C.O. Building Official CMF 1046-30 I •. City of Costa Mesa Development Services Department Building Safety division CERTIFICATE OF OCCUPANCY No. 003567 P. O. Box 1200 Costa Mesa, California The Building located at 3333 Bristol Street-, gnxkr a >A17 _ has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group B2 Occupancy. Use of Building Retail Legal Description 412-k01-02 (See reverse side for Metes and Bounds) Building Permit No B 49311 Electrical Permit No. E 49565 Plumbing Permit No. P 4A37F; Mechanical Permit No. M AQ1Qd Number of apartments and/or guest roams ISSUED TO: C.J. Saaprstrnrn & .¢ nQ 3315k FairviewkRoad Costa Mena. rA Q?A 9 Building Official Tony C' De R r-, by Date January 30, 1991 This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. CMF 1015.46 rev. 1/83 White - Owner; Canary - Numerical File; Pink - Bldg. Permit File 0 JV Development Services, Division of Building and Safety CERTIFICATE OF',OCCUPANCY ✓rte`= `'� ��'d`'--. This certificate is issued pursuant to�thefrequirernents of the Uniform Building Code, Section 308 adopted by the City of Costa Mesa certifies,that.at the nine oflits Issuance the building structure herein �7l/� \ � r— .y /ri `cry bel was inspected and app`r�ovd for- occupanGya�follow� Building Address 3333 BRISTOL STRBBT, SUITE, 2612 Use RETAIL n Group B--2 Type,of/'Constr�ction I FR . ... Fire- n sirwnnww.. '�lL��J�'�.. .`'/.i V♦,1 a41w.� Owner of Building C J Address _ 3315 FARIVIEH aRonn_ BUILDING OFFICIAL -Cony 0"I 0 Permit No. B 72515 Use Zone CI -S WMIA DOW 1 C1k0.kkl 001 �By,l %rrf �s6pt Dat &er 20, 1995 REQUIRED TO BE POSTED IN A CONSPICOUS PLACE .Ar— CITY OF COSTA MESA DEVELOPMENT SERVICES/BUILUI NG SAFETY RECORD PACKAGE FOR: 6camd ra, nowt i n+o L *--AUP iI ")-- STREET ADDRESS rRL+a;,� 4n, prylT WORKDONE ! Building Permit # r Certificate of Occupancy ❑ Electrical Release Form F--1 Gas Release Form Sanitation Fixture Form ❑ Plumbing Permit # Mechanical Permit #r 1J�i�✓,L�ti�L� Electrical Permit =* ✓L �� ❑ Reinspection Permit # ❑ Health Department Approval ❑ Roofing Certification ❑ Insulation Certification ❑ Dry Chemical System Certification ❑ Flame Spread Certification ! Fire Sprinkler Certification ❑ Soils Certification ❑ Special Inspection Certification ❑ Other: All Required Documents Included CtA O.K. to Approve C.O. Inspector O.K. to Release C.Q. Building official CMF 1046-30 Cl'-' I OF COSTA MF'A Development Services, Division of Building and Safehl koll�: woo CFRTIFICATB'OF OCCUPANCY This certificate is issued pursuant to the requirements of the Uniform Building Code, Section 308 adopted by the City of Costa Mesa certifies that at the time of its issuance the building structure herein below described was inspected and approved for occupancy as follows: ;v 3333 Bristol '.St. -_.Ste 1200 B07--00378 Building Address _ .:Bldg. Permit Number Use Display/Sale Merchandise [2_,400 Group M Type of Construction 1'FR Fire Zone XXXXX Use Zone PDC OwnerofBuilding South Coast Plaza Tenant MARNI Address 3315 Fairview Rd., Costa Mesa, CA BUILDING OFFICIAL-Khanh Q. Nguyen, C.B.O. Date' 11/21/07 REQUIRED TO BE POSTED IN A CONSPICUOUS PLACE 4brITY OE COSTA MESA 4 BUILDING DIVISION r77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 - Fax (714) 754-4856 www.ci.costa-mesa.ca.us FOR INSPECTIONS CALL: (714) 754-5626, PERMIT NUMBER: BX07-00035 PERMIT TYPE B TMISC STATUS: ISSUED DATE ISSUED: 07/2312007 -:k:: "ISSUED BY: SOK JOB ADDRESS: 3333 1200 BRISTOL -ST CM ....1 t4 i SuitelUnit � �.,1200 Vicinity: SPACE 1200 PriinaryOcc' Const Type:?? SQ. FT: 0' Valuation 1 $800.00 SCOPE OF WORK: INSTALL<;1 STORE F..RONT ILLUMINATED, CHANNEL LETTER'10'S,F SIGN FOR "MARNI" IN SPACE 1200. ELECTRICAL INCLUDED. OWNER: SOUTH COAST! Pt -AZA; ;�, p."� ; . ;"'Address: I i Unit:COSTA MESA VIEW C t� PHONE, r 1{ " - CitylState/zip. 3315 FAIR$y APPLICANT: JENNIFER KERNS Address:=1696:COMMERC ^ OCA PHONE: 909-734-6275 '� CitylStatelzZip: CORONA, CA YYYYYY^ ,� / q. its CONTRACTOR: SOUTHWEST SIGN CO + .. :"=: ; _..._ ' " -: License No, 7249z9 Address:1696'COMMERCE STUnit:- - ' PHONE: 909-734-6275 CitylState: CORONA_, CA ZipCode: 92880 - CELL: i ARCHITECT; License No. PHONE: ENGINEER: �,-; License No. _ f;' PHONE: MISCELLANEOUS PERMIT FEE SUMMARY; Building Plan Check: Building Permit: t' _ ", $32:65r Electrical Permit:$23.50k` `+ Other Fee: - 5 ✓�- $0 .t30: 7 , SMIP Residential r 's', i"$0:00 - - SMIP Commercial TOTAL FEES ' y-$77.37' NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE S. INSPECTION TYPE 1616 Fixed System Final Fire Prevention 1266 Pool Spa Final 200 Final Re -Roof 201 Final Block/Retaining Wall 202 Final Factory Fire Place 203 Final Sign 204 Final Demolition DATE INTMALS CODE; INSPECTION TYPE 206 Final Mechanical 208 Final Plumbing 210 Final Electrical 212 Final Fire Prevention 220 Final Planning Approval 222 Final Site 250 Final Building/Occupancy DATE tNTMALS CITY OF COSTA MESA BUILDING DIVISION ut"LO) 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 www;ci.costa-mesa.ca.us FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: E07-00697 PERMIT TYPE ELEC STATUS: ISSUED DATE ISSUED: 07/26/2007 -> - ISSUED BY: t' '; I_ . ; SuitelUnit"== .'.1200 JOB ADDRESS: 3333 1200 BRISTOL -ST. -.CM, Vicinity: MARNI, SPACE 1200. - rr h.' �� � �' V 1rmow' f �ni.•• .- _ r? x 3 � 54b. SCOPE OF WORK: SUPPLEMENTAL ELECTRICAL`PERMIT FOR 3 LIGHT FIXTS AND 4 -MOTOR TO'1'HPYFOR WARN I", SPACE 1200, REF#: E07-00488 AND Bd7-40378.`, OWNER:' SOUTH COAST PLAZA r= Address: Unit:COSTA MESA CA PHONE: # r. City/State/Zip:.-. 3315 FAIRVIEW ROAD APPLICANT: BLUM, JOHN r Address: 17 HANiMAND Unit:STE 412 PHONE: 949-454-1877 City/StatelzZip: IRVINE, CA .k. CONTRACTOR: SUNSET ELECTRIC INC' ' -�^? " ` T License• No. 672552 Address: 17 HAMMAND Unit:;STE 412 PHONE: 949-454-1877 City/State: IRVINE. CA ZipCode: 92618 CELL: ELECTRICAL PERMIT FEESl� Electrical Plan Check Fee::' �;, ,$0.00 Electrical Permit Fee: s . $31.55 Reinspection Fee TOTAL FEES `s $31.55-., - 0 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: - In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required Inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE I INSPECTION TYPE DATE INTITIALS CODE A INSPECTION TYPEe¢ iRMALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 200 Final Re -Roof 201 Final Block/Retaining Wall 202 Final Factory Fire Place 203 Final Sign 204 Final Demolition 208 Final Plumbing 210 Final Electrical 212 Final Fire Prevention 220 Final Planning Approval 222 Final Site 250 Final Building?Occupancy WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: y STAt " (This sedioa need ro be ogrrrpl�ted�/the perDl� is valued at one hundred da6ars (S t 00)or less ) d'oficy�r. lrJ I /«'/AI Ifs [/vy1 ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor CodeI hallo with comply with these provisions. X44-6 -7 A plica,0t'sSignature� ' IUala1 WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL- SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that i am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic' l�7 ss �—Glasses#��• ( 10 Ltractar's Signature CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031_5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder wilt have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property,. am EXCLUSIVELY. CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature 3057-46 (3107) Owner Ill verified by drive :rise. ❑ Yes ❑ No Driver's License No. Expires: -Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, fatsework, or demolition or dismantling thereof, will be more than thirty -sic (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Date Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or wilt the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes Cl No (if "yes", the facility must meet the requirement of Sections 25534 and 42303 of the Califomia Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No. 8. (If 'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjurythe information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signalil o or Lef O er(s) Date CAndrerftwrizedApplicantr Date CITY .OF CQSTA MESA c �j _.OoP Development Services, Division of Building and Safety CERTIFICATE- OF -OCCUPANCY This certificate is issued pursuant to the requirements of. the'Unif_om'Bu7ilBv�g Code, Section 308 adopted by the City of Costa Mesa certifies that at the time of. its of its structure Here below described was inspected and approved for occupancy asfollows;,(< Building Address 3 3 3 3 Wi`i`s t-o]r S t . s n. 2 lk .; r, , . – Use Retail GroupB'2 Type of Cos uctioEf-r-tr,rn,e -rsrv,Fire Zone Owner of Building C S e. rr ]g. r s t r o r.nc i' �' '� ,Tenani Address 3315 Fairvieii Rc3� �Cost�a Mesa, C�A92f 2b 's B - BUILDING OFFICIAL -Rick A', Browft C.B.Oae . Number Boa -3 -809 -- Use Zone 80p UseZone CTumx 'Chief of: Inspections /ng/o4 REQUIRED TO BE POSTED -IN -A CONSPICOUS PLACE i, CITY OF COSTA MESA Development Services, Division of Building and Safety CERTIFICATE` OF O=CCUPANCY This certificate is issued pursuant to the requirements"of the Uniform Building Code, Section 308 adopted by the City of Costa Mesa certifies that at the time of its issuance the building structure hereinbelow described was inspected and approved for occupancy as follows: Building Address 3 3 3 3; B r i s.t o f S,t . Ste '2 6 3 Bldg. Permit Number B C 0 7- 0 0 2 8 2 Food Retail {1.007- "s.f.)'" Use01a> Group M Type of Construction 17 FR Fire•Zone XXXXXXXX Used one PDC Owner of Building South Coast Plaza Tenant GODIVA Address 3315 Fairview Roa.d.;Casta Me'sa'.CA 92Fi25� By BUILDING OFFICIAL-Khanh Q. NgUyeiv ."B.O Date 0 5 3 REQUIRED TO BE POSTED IN A CONSPICUOUS PLACE WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the perfqprrance of the work for which this permit is issued. ( I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: /� f �Lari,�r 1rtGri•�pv /,h rhe 4; Carrier: � h`D'yt. L. C ,�r.s:L� s (This secLo�be completed irthe permit iyNalued at one hundred dollars ($100) or fess.) Po'li'cy NNuumbbe`r: jj� 0 ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subje to the workers' compensation provisions of Section 3700 of the Labor C , I shat fo th comply with these provisions - Ael I App cant's Si ure L_Date �-- l WARNING: FAILURE T SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'$ FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. ,C1 —C actor's Signature — Date I. _ CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or, she did not build or improve for purpose of sale.). ❑ I, as owner, of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Seca 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Cade for this reason: Signature 3057-46 (3107) Date Owner ID verified by driver's I,. e. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Date Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION - 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? © Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be fumished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (if `yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. S' toe of Lega er(s} Date 'Andlor Authorized piicant _ Date CITY OF COSTA MESA BUILDIMG DIVISION 0 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 www.ci.costa-mesa.ca.us FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BX08-00024 PERMIT TYPE B_MISC STATUS: ISSUED APN: 41250107 DATE ISSUED: 01/22/2008 Zoning: PDC, ISSUED BY: JOB ADDRESS: 3333 2634 BRISTOL ST CM Suite/Unit: 2634 Vicinity: Primary Occ: Const Type :?? SQ. FT: 0 Valuation: $1,850.00 SCOPE OF WORK: 30SF INSIDE THE MALL WAL SIGN FOR "GODIVA/CHOCOLATIER". NO ELECTRICAL WORK W/THIS PERMIT OWNER: SOUTH COAST PLAZA Address:: MESA CA City/State: 3315 FAIRVIEW.ROAD Zip Code: 92626 Phone: APPLICANT: BOBBIE DUDDEY - Address City/State: Zip Code:.. Phone: 951-471-8419. . CONTRACTOR: COMMERCIAL- SIGN AND LIGHTING INC. License No. • 263327 Address: 7422 VARNA ST City/State: NORTH HOLLYWOOD, CA Zip Code: 91605 . Phone' 818-764-6791 Cell: ARCHITECT: - Ucense,No. Phone ENGINEER: _ License No. Phone Building Plan Check:' Building Permit: Electrical Permit: ; SMIP Residential SMIP Commercial $O.00TOTAL FEES FEE SUMMARY, $43.03 T, - $66.20 $6.00 $0.00 $0.00 $109.23 r /' 11. Unit COSTA Unit: Unit: NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE. O, INSPECTION TYPE DA7 INTMAL CODE i INSPECTION TYPE DATE INTMALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing r 200 Final Re-Roof'nal I ctricaf 201 Final Block/Retaining Wall re Pr 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final BuildinglOccupancy 0 WDIiKERS' COMPENSATIgN DECLARATION60 I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the pert mance of the work for which this permit is issued. have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which [his permit is issued. My workers' compensation Insurance carrier and policy number are: n p Carrier: (RW seaW need rpt be MmPiereddthe p&W d shred at We hundred dbr/ars ($1001 or Aess) Policy Number: L 3 LA -0 <? 9 ❑ 1 certify that in the performance of the work for which this permit is issued. I shall not employ any person in any manner so as to become subject Owner ID verified by drivel slice-_ ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding. falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title B, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which vmuid require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of t e Labor Code, i shall forthwilh comply with these provisions. Applicant's signature nate O —'Division of Industrial Safety Permit Number: Applicant's Signat r Date V WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,1100), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTOR$ DECLARATION: hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lit:. # 3 3�7 / Glass # C__`l, } CONSTRUCTION LENDING AGENCY: ❑ I hereby arm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption, Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than rive hundred dollars ($500).); ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature 3057.46 (3107) Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file astration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by peach business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of $00 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No {Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If yes the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If yes', attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I cerlify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state taws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature of Legal Owner(S) 47�Date Andlor Authonzetl Apolicant Da 0 CITY OF COSTA MESA BUILDING DIVISION r 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 • www.ci.cwsta-mesa.ca.us r FOR INSPECTIONS CALL: (714) 754-5626 F07 -003G7 FIRE SUPRESSION PERMIT Job Address: 3333 BRISTOL ST Status: ISSUED Suite: 2634 Applied: 12/13/2007 Vicinity: Issued: 01/04/2008 Parcel Nunmber: 41250107 Zoning: PDC PDC `. Applicant: SHrILA-LOONEY' Address: 5200 E HUNTER AV SUITE B" - Phone: 714-993-2822 r ANAHEIM, CA, Zip: 92807, Owner: SOUTH COAST PLAZA Z"ii -(jN6 Address COSTA MESA CA Phone: 3315 FAIRVIEW ROAD, Zip: 92626 Contractor: ALrRT FIRE PROTECTION INC - - Address: 5200 E HUNTER AV SUITE B - -- = Phone: 7.14-993-2822 ' ANAHEIM, CA'11! Zip: 92807, I=S• ' License: 316324- ! 1 ,'13r2GU7 , =SCOPE OF PERMIT ADD 1 OVERHEAD SPRINKLER, PLUG3 EXISTING HEADS AND RELOCATE 10 FOR "GODIVA" IN SPACE 2634. ; BC07-003f3 FEE SUMMARY' Plan Check; $54,11 ",: Calc Valuation: $2,100.00 Permit: $$3.25 Claimed Valuation: $2,100.00 Other: $0.00 '- - - Total: $137.36 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under. California statutes;and related reguiations. (Ord. No. 92-28, § 1, 12-21-92) 11 i „41 -. 11.18 EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. - - — — INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE t. INSPECTION TYPE DATE INTMALS CODE R INSPECTION TYPE DATE INTITIA 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 0f 0 201 Final Block/Retaining Wali 212 Final Fire Prevention i O� Gt13•G,��J$ 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the _pg,rformance of the work for which this permit is issued. have and will maintain workers' compensation insurance, as required by ection 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: I { / r �Carrie� Gf/ L . L7vI' s. (This sedron need nor be comple d e pemtd ' at an hundred dollars (5100) or less.) Policy�yumber: ❑ I certify that in the pe orman9 th'L who or which this permit is issued. I shall not employ any person to any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subje to the workers' compensation provisions of Section 3700 of the Labor Cod , I half fo with co ply with these provisions. rApplicant's Signature �e WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUEUECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Licr.#�s # r� e&' 0, U C5ntra5ors'Signatvre D tem CONSTRUCTION LENDING AGENCY: ❑ 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lenders Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penally of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to Construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption, Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner-buildef will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature 3057-46 (3107) Date Owner ID verified by driver's tic._ �, ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirly-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Date Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4, If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 85850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? []Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (if "yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state lacus and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. y Signature 1 l o. -r ) / Da:e . j „ {i Arl�dl�Or^ALthorizedippbcant [)ate C 74F COSTA V'SA c Development Services, Division of Building and Safety CERTIFICATED OCCUPANCY This certificate is issued pursuant to the regiiirements of.tlie Uiiiform'8uildingGode, Section 308 adopted by the City .. `-<_-_�-_ _�..�.�.t sur �:�ti� of Costa Mesa certifies that at the time of its issuance the building structure herern below described was inspected and approved for occupancy as follows:%Y� Building Address 3333 BRISTOL STREET, SPACE 12630 AldgrPermit Number BOD -00872 Use RETAIL — 9,006 Mu' T'.I .-:'FOR;WI-LLIAMS SONOMA ��! � �"fdi%l iii11 i r"^"".` Group M • Ty e of�CIstructio—Wq;,,F,4 ;Fire Zone + = Use Zone SOUTH`-OAST'PLAZA'CIO—CJ—SEGERSTROM=—' 1. ' . Teriant Owner of Building, u ---�'=`— ' "WfwliMS� — SON". �- 3315 FAIRVIEW TiOAD% COSTA'MESA 92626 f f Address Af x,:-. 'n BUILDING OFFICIAL -Rick A' Browh;X B.O. J. ~�= r; Date10%2712000 REQUIRED TO BE POS CONSPICOUS PLACE I.. v.j4y...-;...,.,:i..+�•\ori%'e..?-`u'?.�''�S,Jay"+rv�w.+-w�+*�era+l"v�++•a�W.n�,.•- -T �.�..�,q,"��✓"*—y#�y+!"�-�^--rFwr�w•yw+�-va--�.+:a r�' -^ r ��. Cite of Costa Mesa � l Development Services, Division of Building and Safety CERTIFICATE OF OCCUPANCY This certificate is issued pursuant to the�requiremerits of,�the Uniform Building Code, Section 308 11 i r •�\ adopted by the City of Costa Mesa certd'ies:that at the tune of-its.issuance the building structure herein below described was inspected and a�p/p%wedefor-'occuparicy�as�f ws: Building Address 3333 Bk� �; b.: i( Lfir'iS_l DiT 2 , 80'Bldg. Permit No. -R 79922 V\ erAi'Use rlZC'7 Group - M Type of-Constructi°n I FR" Fire,Zone,� =r- Use Zone Cls Owner of Building C_ �' 'Seg�'retrom & Se s ��Tenant " Address" "° ' By' IL�G BUDING OFFICIAL - tong t}.�e taca �y,' z`: bDateNopember 21, 1996 REQUIRED TO BE POSTED -IN A CONSPICOUS PLACE i, `..+.r.. �,. y.'h�a'[�yi:.+,+rti?y,�tty.lie''if7rY�f�4�'i�''�'i^'�Ti.�+*Y•�.���...*`.=.�...%i.'v�C1:v�Vi'+'�ilMY=t'#iJi--'^tiw',�,ls.ti�4 :YJfl.ivl�,, .,,�:i��V•�-+�.� ..w'i CITY OF -COSTA MESA Development Services, Division of Building and Safety klwa� ago CERTIFICATE OF OCCUPANCY This certificate is issued pursuant to thie requirements of-the Uniform Building Code, Section 308 adopted by the City of Costa Mesa certifies that at the time of its'issuance the building structure herein below described was inspected and approved for occupancy as follows: Building Address 3333 J2800''Bri-stol. st. B Idg. Permit Number B05-00968 Use Commercial M7,Z:I=N:`''.: �� Use Zone Com Group Type of Construction OwnerofBuiiding.South Coast Plaza/CFO--- Tenant Senhara— Address 3315 Fairview'-Rd: Costa Mesa Y CA 9 2 C Loci)k" BUILDING OFFICIAL-Khanh Q. Nguyen, C.B.Q.Pe.te T race, Combination Inspector Date 12/29/05 REQUIRED TO BE POSTED IN A CONSPICOUS PLACE i Of Costa 2A) v5a Development Services, Division of Building and Safety CERTIFICATE OF OCCUPANCY This certificate is issued pursuant to�theFrequiremerits of che,Uniform Building Code, Section 308 adopted by the City of Costa Mesa certifies �that.'at-the time of its:issuance'the building structure herein below described was inspected /0� annd<approved for•occupancy-as,zf;fo aws: a�� 4A� B-85829 Building Address 3333 srdst�l Street 2�7• � Bldg. r�rmtt N�. Use _interior offices nn! /Tian r1W. )fid Group M/B TypeW,Consi Owner of Building Address 3315 Fairview.'%Avenue Building Official - ion 1 -SP Fire,Zone�\d,` Use Zone PDC enant A and sta Meaa � CA �92626 Y. 4hip, C.B.O. Date .�F but r3' 13,, 1998 �,•moi ��t:':,- ., ifs REQUIRED TO BE CONSPICOUS PLACE p . ♦ 2-: -. ® CITY OF COSTA MF"A Development Services, Division of Building and Safety CERTIFICATE,-OF 01CCUPANCY This certificate is issued pursuant to the requirements of time Uniform Building Code, Section 308 adopted by the City of Costa Mesa certifies that at the time of its issuance the building structure herein below described was inspected and approved for occupancy as follows: 3333''­Br,istol St. Ste: -.2670 BC07--00519 Building Address Bldg. Permit Number - Retail Use Group M Type of Construction IFR Fire Zone - Use Zone PDC Owner of Building South' Coast Plaza Tenant Bottega Veneta Address 3333 Bristol St ,,..Ste. 2670 BUILDING OFFICIAL-KhanhQNguyen, C.B.O.en, S ^.J .y— Date y Date , 5%21/08 REQUIRED TO BE POSTED IN A CONSPICUOUS PLACE CITY OF COSTA MESA 9MIMP-11 BUILDING DIVISIONF08-00045 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us FOR INSPECTIONS CALL: (714) 754-5626 FIRE SUPRESSION PERMIT Job Address: 3333 BRISTOL ST "_ Status: ISSUED Suite: 2670 Applied: 02/19/2008 Vicinity: SPACE 2670, BOTTEGA VENETA °, Issued: 02/29/2008 Parcel Nunmber: 41250107 Zoning: PDC PDC Applicant: COMMFAN, JASON.' Address:' Phone: 714-870-1010 Zip: 92626 Owner: SOUTH COAST PLAZA Address %C J SEGERSTROM & SONS _,COSTA MESA, CA Phone: 3315 FAIRVIEW. RD Zip: 92626 Contractor: '` COFFMAN, JASON -` - Address: A 701 W SEQUOIA AVENUE ' Phone: _744-670-1010. ORANGE, CA ., Zip: 92686 ~`802591 I " -.- License:' - SCOPE OF PERMIT REPLACE 25 SPRINKLER HEADS FOR "BOTTEGA VENETA" STORE TI, RE:BC07-00519- FEE SUMMARY Plan Check: $72.31. Calc Valuation: $4,890.00 Permit: $111.25 _ Claimed Valuation: $4.890.00 Other: $0.00 Total: $183.56 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE /. INSPECTION TYPE DATE INTITIALS CODE 0 INSPECTION TYPE DATE 1"TIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final EleFire Prov cal 201 Final Block/Retaining Wall 212 Final Fire Prevention ` 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performs ce of the work for which this permit is issued. have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number -are Carrier: t/A6W • e& (This section need not be completect dthe is vahmd at one hundred da0ars (S100) or less.) Policy Number:- T�/� / /G— ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of Califomia, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forth mply with these provisions. a'2 •z9•d8 (Ap ignature —Date A • AILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lic. # Crass # » Z5:, or's Signature Date CONS TION LENDING AGENCY: ❑ hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lenders Name: Lender's Address: Signature OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to lite a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than Five hundred dollars ($500),): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ 1 am exempt under sec. Business and Professions Code for this reason: Signature 305746 (3107) Date Owner ID verified by driver's lice. ❑ Yes ❑ No Driver's License N0. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into Mich a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Date Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and Ming with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'fres", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safely Code Section 42303 been made? ❑ Yes ❑ No 8. (If 'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Dale CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Owner(s) Date M Ap CITY OF COSTA MESA BUILDING DIVISION i 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 - Fax (714) 754-4856 - www.ci.costa-mesa.ca.us 1- s ` FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BC07-00519 PERMIT TYPE: B_COMBO STATUS: ISSUED Sub Type: COM—ALT DATE ISSUED: 01/25/2008 u ISSUED BY: RMD JOB ADDRESS: 3333 2670 BRISTOL ST. CM. ! Suitd/Unit: 2670 APN: 41250107 Zoning:PDC, , Vicinity: BOTTEGA VENETS Primary.Occ: Const Type: IFR SQ. FT:, 1491 Valuation: $350,000.00 SCOPE OF WORK: 1419 SF INTERIOR Tl FOR "BOTTEGA VENETS", SUITE 2670 WITH 112 LIGHT FIXTS, 55 OUTLETS, 1 CONTROL PANEL AND 2 REPAIR/ALTER COOLING/HEAT. OWNER: SOUTH COAST PLAZA Address: Unit: COSTA MESA CA Phone: City/State/Zip: 3315 FAIRVIEW ROAD APPLICANT: UELLER, BERNHARD Address: Unit: Phone: 323-580-1200 CitylStalelzZip: CONTRACTOR: A A CONCEPTS INC License No. 892966 Phone: 323-850-1686 Address: 7215 HILLSIDE AVENUEUnit: UNIT 1 Cell: I CitylState: LOS -ANGELES, CA - zipCode 90006 ARCHITECT: DAVID MONTALBA License No.28726 PHONE; ENGINEER: License No. - PHONE: �asllt,l 71kq 111111 111rMl1■»_I A 1111&!I!1�_4i1TIT,1jZI NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE N. INSPECT1oN TYPE DATE INTMAL CODE R INSPECTIGN TYPE DATE INTMAL' 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing /I 200 Final Re -Roof 210 Final Electrical 201 Final BlocWRetaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition ZU1/2k 250 Final Building/Occupancy Building Plan Check: $388.99 Building Fees: -;,: $2,393.75 Electrical Fees: $178.41 , Mechanical Fees: $50.90 Plumbing Fees: $0.00 SMIP Residential: $0.00 SMTP Commercial: $73.50 TOTAL FEES: $3,085:55 "Refer to fee receipts for all fees paid for project NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE N. INSPECT1oN TYPE DATE INTMAL CODE R INSPECTIGN TYPE DATE INTMAL' 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing /I 200 Final Re -Roof 210 Final Electrical 201 Final BlocWRetaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition ZU1/2k 250 Final Building/Occupancy ,r WORKERS' COMPENSATION DECLARATION: ` I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which (his permit is issued. ❑ I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: Carrier: (This section need not be completed if the permit is valued at one hundred dollars ($100) or fess.) Policy Number: certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall with c mply with these provisions. � zs 4� r, -Applicant's Signature �Oata WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. iontractor'sSignature Date- CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lenders Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ 1, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature 3057-46 43107) Date Owner ID verified by driver's f1i"s❑'Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property lax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Date Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: t. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? 0 Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be furnished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? []Yes ❑ No 8. (If "yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state Yaws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: i certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signator egalOwner ) ale And/or Authorized Applicant_- �ITate--- _ _ . i t -•r _ is .f,t^.'/:r=,,.;%e--:e*:7'"W ,,,_ ,. ?�. irW�i�-� =. 't=rr .'r Y..-. "_... !i_f --. , 4. ��= CIr Y OF COSTA ME A � Development Service Division of Building and Safety CERTIFICATE OF OCCUPANCY This certificate is issued pursuant to the requirements of the Uniform Building Code, Section 308 adopted by the City of Costa Mesa certifies thatat the time of its issuance the building structure_ herein below described was inspected and approved foroccupancyasfollows: , Building Address 3333,, Bristol -St. 2662- Bldg. Permit Number 806-01097 Use Display/Sale/kerchanfli'se 2 s Group M Type of'Construction' '; £R'' ':FKrLYX Ye. Use Zone MP OwnerofBuilding Soutli Plaza Tenant CARTIER Address 3315 Fairview Rd.. Costa Mesa, CA 92626 By., BUILDING OFFICIAL-Khanh Q., Nguyen,C.B.O. Date 09/07/06 REQUIRED TO BE POSTED IN A CONSPICOUS PLACE WMW -17- titp of to,5ta 2'Oe5a Development Services, Division of Building and Safety CERTIFICATE OF OCCUPANCY This certificate is issued pursuant tthe-requirements sof-thee Uniform Building Cade, Section 308 adoptebi by the City of Costa Mesa certifies�that. at -the tithe of its.issuance the building structure herein it i ; � . ..y�rt :--_. r... �C r`� � ��ti� below described was inspected and{approved=for occupanty�as•fW6 s: 3333 »SSTaL.S?REET UNIT 2660 ��� Building Address � _ � Bldg. Permit No. B 73518 //,1�� Use RETAIL Group_ B-2 Type' of,Construction I -FR Fife,Zu a? Tr Owner of Building C. 7. segerst rv�� Tenant Address 3315 Fairview, Roa3; Costa Meaa,- CA X92626, BUILDING OFFICIAL-tOnIp Date>> , � Vz REQUIRED TO BE POSTED INA CONSPICOUS PLACE Use Zone _C1 -S CITY OF COSTA MESA. BUILDING DIVISIOIN. ` 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 www.ci.costa-mesa.cam"B-009 0 y FOR INSPECTIONS CALL: (714) 754-5626 FIRE SUPRESSION PERMIT Job Address: 3333 BRISTOL ST Status: ISSUED Suite: 2664'%'' �.aW; Applied: 05/27/2008 a �, �, Vicinity: .- Issued: 06/10/2008 Parcel Nunmber: 41250101P -DC � .� 9 Applicant: ALERT.^FIRE PROTECTION INCA Address:' 5200 E HUNTER AV SUITE -B' f:= Phone: ':,.714-993-2822 c ti ANAHEIM CA' �� _ Zip '92807 � 51 Owner: SOUTH COAST PLAZA Address - 3315 FAIRVIEW-` RD Phone: COSTA 'MESA, CA -Zip .92626." Contractor: AL'ERT,.FIRErPROTECTION INC _ Address: 5200 E'HUNTER AV'i SUITE B Phone: ` 714-99372822 ANAHEfM, CA ° ; s Zip: 92807-. - d License.` 316324, SCOPE:'OF.PERMIT, {` TENANT' IMPROVEMENT,FOR,"HARRY WINSTON"�SPACE,2660 BC08-00165 ADD,1 NEW SP HAED AND PLUG 1. RELOCATE -18 SP;HEADS '' r - z- ' _FEE SUMMARY Plan Check: $63.21 < Calc Valuation: $4,000.00 Permit: $97.25�_�.`� •.�r '`'�,�u�,r=... Claimed Valuation: $4,000.00 Other: $0.00 �l�'t =, i Total: $160.46 fiF w NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE i. INSK"ON TYPt 1616 Fixed System Final Fire Prevention 1266 Pool Spa Final 200 Final Re -Root 201 Final Block/Retaining Wall 202 Final Factory Fire Place 203 Final Sign 204 Final Demolition DATE tNTMAL CODE r INSKOONTYPE 206 Final Mechanical DATE INTMALS 208 Final Plumbing 210 Final Electrical ``rr 212 Final Fire Prevention 220 Final Planning Approval 222 Final Site 250 Final BuildinglOccupancy WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ` ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ 1 have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: airier: f5_ _ (This sedim need nor be completed if the permit is valued at one undyed "ars (S 1 oa) or fess.) Pol cr y Number: �O�O C� 0 ,e,?_5 � ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation taws of California, and agree that it t should become subject to the workers' compensation provisions of Section 3700 of the LaborC sha rthwlth omply with these provisions. Applicant's Signature Date — WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full forceLandffe t. Lir;.# - �3 6'Class-# — G - antractor's Signature- - Date _ CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden_ of -proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH. LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not -apply -to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.), ❑ I am exempt under sec. Business and Professions Code for this reason: Signature Date 3057.46 (3/07) Owner ID verified by drivc rise. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Date Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safely Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Goverment Code requires that the requested information be fumished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If 'yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No, 8. (If "yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of,perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signat oyLegal i(s) /� pate Analis Authorized Applimnl �� Date CITY OF COSTA MESA BUILDING DIVISION >� 77 FAIR DRIVE, COSTA MESA, CA 92626 - (714) 754-5273 - Fax (714) 754-4856 - www.costamesaca.aov � FOR INSPECTIONS CALL: (714) 754-5626 n PERMIT NUMBER: BC12-00248 PERMIT TYPE: B_COMBO STATUS: ISSUED Sub Type: COM—ALT DATE ISSUED: 05/24/2012 ISSUED BY: RMD JOB ADDRESS: 3333 2648 BRISTOL ST CM - Suite/Unit: 2648 APN: 41250107 Zoning:PDC, , Vicinity: SPACE 2648 Const Type:l-A Primary Occ: SQ. FT: 725 Valuation; . $95,000.00 SCOPE OF WORK:PHASE II - 725 SF INTERIOR TI FOR "ERMENEGILDO ZEGNA", SPACE 2648. WORK TO INCLUDE THE REN OVATIONIRECONFIGURATION OF AN EXISTING RETAIL SPACE; ALTER AN EXISTING INTERIOR EXIT CORRIDOR WITH THE REPLACEMENT/RECONFIGURE OF AN EXISTING RATED WALL AND REPLACE EXIT DOOR; ALTER SALES AREA; FITTING ROOM; TAYLOR AREA; STORAGE AREA WITH NEW GYMPSM BOARD; LIGHTING; STORE FRONT; MILLWORK AND FURNITURE WITH ALTER DUCTING FOR COOLING IN 1 ZONE, 1 SMOKE DAMPER, 1 FIRE DAMPER, 1 AIR HANDERL, 23 LIGHT FIXTS, 7 OUTLETS, 8 SWITCHS. OWNER: SOUTH COAST PLAZA Phone: APPLICANT: STURM, CARL Phone; 617-293-0264 Address: 3315 FAIRVIEW RD Unit: City/State/Zip: COSTA MESA, CA Address: Unit:: City/State/Zip: CONTRACTOR: SHAWMUT DESIGN AND CONSTRUCTION License No:747583 Phone: 617-622-7000 Address:560 HARRISON AVENUE Unit: Cell: City/State: BOSTON, MA 02118ZipCode02118 ARCHITECT: PIERLUIGI BONVICINI ARCHITECTURE INC PHONE: 714-957-8250 ENGINEER: License No. COMBINATION PERMIT FEE SUMMARY Building Plan Check: $155.80 Building Fees: $958.75 Electrical Fees: $64.19 Mechanical Fees: $62.35 Plumbing Fees: $0.00 SMIP Residential: $0.00 SMIP Commercial: $19.95 Bldg Std Admin Fund $4.00 TOTAL FEES: $1,265.04 License No.C17303 PHONE: 'Refer to fee receipts for all fees paid for project HOURS FOR CONSTRUCTION ACTIVITY: EFFECTIVE 3/18/2010 - PER CMMC Sec. 13-279 484yety' 11W r � �� qq, In,��pe rid nceEOa91L'abiAWi6rDayThank Christmas Oa°d'll 0i&%g9(M°1�4YHiated 094WIO,ir w- a, 44 qn3p, EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE I. INSPECTION TYPE 1616 Fixed System Final Fire Prevention 1266 Pool Spa Final 200 Final Re -Roof 201 Final Block/Retaining Wall 202 Final Factory Fire Place 203 Final Sign 204 Final Demolition rPJurlSkl CODE INSFECM01?TYPE 206 Final Mechanical 206 Final Plumbing 210 Final Electrical 212 Final Fire Prevention 220 Final Planning Approval 222 Final Site 250 Final BuildinglOccupancy 2M INIMALS i WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy number are: fC rri6r:r_ LPF.'e.h ZIJC� (This section need not be canpleied alae perm4 is valued at are hundred "ars (S t 00) or less.) Pnticy Numlaer: �&) i _�_� ^ Q 1,0 2 ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Codwith comply with these provisions. (!2E 11. 's ignature Date }- WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby'affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Lica#--r* c. Class'.,.. Gam` . . on ar s Signature plc r CONSTRUCTION LENDING AGENCY: El I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code). Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (Commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature Dale 3(157-46(3)07) Owner ID verified by driver a license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend. will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title B, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Apglicanl's Signature Date Division of Industrial Safety Permit Number: HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the Califomia Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safely Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Govemment Code requires that the requested information be fumished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If "yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code), 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (If 'yes", attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signal x er(st Date Andlor Authorr61 Applicant__wti Z ..<. �. , v.- �_:,1v^^+r•-.n.; - q'+a.ir.+-s., .,..K>:?-CTi:T%."Fy�'S'i-:�� ,1y •';.s� C ; -Y OF COSTA M-- )A7L--� _ Development Services, Division of Building and Safety CERTIFICATE OF OCCUPANCY This certificate is issued pursuant to the requirements of the 2007 California Building Code, Section 110 adopted by the City of Costa Mesa certifies that"at the time of its issuance the building structure herein below described was inspected and approved for occupancy as follows: Building Address 3333 2802 Bristol St. 4: CM, Bldg. Permit Number BC09-04456 Use Restaurant Group A-2 Type of Constru'dion ' T»:A Fire Zone Use Zone RC Owner of Building South Coast Plaza " Tenant '�ea®ons 52 Address 3315 Fairview Rd�%--rosta Me�i By Q.. Nguyen; CS.O BUILDING OFFICIAL-Khanh 4' � Date 0-7 23/20 REQUIRED TO BE POSTED IN A CONSPICUOUS PLACE Ar a rtOf Costa nc-"Ia of Development Services, Division o f Bu ilding and Safety CERTIFICATE OF OCCUPANCY This certificate is issued,,pursuant to�,the-requiremen"ts of�,th��Uniform ldi g ode, Section 308 adopted by the City of Costa Mesa cerxifies.that_at-the ti'' of rts.issuance the building structure herein below described was inspected and�approved=for-occupan-&'a �follows:" Building Address 3333 BR�I3TOi:MIET SPACE 2802 �v���`!, 1'%ldg. Permit No. B99-00415 Use RRSTAITRANT H ✓ �� Group • 1$ Type`'o c(io t coon IFR lore Zone ,rt;, ,rl `� Use Zone PDC N Owner of Building C. J: �Segeietrom�-& Sana _ _ Tenant Ta'CLITBHOIISE Address 3315 Fai.rview;�Road: CnRt".fLMeF�B {,A` :49f,�6_ i rte. -, Rick Brown, CBO %1� BUILDING OFFICIAL - REQUIRED TO BE A. y �. B _Date' 26, 1999 - EXPIRES 91271OW A CONSPICOUS PLACE 1=1 CITY OF COSTA MESA BUILDING DIVISION s 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us r ` FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BC09-00476 PERMIT TYPE: B_COMBO STATUS: ISSUED. Sub Type: COM—ALT DATE ISSUED: 01105/2010 ISSUED BY: RMD JOB ADDRESS: 3333 2802 BRISTOL ST CM Suite/Unit: 2802 APN: 41250107 Zoning:PDC, , Vicinity: SUITES 2802 AND 3802 Primary Occ: Const Type: I -A SQ. FT: 10000 Valuation: $75,000.00 SCOPE OF WORK: INTERIOR RESTAURANT DEMOLITION TO SHELL CONDITION FOR SUITE 2802 AND THE NEWLY CREATED SUITE #3802 (EXISTING SPACE ON THE 3RD LEVEL). DEMOLITION AND RECONSTRUCT EXIT CORRIDOR & PROVIDE UTILITY HOOK-UP FOR FUTURE RESTAURANT TI. WORK WILL ALSO INCLUDE REMOVE/PATCH ROOF AREA FOR THE EXISTING MECHNICAL UNITS. REF: BC09-00456, BC09-00463 OWNER: SOUTH COAST PLAZA Phone: APPLICANT: BOWERS, JOHN Phone: 714-883-5172 CONTRACTOR: BOWERS CONSTRUCTION Phone: 714-883-5172 Cell: ARCHITECT: MARK E LEVINE ENGINEER: COMBINATION PERMIT FEE SUMMARY Address: 3315 FAIRVIEW RD Unit: CitylStatelZip: COSTA MESA, CA Address: Unit: CitylState/zZip: License No. 930403 Address: 3231 CUTTING HORSE RDUnit: City/State: NORCO. CA ZipCode 92860 License No.C30669 PHONE: 714-979-8100 License No. PHONE: Building Plan Check: $532.19 Building Fees: $818.75 Electrical Fees: $33.30 Mechanical Fees: $0.00 Plumbing Fees: $33.30 SMIP Residential: $0.00 SMIP Commercial: $0.00 Bldg Std Admin Fund $3.00 TOTAL FEES: $1,420.54 "Refer to fee receipts for all fees paid for project Final Fire Prevention NOTICE: The work authorized by this permit shall comply with all applicable Handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE / INSPECTION1YPE DATE INMMAL CODE INSPECMONTYPE 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy DATE INMMALS CITY OF COSTA MESA o BUILDING DIVISION r 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 - Fax (714) 754-4856 • www.ci.costa-mesa.ca.us f - FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BC09-00456 PERMIT TYPE: B_COMBO STATUS: ' ISSUED Sub Type: COM—ALT DATE ISSUED: 02/03/2010 ISSUED BY: RMD JOB ADDRESS: 3333 2802 BRISTOL ST CMSuite/Unit: 2802 APN: 41250107 ZoniOg.PDC,, Vicinity: SEASONS 52 IN SUITE 2802 Primary Occ: Const Type: I -A SQ. FT: 8258 Valuation: 1,200,200.00 SCOPE OF WORK: 8258 SF INTERIOR REMODEL OF THE EXISTING RESTAURANT SPACE FOR "SEASONS 52." WORK INCLUDES: DEMOLITION & REMOVAL OF ALL EXTERIOR WALKS, WINDOWS/DOORS, ELEVATOR, ETC AS RELATED TO THE FORMER RESTAURANT, INCLUDING LANDSCAPE/PATIO. TI INCLUDES NEW 267 SF COVERED ENTRY WAY WIWATER FEATURE, 1,603 SF OPEN TRELLIS PATIO AREA, NEW WALKWAY 8 LANDSCAPING, CONSTRUCTION OF A NEW 1,124 SF OPEN TRELLIS PATIO WITH CANVAS SHADING. 1 FAU< 100 K BTU, 2 REFIG < 100 K BTU, 5 HOOD W/DUCT, 9 VAV, 2 VENT FAN, 411 LIGHT FIXT, 60 OUTLETS, 10 SWITCHES, 7 NON RES APPL, 1 SVC TO 1000A, 9 MOTORS, 4 MOTORS TO 10 HP, 24 COMM DROPS, 20 TRANSFORMERS TO 1 KVA, 3 TRANSFORMERS TO 50 KVA, 1 BKFLW PRV, 2 ICE/COFFEE CONN, 1 DISHWASHER, 31 FLOOR DRAINS, 1 EXP TANK, GAS OUTLETS (1-4), 5 ADD GAS OUTLETS, 1 GAS SVC, 19 FLOOR SINK, 2 KITCHEN SINK, 1 SVC/MOP SINK, 1 TRAP PRIM, 1 URINAL, 1 VAC BRKR, 1 WASTENENT SYST, 5 WATER CLOSETS, 1 WATER HEATER, 1 WATER SVC, 1 WATER SOFTNER. TRAFFIC IMPACT FEE PAID TI -10-03 SAN JOAQUIN CORRIDOR FEE PAID SJ -10-01 OWNER: SOUTH COAST PLAZA Phone: APPLICANT: ELMORE, TOMMY Phone: 386-481-4524 Address: 3315 FAIRVIEW RD City/State/Zip: COSTA MESA, CA Address: City/StatelzZip: CONTRACTOR: HALEY CONSTRUCTION INC License No. 683029 Phone: 386-944-0470 Address: 900 ORANGE AVENUEUnit: Cell: City/State: DAYTONA BEACH, FL Unit: Unit: ZipCode 32114 ARCHITECT: ROBERT J HORNACEK License No.C6605 PHONE: 714-832-1834 ENGINEER: License No. PHONE: COMBINATION PERMIT FEE SUMMARY Building Plan Check: $1,030.64 Building Fees: $6,342.40 Electrical Fees: $836.35 Mechanical Fees: $234.70 Plumbing Fees: $733.45 SMIP Residential: $0.00 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be Considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE I, INSPECTION TYPE DATE INTMALS CODE / INSPECTION TYPE DAFT IMMIAL5 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Roof 210 Final Electrical 201 Final BlocklRetaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 204 Final Sign Final Demolition 222 250 Final Site Final Building/Occupancy . , WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain workers' compensation insurance, as required by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation Insurance carrier and policy numberare: rte r: ILLZV F q 6f 4,fS C.. (This section need not be mplefed idle permit is valued at one hundred dollars ($100) or fess.) W, Number: "f o t 2- 9 (. � 3 ❑ I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of forthwvilh comply with these provisions. , 3 �/ Signature WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINFS UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES, LICENSED CONTRACTOR$ DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. �7 f Signature gppdPaie CONSTRUCTION LENDING AGENCY: ❑ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code), Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the $pplicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500),): ❑ I, as owner of the property, or my employees with wages as their sole compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). ❑ I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTOR$ to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such project with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under se. Business and Professions Code for this reason: Owner ID verified by drive. . ncense. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high, (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Division of Industrial Safety Permit Number: Date HAZARDOUS MATERIALS AND EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. If an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? ❑ Yes ❑ No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air Quality Management District or from any other air pollution control district or agency? [:)Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be fumished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (If `yes", the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7, if a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safely Code Section 42303 been made? ❑ Yes ❑ No 8. (if "yes", attach certificate of compliance from the appropriate air pollution control officer), CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to Comply with all state laws and city ordinances relating to building construction, and authorize representatives at the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. Signature Date 3057-a6{307) rdAfilporr�Sli�litars! Date G 2 03 PERMIT TYPE - -- , ;�_ I - CITY OF COSTA MESA sv BUILDIMG DIVISIOM 77 FAIR DRIVE, COSTA MESA, CA 92626 - (714) 754-5273 - Fax (714) 754-4856 • www.ci.costa-mesa.ca.us FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: SB10-00045 B_SIGN JOB ADDRESS: 3333 2802 BRISTOL ST CM Vcin4: SQ. FT: 0 STATUS: ISSUED - DATE ISSUED: 07/02/2010 ISSUED BY: KJB Suite/Unit: 2802 Valuation: $9,416.00 SCOPE OF WORK: CHANNEL LETTER BUILDING SIGNS FOR "SEASONS 52"'AT SOUTH COAST PLAZA. 2 ILLUMINATED SIGNS AND 1 NON -ILLUMINATED SIGNS. OWNER: SOUTH COAST PLAZA Address: 3315 FAIRVIEW RD Unit: PHONE: $181.25 City/State/Zip: COSTA MESA, CA APPLICANT: BENSON, RICHARD Address: Unit: PHONE: 818-974-5808 City/State/zZip: $1.00 CONTRACTOR: AD ART License No. 826051 Address: 1300 W SHAWUnit: SUITE30 PHONE: 559-225-2138 City/State: FRESNO ,CA ZipCode: 93711 CELL: ARCHITECT: License No. PHONE: ENGINEER: License No. PHONE: SIGN PERMIT FEE SUMMARY PLAN CHECK FEE: $117.81 HOURLY PC FEE: $0.00 PERMIT FEE: $181.25 ELECTRICAL FEE: $72.70 SMIP FEE: $1.98 OTHER: $0.00 INSPECTION: $0.00 BLDG STD ADMIN FUND $1.00 TOTAL FEE: $374.74 NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be Considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. CODE N• INSPECTION TYPE p4TE IHititALS COBE i iHSP TI N TYP DATE INiifIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 206 Final Plumbing nr��� — ///��� 200 Final Re -Roof 210 Final Electrical A'25 II i�p Rim 201 Final BlocklRetaining Wall 212 Final Fire Prevention 7_ 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Bu'tldingfOccupancy 4k,. CITY OF COSTA MESA o F BUILDING DIVISION 0 } 77 FAIR DRIVE, COSTA MESA, CA 92626 - (714) 754-5273 • Fax (714) 754-4856 - www.ci.costa-mesa.ca.us FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER- BX10-00154 PERMIT TYPE B MISC STATUS: ISSUED APN: 41250107 r DATE ISSUED: 07123/2010 Zoning: PDC, ISSUED BY: P[ u JOB ADDRESS: 3333 2802 BRISTOL ST. M Suite/Unit: 2802 Vicinity: MALL StB£ TRY STORE FRONT Primary Occ: Const Type SQ. FT: 0 Valuation: $20,000.00 SCOPE OF WORK: INSTALLATION OF NEW STORE FRONT FOR "SEASONS 52" WITH 4 LIGHT FIXTS, 3 OUTLETS. REF#: BC09-00456 OWNER: SOUTH COAST PLAZA City/State: COSTA MESA, CA Phone: APPLICANT: ELMORE; TOMMY City/State: Phone: 386-944-0470 Address:: 3315 FAIRVIEW RD Zip Code: 92626 Address: Zip Code: CONTRACTOR: HALEY CONSTRUCTION INC License No. Address: 900 ORANGE AVENUE City/State: DAYTONA BEACH, FL Zip Code: 32114 Phone 386-944=6470 ARCHITECT: License No. Phone ENGINEER: License No. Phone FEE SUMMARY Building Plan Check: $0.00 Building Permit: $321.25 Electrical Permit: $36.40 SMTP Residential $0.00 SMIP Commercial $4.20 Bldg Std Admin Fund $1.00 Unit Unit: 683029' Unit: Cell: TOTAL FEES $368.75 HOURS FOR CONSTRUCTION ACTIVITY: EFFECTIVE 3/18/2010 - PER CMMC Sec. 13-279 Monday thru Friday - 7:00 am thru 7:00 pm. Satrudays -9:00 am thru 6:00 pm. Prohibited all hours - Sundays and the following Federal Holidays: New Years Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day and Christmas Day NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval will result in the expiration of this permit. D R INSPECTION TYPE DATE INTMAL CODE f INSPECTION TYPE OATSNI TRIALS 1616 Fixed System Final Fire Prevention 206 Final Mechanical 1266 Pool Spa Final 208 Final Plumbing 200 Final Re -Root 210 Final Electrical 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site 204 Final Demolition 250 Final Building/Occupancy PO WORKERS' COMPENSATION DECLARATION: I hereby affirm under penalty of perjury one of the following declarations: [❑ I have and will maintain a certificate of consent to self -Insure for workers' compensation, as provided for by section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain workers' compensation insurance, as required by section 370erfarmance of the work !or which this I is issued. rs' compensa -insurance carrier and policy number ar sect need IxYnpleled d the permd is valued at are hundred ddears lS �wlessl Nu r: �] I certify that in the perfortnbnce of the work for which this permit is issued, I shalt not employ any person in any manner so as to become subject t4 the workers' compensation laws of California, and agree that if I should became subject to thrs' compensation provisions of Section 3700 of ! wit ply with these provisi ns. gnature alt" WARNI TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and M license is in full force and effect. ass W'7 ir re CONSTRUCTION LENDING AGENCY: 0 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code), Lender's Name: Lender's Address: Signature Date OWNER -BUILDER DECLARATIONS: I hereby affirm that under penalty of perjury that I am EXEMPT FROM THE CONTRACTORS LICENSE LAW for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its ibsuance, also requires the applicant for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (5500).): ❑ 1, as owner of the property, or my employees with wages as their sole Compensation, WILL DO THE WORK, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors I,icense Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or herself or through his or her own employees, provided that such improvements are not intended or offered for sale. if, however, the building or improvement is sold within one year of Completion, the owner -builder will have the burden of proving that he or she did not build or improve for purpose of sale.). L—) I, as owner of the property, am EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS to construct the project (Sec. 7044, Business and Professions Code: The contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for Such project.with a contractor(s) license pursuant to the Contractors License Laws.). ❑ I am exempt under sec. Business and Professions Code for this reason: Signature Date 3057-46 (3107) Owner ID verified by drivers license. ❑ Yes ❑ No Driver's License No. Expires: Verification of Ownership by (type of document, i.e. - property tax bill or deed): DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: ❑ 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap. 3.2, Grp 2, Art 2, Sec. 341, Title 8, California Administrative Code). ❑ As owner -builder, I- will not employ anyone to do work which would require a permit from the Division of Industrial Safety, as noted above, unless such person has a permit to do such work from the division. Applicant's Signature Division of Industrial Safety Permit Number: Date HAZARDOUS MATERIALS AND, EMISSIONS CERTIFICATION: 1. Will the applicant or present or future building occupant need to file and certify a Business Plan for emergency response to release or threatened release of a hazardous material? ❑ Yes ❑ No (Section 25505 of the California Health and Safety Code requires, with some exceptions, that a Business Plan be filed with the Costa Mesa Fire Department by every business which has at any one time during a reported year a quantity of hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 2. Does or will the applicant or present or future building occupant need to file a registration form for acutely hazardous materials? ❑ Yes ❑ No (Section 25533 of the California Health and Safety Code, with some exceptions, requires registration with the Costa Mesa Fire Department by each business which at any one time has on hand a quantity of acutely hazardous materials equal to or greater than a weight of 500 pounds, or a volume of 55 gallons, or 200 cubic feet of compressed gas at standard temperature and pressure). 3. Does or will the applicant or present or future building occupant need to prepare an RMPP (Risk Management and Prevention Program for acutely hazardous materials)? ❑ Yes ❑ No (Section 25534 of the California Health and Safety Code provides that the Costa Mesa Fire Department may require the preparation, certification and filing with the Fire Department of an RMPP by businesses which are required to register acutely hazardous materials with the Fire Department. 4. if an RMPP is presently required, has Section 25534 of the California Health and Safety Code been fully complied with? []Yes [] No 5. Does or will the applicant or present or future building occupant require for the work which is the subject of this application a permit for such construction or modification from the South Coast Air quality Management District or from any other air pollution control district or agency? ❑ Yes ❑ No (Section 65850.2 of the California Government Code requires that the requested information be fumished on applications for non-residential building permits). 6. Will any part of the facility to be constructed under this permit be within 1000 feet from the outer boundaries of a school? ❑ Yes ❑ No (if 'yes". the facility must meet the requirement of Sections 25534 and 42303 of the California Health and Safety Code). 7. If a permit from the South Coast Air Quality Management District or other air pollution control district or agency is required for the work which is the subject of this application, have all of the disclosures prescribed by California Health and Safety Code Section 42303 been made? ❑ Yes ❑ No 8. (if 'yes". attach certificate of compliance from the appropriate air pollution control officer). CERTIFICATE OF COMPLIANCE: I certify that under penalty of perjury the information given above is correct. I agree to comply with all state laws and city ordinances regarding Hazardous Materials and Emissions. Signature Date CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify under penalty of perjury that I have read this application and state that the information given is correct. I agree to comply with all state laws and city ordinances relating to building construction, and authorize representatives of the City of Costa Mesa to enter upon the above-described property for inspection purposes. I agree not to occupy or allow occupancy of any building authorized by this permit until final inspection. CITY OF COSTA MESA DEVELOPMENT SERVICES./BUILDING SAFETY RECORD PAC1 AGE FOR: STREET ADDRESS WORK DONE Kl Building Permit #, Certificate of Occupancy ❑ Electrical Release Form ❑ Gas Release Form F Sanitation Fixture Form ❑ Plumbing Permit # ❑ Mechanical Permit Electrical Permit # �+ ❑ Reinspection Permit # ❑ Health Department Approval ❑ Roofing Certification ❑ Insulation Certification ❑ Dry Chemical System Certification ❑ Flame Spread Certification r, Fire Sprinkler Certification I i Soils Certification ❑ ecial Inspection Certification Other: tip All Required Documents Included;jg Clerk O.K. to Approve C.O. Inspector O.K. to Release C.O. SuIlding Official CMF 1046.30 '' ' City of Costa Mesa DevelopmQnt Services Department CERTIFICATE OF OCCUPANCY NO. 00271 { Building Safety Division P. O. Box 1200 Cost;♦ Mesa, California The Building located at '4'n'A Rriarnl S _rEt t, Staace 2517 _ has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group B-2 Occupancy. Use of Building Retail Legal DEscription 412-501-02 (See reverse side for Metes and Bounds) Building Permit No B 3$438 Electrical Permit No, E 35524 Plumbing Permit No. Mechanic,il Permit No. dire Brev. Permit No. F 35190 CSSUED TO: R -A_ Seaerstrom & Sons 3315 Fairview Road rr-n4t_a Mesa, CA 92626 Number of apartments and/or guest rooms Building Official William T. Howard by -.-� /., i --7;f' to Date November 1, 1988 This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. CMP 1015.46 rev, 1/83 White - Owner; Canary - Numerical File: Pink - Bldg. Permit File .. -. .� •-..r •�� .. � meg'`:::.-..� .� - ti � .Si ... -. 1� aC' ,� _ +. .. r� e - Cl- _Y -OF COSTA MI Fft Development Services, Division of Building and Safety kft, CERTIFICATE OF OCCUPANCY This certificate is issued pursuant to the requirements of the Uniform Building Code, Section 308 adopted by the City of Costa Mesa certifies that at the time of its issuance the building structure herein below described was inspected and approved for occupancy as follows: 3333 Bristol St. Ste.2516 BCOS-002b5 Building Address Bldg. Permit Number Watch/Jewelry Retail Use M 1—A Group Type of Construction South C t Pl (1,627 s.f.) Fire Zone xXXxx Use Zone POC Owner of Building oas aza Tenant 3315 Fbirview Av., Costa Mesa, CA Address By BUILDING OFFICIAL-Khanh Q. Nguyen, C.B.O. Date TOURBILLON 09/09/( REQUIRED TO BE POSTED IN A CONSPICUOUS PLACE Fd- '•1v ;11 t..' �,1 �. .r •, yv. '6 .�: �Nti.._Y - .y �'' �,��:Ni' �1y •''�`/F;•f� '• �•'-���.a.xif . • ..:x k� ..x :,'d.. -.qp t,.,�?:i'�;.� - y'. ' -..+i. ;1��%� LY�4,��e+.N�-ab. ?a �'w=� \ �F.•''7 l�dti-` ;1 Y 1. w_ ' .;. •:- ''cx•'nr'�i->�'i.'5�.. �..a �i�»�% i;l'i' hyo;; •,'��:kz �?li��'�'`•: 3333 BRISTOL Unit#2516 B-47094 PC#3758-90 A Retail StoreAN T. I E-47100 Retail Store T.I. (B-47094) ®M47318 unit: 2516 (B47094)1�/ 6 _490 Emu= P47485 unit: 2516 �. (847094) -6%p�� wh E47505 unit: 2,536--,-" (B47094) /v�7�t�a B68329 Unit 2516_ PC#2477-94A M68380 Unit 2516 (B68329)E6843J� — 029) Unit 2516 (B683"'1 114 F68524ill) I _ PC#2892-94 L (B68329�j�5 U v CITY OF COSTA MESA BUILDING DIVISION a 77 FAIR DRIVE, COSTA MESA, CA 92626 • (714) 754-5273 • Fax (714) 754-4856 • www.ci.costa-mesa.ca.us FOR INSPECTIONS CALL: (714) 754-5626 PERMIT NUMBER: BC08-00265 PERMIT TYPE: B_COMBO STATUS: ISSUED Sub Type: COM—ALT DATE ISSUED: 07/0312008 ISSUED BY: RMD Boa ADDREss: 3333 2516 BRISTOL, ST CM _ ` SU ---2516 " APN: 41249102 Zoning:PDC Vicinity: 2516 `- _ 'Primary Occ: M Const Type: I-ASQ.'FT�1627 Valuation:. $95,000.00-"`` 1n Y1� 'F i `•Y - - - SCOPE OF WORK: 1627 SF"INTERIOR TI'FOR "TO URBILLON", SUITE 2516. 2 VAV BOX, 2 VENT FANS, 64 LIGHT FIXTS, 24 OUTLETS, 1 DISHWASHER; F1 FLOOR.DRAIN, 1 KITCHEN SINK", .1 WASH BASIN, 1 WATER CLOSET AND 1 WATER HEATER. OWNER: SOUTH COAST PLAZA Address:. ,3315 FAIRVIEW AVE Unit: MISC. a, Phone: °' F_: ; , City/State/Zip:., 'C'OSTA MESA; CA w APPLICANT: PORZIO, LEONARD Address: =` i j, '` Unit: : Phone: City/State/zZip: CONTRACTOR: CANCAL'CONSTRUCTION IN` C' '. License No. 873825.E. Phone: 714-799 4041 Address: ` 15581 -PRODUCT LANEUnit: Cell: = Citylstate: HUNTINGTQN BEACH, CA n:< ZipCode 92649 ARCHITECT: GRUEN ASSOCIATES,,!,,.. License No.C26014,• PHONE: 323-937-4270 ENGINEER: '' Y License No. PHONE:' - COMBINTATION PERMIT FEE SUMMARY ' Building Plan Check: Building Fees: _$958.75. Electrical Fees: $102 54 Mechanical Fees: -. $59.30-,. Plumbing Fees: $82.30' SMIP Residential: $0.00 _ SMIP Commercial: TOTAL FEES: $1737$.64. . '•Refer to fee receipts for all fees paid for project NOTICE: The work authorized by this permit shall comply with all applicable handicap access requirements under California statutes and related regulations. (Ord. No. 92-28, § 1, 12-21-92) EXPIRATION: PERMIT EXPIRES 180 DAYS FROM DATE OF ISSUE OR DATE OF LAST INSPECTION. INSPECTIONS: In order for the work authorized under this permit to be considered legal, such work must comply with all applicable codes, and all required inspections and final approval must be obtained. Failure to obtain inspections and final approval wilt result in the expiration of this permit, CODE R. INSPECTION 1YPE DATE INiMAL CODE M lWEcTlQN DA "IN 1616 Fixed System Final Fire Prevention 206 Fi al Mechanical 1266 Pool Spa Final 208 V Final Plumbing 200 Final Re -Roof 210 Final Electrical P14 � aZ D R R 201 Final Block/Retaining Wall 212 Final Fire Prevention 202 Final Factory Fire Place 220 Final Planning Approval 203 Final Sign 222 Final Site DI 204 Final Demolition 250 Final Building/Occupancy r/A CITY OF COSTA MESA DEVELOPMENT SERVICES/BUILDING SAFETY RECORD PACKAGE FOR: STREET ADDRESS WORK DONE Building Permit # Certificate of Occupancy ❑ Electrical Release Form ❑ Gas Release Form Sanitation Fixture Form i Plumbing Permit- ,�, Mechanical Permit #1� Electrical Permit #E!%7/On �y�s ❑ Reinspection Permit =If - F -1 ❑ Health Department Approval ❑ Roofing Certification ❑ Insulation Certification ❑ Dry Chemical System Certification ❑ Flame Spread Certification ❑ Fire Sprinkler Certification t Soils Certification ❑ Special Inspection jCCertification VT— Other: Z ' � �5 All Required Documents Included Clerk O.K. to Approve C.Q. Inspector O.K. to Release C.O, Building Official CMF 1046-30 City of Costa Mesa Development Services Department CERTIFICATE O F OCCUPANCY No. Building Safety Division 003189 P. O. Box 1200 Costa Mesa, California The Building located at '1311 Ttriaf-n1 tr l-. .Rryi a 7c,16 has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group b-1 Occupancy. Use of Building- Tnn+-ai 1 ,f 'It t Legal Description A�—fl1—n7 it I (See reverse side for Metes and Bounds) Building Permit No 'R A7QQA Electrical Permit NoP.477 0.r-4 St?S Plumbing Permit No. P A7d129 Mechanical Permit No. '-=f A7113 Number of apartments and/or guest rooms Fire Preventton Pmt No. F 47235 ISSUED TO: Building Official m-I.,tr Oq":% ru4-.� C. J,_ St'aerst= & Sons 3315 Fauvi.eW fo by Costa Mesa, gh 92626 Date T„a t,Z nan This Certificate of Occupancy SHALL BE posted in a clonspicuous place an the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. CMF 1015-46 rev. 1/83 White - Owner; Canary • Numerical;File; Pink - Bldg. Permit File PLAN CHECK#2477-94A CITY OF COSTA MESA DEVELOPMENT SERVICESIBUILDING SAFETY RECORD PACKAGE FOR: 3333 BRISTOL ST. #2516 412-501-07 B-2 STREET ADDRESS RETAIL—"®ARLES JOURDAN DE PARIS WORK DONE ® Building Permit # B68329_ ® Certificate of Occupancy ❑ Electrical Release Form ❑ Gas Release Form r Sanitation Fixture Form ❑ Plumbing Permit # — ® Mechanical Permit #M68380 ® Electrical Permit # E68430 ❑ Reinspection Permit ## ❑ Wealth Department Approval ❑ Roofing Certification ❑ Insulation Certification ❑ Dry Chemical System Certification- - - ❑ Flame Spread Certification ❑I Fire Sprinkler Certification L Soils Certification ❑ Special Inspection Certification ® Other: FIRE PERMIT# F68524 All Required Documents Incl de MMONTEZ 2/24/9 O.K. to Approve C.O. InSpector O.K. to Release C.O. Building Official CNIF 1046-30 City of to-sta N e-5a Development Services, Division of Building and Safety CERTIFICATE OF OCCUPANCY This certificate is issued pursuant tNthereginremerits of�th�`Uniform Building Code, Section 308 adopted by the City of Costa Mesa certifies,that_at-fhe time of-,its-issuance the building structure herein below described was inspected and5li5 rove& _6ccupancy.as f6aws:1 3333 ,BMSTOL ST 2516 B68329 Building Address # � Bldg. Permit No. Use RETAILfi.Sd t8S! STOR13..-, B-2 �4� � J J �� �_r!� � C L\ �7P` �- a�r S+1V , \l1 Group Type of- ConstructionN Fire'Zone Use Zone Cl-S Owner of BuC.J.'�SEGERSTROM ,&'-Te- 1nant SON8--' ` ' C#iARi,EB JOt33RDAN DE PARIS ilding -Te Address 3315 FAIRVIEW-ROAD COSTA- MLSAii =CA X92626 y' �._ ;,fj BUn.DING OFFICIAL-tonp C'�7� `aca ,;- Y' �_,' = j% �� / Date���FEBRIJARY 24, 1995 REQUIRED TO BE POSTED IN- CA ONSPICOUS PLACE i Z y R—A 3333 Bristol St. Space#2513 E30743L IT -- Meter -sub PanelUnit 2513 yF 8 UNit 2513 Tenant Improvement M3076Js1i &51 .-Registers � � P30763-L�z � Bar sint t MWEEMMEMMMM IM 3 3 0 8 j_ 1 Add " Beam (Icf��4Unit#2513 IM Beam E30323 J% — OMMMEMIMMEMMOM V7 o' ie. misc., Unit 251--t- -130934 unit Duct-ventil t 251�__ ®===MMM=jMj 2 -1 n 9 3, 5 0 ) o F31078 Fi-I-e Sprinklers $2,40 7-- 0:,, PC#3537-94 A CITY OF COSTA MESA DEVELOPMENT SERVICESIBUILDING SAFETY RECORD PACKAGE FOR: 3333 BRISTOL STREET UNIT 2512 PARCEL #412-501-07 B-2 STREET ADDRESS RETAIL STORE "BOTTEGA VENETA" WORKDONE Building Permit # B69890 Certificate of Occupancy ❑ Electrical Release Form ❑ Gas Release Form Sanitation Fixture Form RX Plumbing Permit # P70017 R2 Mechanical Permit #M7DD-43— R1 Electrical Permit # E69890 ❑ Reinspection Permit # ❑ Health Department Approval ❑ Roofing Certification ❑ Insulation Certification ❑ Ory Chemical System Certification ❑ Flame Spread Certification F-1 Fire Sprinkler Certification Soils Certification ❑ Special Inspection Certification NX Other: F70131 All Required Documents IncludedJIX Clerk O.K. to Approve C.O. Inspector O.K. to Release C.O. Building Official CMF 1046-30 Citvof Costa Nesa Development Services, Division of,Building and Safety CERTIFICATE OF OCCUPANCY i This certificate is issued pursuant to thefrr� equ='I erit� s o the Uniform Building Code, Section 308 ;- adopted by the City of Costa Mesa certifies`,that at the time of its -issuance the building structure herein below described was inspected and approved'for•occupaney=as�follows.. Building Address 3333 BRISTOL'�STREET UNIT 2512 Bld .Permit No. B69890 Use RETAIL STORE /1/ /<4 ,"�' ! `� . i Group B-2 Type of Coiirii�etipn 1 -FR 'Fire ZCt�� :.,; }� Use Zone G1S Owner of Building C.,7':: SEGERSTROM-&-SONS --Tenant BOTTEGA VENETA Address 3315NTAIRVIEW R89D, COSTA MESA --'CA 926274--, BY 60 BUILDING OFFICIAL-ItO'11.p�6 ,Date REQUIRED TO BE POSTED -1 -A CONSPICOUS PLACE ..�.-.,Y- ..r.....-�.-.-�.---,-.�..-..-.i,._....----�-a1:...:...-:..--•�--...r-1-,r.r.-+.�..'L,,;.�.;1�isfS:a+�:i�..'76;isr.itu�ij;,,•-..:r--^•-.�--...-..r4--�...�.-+�---�.,,•y„�.,.-,�:w.-...-� �. �. of Costa N ("a Development Services, Division of Building and Safety CERTIFICATE OF OCCUPANCY This certificate is issued pursuant to�therregturementsti of`t1ie�IIniform Building Code, Section 308 adopted by the City of Costa Mesa certifies.that. at -the rime of its issuance the building structure herein ��".e . � . �_-- � � --, � � / tee.. below described was inspected andCa\p�proved-for�occupanCY.. � �: e $ 8-01.417 BuildingAddress 3333 Bristol, Street Suit 2533 i $ld . Permit No. 9 Use Retail �g ,11�� �� PDC Group M Type�of,Canstructi _ _ _ Fir ne ; Use Zone C.J. Segerst f o & �ons�-- =' �" St , johWs Knits Owner of BuildingTenant Address 3315 Fairview Nk"a stat` -sa = A=92(-26 Rick Brown CBO Building Official y, �t� Byt Ul'� _ Date`December 4, 1998 ��?/,�� l THIS TEMPORARY CERTIFICATE OF�OCCUPANCY,ISrVALID3FOR-9O DAY (EXPIRES 3/k/99} " U! i�iU- REQUIRED TO BE POSTED --IN — CONSPICOUS PLACE CITY OF COSTA MESA DEVELOnMENT,SFRVICES/RUILDING SAFETY RECORD PACKAGE FOR: 2133--4&4 —f/ STREET ADDRESS WORK DONE Building Permit 7� Ce ificate of Occupancy Electrical Release Form ❑ Gas Release Form Sanitation Fixture Form L] Plumbing Permit /�j & Mechanical Permit 4md� , Electrical Permit �d ❑ Reinspection Permit =#- 1:1 ❑ Health Department Approval ❑ Roofing Certification ❑ Insulation Certification ❑ Dry Chemical System Certification ❑ Flame Spread Certification El Fire Sprinkler Certification L Soils Certification ❑ Special Inspection Certification L2 ---Other: All Required Documents Included :!�J 6 Clerk O.K. to Approve C.Q. Inspector O.K. to Release C.O. Building Official L\CMF 1046-30 City of Costa Mesa n Development Services Department Building Safety Division CERTIFICATE OF OCCUPANCY No. Q D 2. \0 3 JL P. O. Box 1200 Costa Mesa, California The Building located at 3333 Ftriratril Strc#at. Srvnca 2533 has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group R'> Occupancy. Use of Building Rpt—nim Legal Description 411 —501--t)2 (See reverse side for Metes and Bounds) Building Permit No B 44775 Electrical Permit No. S 045306 Plumbing Permit No. MP 453'12 Mechanical Permit No. MP 45332 Fire Prevention Permit Nop F 44993 ISSUED TO: C. J. Segerstrom & Sons t>v315 Fairview Road Costa Mesa, CA 92626 Number of apartments and/or guest rooms Building Official George Edmiston b Date_ Barth 6. lggtl This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. CMF 1015-46 rev. 1/83 White . Owner; Canary - Numerical File; Pink - Bldg. Permit File CITY OF COSTA r 4 -ESA Development Services, Division of Building and Safety CERTIFICATE OF OCCUPANCY This certificate is issued pursuant to the requirements of the Uniform Building Code, Section 308 adopted by the City of Costa Mesa certifies that at the time of its issuance the building structure herein below described was inspected and approved for occupancy as follows: Building Address 3333 Bristol --.St. Ste 252.9 BIdg.PermitNumberBC08-00242 Use Clothing retail (2,569 s.f.) Group M Owner of Building Type of Construction 1—A South Coast Plaza Fire Zone xxxx _ Use Zone PDC Tenant YVES SAINT LAURENT Address 3315 'i5airview Ave. , Costa Mesa, CA By � = (n_ BUILDING OFFICIAL-Khanh Q. Nguyen, C.B.O. 1 /a Date REQUIRED TO BE POSTED IN A CONSPICUOUS PLACE City of Costa Mesa Development Services Department Building Safety Division CERTIFICATE OF OCCUPANCY No. d 0 3 J fi 2i P. 0. Box 1200 Costa Mesa, California The Building located at� 3333 Bristols Street, Space 2529 has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group R7 Occupancy. Use of Building Rpt- I i 1 Legal Description 412-501-05 ISee reverse side for Metes and Bounds) Building Permit No B 47886 Electrical Permit No. E 47984 Mechanical Permit No. M 48020 Number of apartments Eire Prevention Perini- No. F 48202 ISSUED TO: Building Official Plumbing Permit No. and/or guest rooms Tony M'De Baca t^_.T_ Spaorstrom & Sons 3315 Fairview Road by ('nArn G7aga. CA 92626 Date January 31, 1991 This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 le) U.B.C. CMF 1015-46 rev. 1/83 White - Owner; Canary - Numerical File; Pink - Bldg. Permit File CITY OF COSTA MESA Die�+ELOPMENT SERVICESIBUI,LDING SAFETY RECORD PAC,:AGE FOR: o2��D TRF -ET ADDRESS �'� WORK DONE ;[!s B�u' ��g Permit # M -! � �ice' C icate of Occupancy Elec�trical Release Form ❑ Gas Release Form Sanitation Fixture Form runPIbing Permit Mechanical Permit Electrical Permit ❑ Reinspection Permit # ❑ Health Department Approval ❑ Roofing Certification ❑ Insulation Certification ❑ Dry Chemical System Certification ❑ Flame Spread Certification n Fire Sprinkler Certification �i Soils Certification ❑_,Special Inspection Certification All Required Documents Included O.K. to Approve C.O. O.K. to Release C.O. CMP 1046-30 Clerk Inspector Building Official 1 City of Costa Mesa Development Services Department Building Safety Division CERTIFICATE OF OCCUPANCY No. 002645 P. O, Box 1200 Costa Mesa, California The Building located at 3333 Bristol street, Snace 2520 _ has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group 8-2 Occupancy. Use of Building Retail Legal Description 412-501-02 ISee reverse side for Metes and Bounds) Building Pgrmit No B 34437 Electrical Permit No. E34$34.E346 Plumbing Permit No. P 34668 Mechanical Permit No. M 34472 Number of apartments and/or guest rooms ISSUED TO: C. J. Segerstrom & Sons _ 3315 Fairview Road Costa Mesa, CA 92626 Building Official William/T. Howard by'`� Date Seotemhe-r 23, 1988 This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Bpilding Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. CMF 1015-46 rev. 1/83 White - Owner; Canary - Numerical File; Pink - Bfdg. Permit File City of Costa Mesa Development Services department Building Safety Division CERTIFICATE OF OCCUPANCY No -0030"'03 P. O. Box 1200 Costa Mesa, California The Building located at 3333 Bristol Street, Snacp ..251.9 has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group. 82 Occupancy. Use of Building Retail Legal Description 412-501-02 (See reverse side for Metes and Bounds) E49476 Building Permit No B 49453 __Electrical Permit N o7,A9673, E49580lum Bing Permit No. P 49506 Mechanical Permit No. M 49465 Number of apartments and/or guest rooms ISSUED TO: C.J. Segerst:rom & Sons 338I Fairview Road Costa Mesa,' CA 92626 Building Official Ton. C' De Baca by ,, , / - , , Date January 31, 1991 This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 (0 U.B.C. C%JF 1015.46 rev, 1/83 White - Owner; Canary - Numerical File; Pink - Bldg. Permit File �— CITY OF COSTA MESA DEVE LOPMENT SER VICESIBUI 1-01 NG SAF ETY RECORD PA CKAQE FQR: REET ADDRESS WORK DONE Bu' ing Permit Certificate of Occupancy ectrical Release Form ❑ Gras Release Form 'Sanitation Fixture Foor�r��m I P umbing Permit #��2 Mechanical Permit # Ayr Electrical Permit6,10 ❑ Reinspection Permit # ❑ Health Department Approval ❑ Roofing Certification ❑ Insulation Certification ❑ Dry Chemical System Certification ❑ Flame Spread Certification ❑ Fire Sprinkler Certification C Soil% Certification ❑ Special Inspection CCertifica ion Other: 05J`� 3 All Required Documents Included ./ Clark O.K. to Approve C.O. Inspector O.K. to Release C.O. Building Official CMP 1046-30 s ' COSTA MESA BUILDING -SAFETY DEPARTMENT �• P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626 For Applicant to Fill in Completely — Use Ink 13pnLy— 'U ADDRESS OWNER ELW t M AIL C. TEL. CITY NO. CONSTRUCTION LENDER BRANCH [ADDRESS ARCHITECT ADDRESS l �`MF 6 A H! CONTRACTOR ADDRESS [VL�]t� N� nnaIn)I TEL CITY O NO.� as STATE^ CITY 5 LIC. NO. 14) eQ1 LIC. NO. SIZE NO. OF SLOGS. OF LOT T n f NOW ON LOT USE OF EXISTING BLDG. Separate permits are required for electric, plumbing and heating work. USE OF BUILDING AND WORK TO BE PERFORMED I hereby acknowledge that I hava read this application and state that the above Information is correct and agree to comply with all laws regulating building construction, and I shall not employ any person In violation of the workman's compensation laws of the State of California. I hereby certify that I am properly licensed as a contractor under the State of California Business and Professions Code, Division 3, Chapter 9, and that such licenses are in full force and affect, or I am exempt from the provisions of the State of California Businoss and Professions Code, Division 3, Chapter 9. Slgnature of Permittee Authorized Agent AUG 11-77PA10001231 * ***106. 17 CMSA IRC* PP I TION FOR STRUCTURAL PERMIT Y DATE RECEIVED DE IS�U@G r OWNE FIRE ZONE T PE GROUP APPROVED BY AVA, DATE Z NO.OF USE OF NE PLANS BU IN YARDS APPROVED YARDS APPROVED MAIN BUILDING ACCESSORY BUILDING (FROM C/L STREET) 1 1:3y1���lI� ■5:;��iiv��I� � VAR. rW DATE C.U.P. 0 APPROVED APPROVE .51 k m i� P .41 SO. FT. N THE AMOUNT SHOWN UNDER VALUATION IS FOR CDO�. THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY. VALUATION PERMIT FEE §0,d0.0 �} PLAN CHECK $ 7 r $ 101155--e TAX $ / � u TOTAL PAID $(0 CITY OF COSTN MESA DEVELOPMENT SERVICES/BUILDING SAFE Y REc6RD PACK EFOR: / r5-- & STREET ADDRESS WORK DONE Building Permit 2 Certificate of Occupancy ❑ Electrical Release Form ❑ Gas Release Form l Sanitation Fixture F rrrin ,� D! PI robing Permit # LJ Mechanical Permit 4WO=4 LH' Electrical Permit # 6 ❑ Reinspection Permit # ❑ Health Department Approval ❑ Roofing Certification ❑ Insulation Certification ❑ Dry Chemical System Certification ❑ Flame Spread Certification ❑ Fire Sprinkler Certification C, Soils Certification E-1 Special Ins ection Certification �J Other: �� All Required Documents Included f 'Z Clerk O.K. to Approve C.O. Inspector O.K. to Release C.O. Building Official CMF 1046.30 City of Costa Mesa Development Services Department Building Safety Division CERTIFICATE OF OCCUPANCY No. P. O- Box 1200 Costa Mesa. California The Building located at, 3113 RTao-1 go—cz;t, 9 _ 'N�� has been inspected and found to comply with the provkskons of all City of Costa Mesa Ordinances applicable thereto for a Group R9 Occupancy. Use of Building Pat-n4l Legal Description A17_rflt_f1,i (See reverse side for Metes and Bounds) Building Permit No. B 61924 • Electrical Permit No, E 62754 Plumbing Permit No. P 67125 Mechanical Permit No. M 62256 Number of apartments and/or guest rooms Eire Prevention Permit No.F 62387 ISSUED TO: C.J. SeReratrom 6 Snnsz 3315 Fairway Drive Costa Mesa. Ca 92626 Building Official T...... 0�.. D^ by - - Date July 21, 1993 This Certificate of Occupancy SMALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. CMF 1015-46 rev. 1/83 White - Owner; Canary - Numerical Fite; Pink - Bldg. Permit File arw W AF 4559`I� COSTA,MESA BUILDING -SAFETY DEPARTMENT P.Q. BOX 7200 COSTA MESA, CALIFORNIA 92626 FuSTRUCTION icant to Fill in Completely — Use Ink Onk BUILDING %S-CZO ^ TEL,QLD NO.I� BRANCH ADDRESS ARCHITECT TEL. ADDRESS CONTRACTOR F� fidZ70 ADDRESS/ej/,o TEL � CITY ��� NO. .Z° STATE/ CITY LIC. NO. 6O� LIC. NOI� SIZE NO. OF BLDG& OF LOT NOW ON LOT USE OF EXISTING BLDG. Separate permits are required for electric, plumbing and heating work. USE OF BUILDING AND WORK TO BE PERFORMED vran �" --- rigs fr.f r2_cz—/ 1-v Arra�cItct "A -r 7iAn/94 "le�iJ APPLICATIONFOR STRUCTURAL PERMIT RECEIVED BY 1 DATE RECEIVED nera ccMFn • c _• bill OWNER FIRE VZONE APPROVED TE /V11FRUM _ NO. OF USE OF N PLANS BUILDTDS APPROVED YARDS APPROVEIN BUILDING ACCESSORY BUILDIN C/L E T) I hereby acknowledge that I have read this application and mete that the above information Is correct and agree to comply with ali laws regulating building constructlon, and I shall not employ any parson In violation of the workmen's compensation laws of the State of California. I hereby certify that I am properly licensed as a contractor under the Stateof California Business and Professions Coda, Divlslan 3, Chapter 9, end that such licenses are In full force and effect, or I am exempt from the provisions of the State of California Business and Professions C:Pft Division 3, C apter Signature of ~ Permittee Authorized DISTANCE BET. BET. MAIN & MAIN SLOW. AOCES66 BLD VAR .• DATE SO. FT, m a APPROVED APPROVED THE AMOUNT SHOWN UNDER VALUATION IS FOR C i SO. FT, m a THE AMOUNT SHOWN UNDER VALUATION IS FOR THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY. VALUATION PERMIT FEE t PLAN CHECK 3 $ TAX f u TOTAL PAID S t..-il 474. SEP 29-77P;'I°00 i 567* ***539.09 0ISA COSTA MESA BUILDING -SAFETY DEPARTMENT P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626 AP I A ION FOR STRUCTURAL PERMIT For Applicant to Fill in Completely —Use Ink Only REC D Y I DATE RECEIVED DATE ESSUED r BUILDING.1 ADDRESS 'T zt,h ` o OWNER l.J A.P. NO. E12�dS PERMIT NO. MAIL ADDRESS BUILDINGC+y7, / ADDRESS / L c4lq CITY L. M TEL. TRACT LOT BLOCK CONSTRUCTION NEW DD EPAIR LENDER BRANCH OWNER ADDRESS ��r VALUE S �t`e; a;ar ARCHITECT J TEL. } OR ENGINES FIRE 20NE P � GROUP ADDRESS SU� ,/' %IL.C- CONTRACTOR lJ4J W • APPROVED BY DATE ADDRESS Q AJ, Al 1AJ ZOND. � OF USE OF NEW pl-p BUILDING G� CITY �/2/y�[-� NEOL' D STATE r3 CITY Q�� LIC. NO. d LIC. NO. / YARDS APPROVED YARDS APPROVED MAIN BUILDING ACCESSORY BUILDING SIZE NO. OF BLOCS. (FROM C/L STREET) /07 OF LOT NOW ON LOT FRONT FT. FT. USE OF EXISTING BLDG. R. SIDE F T.;:C__.= Separate permits are required for L. SIDE S, FT. REAR FT. electric, plumbing and heating work. USE OF Bli LOING AND WORK TO BE PERFORMED DISTANCE BET. BET. MAIN & MAIN BLDGS. ACCESS. BLDGS. VAR.* DATE C,U.P, qjE APPROVED APPROVE DATE ay - hereby acknowledge that I have read this application and state at the above information is correct and agree to comply with laws regulating building construction, and i shall not employ any Person in violation of itis workman's compensation laws of e Siete of California. hereby certify that I em properly licensed as a contractor under [Chapter SO. FT. THE AMOUNT SHOWN UNDER VALUATION IS FOR e State of California Business and Professions Code, Division 3, 9, and that such licenses are In full force and effect, or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: exempt from the provisions of the State of California BusinessVALUATION d Professions Code, Division 3, Chapter 9. PERMIT FEE S TAT _6pdPLAN CHECKgnature TAX S of12 `rmittee $ 3 uthorized Agent U TOTAL PAID 3 t] r P�d COSTA MESA BUILDING -SAFETY DEPARTMENT P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626 J04'13, L1'9A-lry CGP 3007e.4.2' 1 -! -1O APPLICATION FOR STRUCTURAL PERMIT For Applicant to Fill in Completely — Use Ink Only RECEIVED BY DATE ReCEIVED TE ISSUED BUILDING � I ADDRESS7 ( . ~ 7 A.P. NO. 1 OWNER MA 'LADDRESS BUILDING � 5333 ADDRESS TEL* CITY NO. TRACT LOT BLOCK CONSTRUCTION NEW ADD ALTER REPA LENDER BRANCH e OWNER ADORESS V UE ARCHITECT TEL. S $ OR ENGINEER N FIRE ADDRESS ZONE TYPE GROUP APPROVED CONTRACTOR BY ZZVLII,7 BATE ADDRESS JS3 'T TEL. ZON NO. OF USE OF NE CITY NO PLANS BUILDING ' .40 STATE CITY YARDS APPROVED YARDS PPROVED LIC. NO. ���_ LIC. NO.62 MAI ILDING ACCESS RY BUILDING SIZE NO. OF SLDGS, (FAO /L STREET) OF LOT NOW ON LOT RO FT. FT. USE OF EXISTING BLDG. FT. FT Separate permits are required for L. DE FT. FT. electric, plumbing and heating work. REA FT. FT. USE OF BUILDING AND WORK TO BE PERFORMED DISTANCE BET. MAIN & MAIN BLDGS, ACC . BLOGS, VAR. + DATE C.U.P. tk APPROV APPROVEp DATE I hereby acknowledge that I have read this application and state that the above Information is correct and agree to comply with all laws regulating building construction, and 1 shall not employ any person in violation of the workman's compensation laws of the State of California. I hereby certify that I am properly licensed as a contractor under �7 SO. FT. ~ 4 m w the State of California Business and Professions Code, Division 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR m Chapter 9, and that such licenses are in full force and effect, or 1 THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY. am exempt from the provisions of the State of California Business VALUATION PERMIT FEE S O� 20o and Professions Code, Division 3, Chapter 9. �+ m PLAN CHECK Signature of r Permittee TAX S U 050 Authorized Agent TOTAL PAI O S .3 3, 50 H C o '0$ta ne$a Development Services, Division of Building and Safety CERTIFICATE OF OCCUPANCY This certificate is issued pursuant adopted by the City of Costa Mesa c below described was inspected ande Building Address 3333 BRISTOL Group MTypes}of-Cons r Owner of Building r ..r . ° � GA$praf BUILDING OFFICIAL -cony Uniform Building Code, Section 308 issuance the building structure herein �'X_ - - Permit No. B 79705 ones = ` Use Zone C1-5 TO BE POSTED IN "A CONSPICOUS PLACE I CITY OF COSTA MESA DEV E LOPME NT SERVICES/131-111-DING SAFETY RECORD PACKAGE FOR: STREET ADDRESS WORKDONE Building Permit # , ❑ Certificate of Occupancy ❑ Electrical Release Form ❑ Sas Release Form ❑ Sanitation Fixture Form �r [:3 Plumbing Permit # � � —S- y ❑ Mechanical Permit #____ 7ff ❑ Electrical Permit # ❑ Reinspection Permit # ❑ Health Department Approval ❑ Roofing Certification ❑ Insulation Certification ❑ Dry Chemical System Certification ❑ Flame Spread Certification C =ire Sprinkler Certification ❑ Soils Certification ❑ Special Inspection Certification ❑ Other: .1^ 07?0/z All Required Documents Included A O.f�. to Approve C.O. j fnspector O.io Release C.O. Building Official CMF 1046-30 11 CITY OF COSTA MESA BUILDING SAFETY DIVISION CCAS OR ELECTRICAL UTILITY RELEASE FORM V TRACT LOT ADDRESS GAS ELEC, NO. UNITS NO. METER OUTLETS NO. METERS RELEASED THESE INSPECTIONS ARE A RESULT OF. (CHECK ONE) " �," ElNEW CONSTRUCTION 1-1REWIRING';_ ® OTHER 1EXPLAtN1 f - `� �+ !_ %n•fi /� __ Date Released CMF 0771-46 /J—/4v— u� r m I, CAT. No. NNO0627 TO 1944 CA (9-84) (Individual) STATE OF CALIFORN COUNTY OF in! TICOR TITLE INSURANCE } s. On --" b re e, a Notary Public in and for said State, personally appeared personally known to me or proved to me on the basis of sfactory evidence to be the person_ whose name � subse ?YP to the within instrument and acknowledged that exe- cuted the same. WITNESS my and and official Signature w OFFICIAL SEAL LORI L. WHITE Notary Public•Calilomie _ © principal Office In Orange County .o.M► My Comm. Exp. Mar. 17, 1989 (This area for official notarial seal) GENERAL ACKNOWLEDGMENT Slate of County of r + r PM AL JOAN RFIGIANCIAL ATASIO NOTARY PUBLIC CAWFOgNIA ORANGE COUNTY EKP. APR, 16,1990 W. 20 Orr this the ay of L L�Q� �� _ 19� a, be tore rite, SSL the undersigned Notary Public, personally appeared E7 personally known tome proved to me on Ills basis of satisfactory evidence 10(2e the persun(s) whose nalne(s) _ _.� ._ subscrilied to the within hisirurnerrl, and acknowledged that —_ ._execuled 11. WITh1ESMiny hand alis} oral seal_ I-je MMIUMAI MOCART AS$470NTION . 21012 Vgrdwa Bial. • P.V. ew 4625 • Wqudrwd R11a. CA 417 i ' STATE OF CALIFORNIA `COUNTY OF ©.Q4AJ6 e- . _ SS. On ot✓To !3 E'_e- — 1 -1 ( 5^ before me, the undersigned, a Notary Public in and for said State, personal appeared 1.-4MF �1LL�ar-is O known to me to be the person %T whose name S RQ�subscribed to the within instrument and acknowledged that executed the same. L SEAL WITNESS my hand and official seal. DDDIAN :N.OTIARYPUBUC-CALIFORNI WUNTY es Jan 24,199 0 (This area for official notarial seal) Signature of Notary SAM PROODIAH t W W x t CAT. NO. NNO0627 TO 1944 CA 19-841 (Individual) STATE OF CALIFORN COUNTY OF �/G On ry l _.- said State, personally appeared 0 TICOR TITLE INSURANCE SS. ,b _111ce, the undersigned, a Notary Public in and for , personally known to me or proved to me on the basis of satisfactory evidence to be the person_., whose name / 5- subsV'Yd to the within instrument and acknowledged that exe- cuted the same. WITNESS my hand and official SAL , Signature N1��N�t•N�M aw OFFICIAL SEAL.LORI L. WHITE Notary Public•California sPrincipal Office In Orange County y Comm. Exp. Mar. 17, 1989 (This area for official notarial sea]) CITY OF COSTA MESA Development Services,' Division of Building and Safety CERTIFICATE ,OF OCCUPANCY „/''.`-, ts of the Uniform 8uildirtg Code, Section 308 adopted by the City This certificate is issued pursuant to the requiremen of Costa Mesa certifies that at the time of -its issuance the buildingstructure herein below described was inspected and et _ approved for occupancy as follows: Building Address 3333 BRISTOL STREET, SUITE Bldg: Permit Number 2611 �i B04--00485 - - ' - Use Retail' Group M / Type of Construction, •.lI,,�R:. ,, Fire Zone Use Zone Owner of Building 3315 Address 1 South,'Coast-Plaza,.. -_--"�Te'nant Fairview,\ Road; costa Mesa, CA : 92626 l BUILDING OFFICIAL -Rick Ai BFOWil C.B.O. FRTTE J'y , . Fj- Ed',Pet'roe', Chief of Inspection Date's �6/21/2004 �i REQUIRED TO BE POSTED IN A CONSPICOUS PLACE PC#1257-93 A CITY OF COSTA MESA DEVELOPMENT SERVICES/BUILDING SAFETY RECORD PACKAGE FOR: 3333 BRISTOL STREET UNIT 2611 PARCL'L #412-501-05 B-2 STREET ADDRESS RETAIL STORE "ALFRED DUNHILL" WORK DONE X7 Building Permit # R61754 X® Certificate of Occupancy X® Electrical Release Form X® Gas Release Form Xff- Sanitation Fixture Form XFJ Plumbing Permit # P62161 X® Mechanical Permit # I6_ -qZ1— X® Electrical Permit # E62362 ❑ Reinspection Permit # ❑ Health Department Approval ❑ Roofing Certification ❑ Insulation Certification ❑ Dry Chemical System Certification ❑ Flame Spread Certification ❑ Fire Sprinkler Certification L Soils Certification ❑ Special Inspection Certification X® Other: F62240 -- All Required Documents Include C er O.K. to Approve C.O. Inspector O.K. to Release C.Q. Building Official CMF I046-30 City of Costa Mesa Development services DepartmentC E R T I F I C A T E' O F .00CUPANCY No. . Buiiding Safety Division P. O. Box 1200, Costa Mesa, California The Building located at 3333 BRISTOL STREET UNIT 2611 has been inspected -and found to comply with, the provisions of all City of Costa Mesa Ordinances applicable thereto -for a Group $-2. Occupancy, U se o f B u i l d i n g RETAI L STOkE "ALFRE6 DUNHILL". - i Legal Description 412-501-05 ISee reverse side for Metes and Bound0 Building Permit No B61754 Electrical Permit No. E62362. Plumbing Permit No, P62I61 Mechanical Permit No. M61977 Number of apartments and/or guest rooms Fire -Prevention Permit No.F62240 ISSU ED'TO: Building Official TONY C'DE BACA . C ..T.. - SEGERSTROM & SONS 3315 FAIRVIEW ROAD by COSTA MRSA. CA'92626 Date This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. CMF 1015-46 rev. 1/83 White - Owner; Canary - Numerical File; Pink- Bldg, Permit File - I CITY OF COSTA MESA DEVELOPMENT SERVICES/BUILDING SAFETY REMAD PACKAG FOR, STREET ADDRESS WORK DONE Building Permit # Certificate of Occupancy ❑ Electrical Release Form ❑ Gas Release Form r Sanitation Fixture Form f I Plumbing Permit # Mechanical Permit # '' Iectrical Permit #9C- 7 ❑ Reinspection Permit # ❑ Health Department Approval ❑ Roofing Certification ❑ Insulation Certification ❑ Dry Chemical System Certification ❑ Flame Spread Certification ❑ Fire Sprinkler Certification L Soils Certification ❑ Specia!jwpection Certification ther. d / All Required Documents Included Clerk O.K. to Approve C.O. Inspector O.K. to Release C.O. Building Otflcial CMF 1046-30 City of Costa Mesa Development Services Department Building Safety Division CERT 1 F I. C A T E O F OCCUPANCY No. 00 2 `T 00295, P. O. Box 1200 Costa Mesa, California The Building located at 3333 Bristol S .cool-. gMr_o ?611 has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group B2 Occupancy. Use of Building Retail Legal Description 412--541-02 (See reverse side for Metes and Bounds) Building Permit No-B33714,B33379 Electrical Permit No. F '41705 Plumbing Permit No. Mechanical Permit No. MNumber of apartments and/or guest rooms ISSUED TO: C. J. Seaerstrofn & Son 3315 Fairview Road Costa Masa, Ca 92626 Building Official William T. Howard by .. Date July 22,. 1988 This Certificate of Occupancy SHALL BE posted in a conspicuous place an the premises and SHALL NOT BE removed except by the Budding Official of the City of Costa Mesa under Sec. 307 {e} U.B.C. CMF 1015-46 rev, 1/a3 White - Owner; Canary - Numerical File; Pink - Bldg. Permit File C, iI� 0576 1/29/80 193.65 TL COSTA MESA BUILDING -SAFETY DEPARTMENTICA FOR STRUCTURAL PERMIT P.O. BOX 1240 COSTA MESA, CALIFORNIA 92626 Y PERMIT 7ForApplicant to Fill in Completely — Use Ink Only N° 4 9 5 7BI TA.P.ND. AODING T /S MAILING ADDRESSE NO. TEL. �.�V. LV I • 4, �. CITY NO. NEW I ADD ALTER REPAIR MOV INGI DEMOLISH CONSTRUCTION LENDER BRANCH OWNER pr ADDRESS %�� �`� i VALUE ARCHITECT TEL. USE �[J/yN QYC I a5�0� OR ENGINEER NQ. ADDRESS �1 ZONE ITYPEV GROUP /— APPROVED DATE CONTRACTO BY c ADDRESS TEL CITY NO. STATECITY APPROVED SETBACKS LIC, NO. 3Q LIC. NO. SIZE NO. OF SLOGS,(FROM C/L STREET) OF LOT NOW ON LOT FRONT FT. USE OF EXISTING BLDG. R. SIDE FT. Separate permits are required for L. SIDE FT. electric, plumbing and heating work.. REAR FT. USE OF BUILDING AND WORK TO BE PERFORMED PLANNING ACTION DATE 01 APPROVED APPROVED DATE I hereby acknowledge that I have read this application and state that the above Information Is correct and agree to comply with all laws regulating building construction, and I shall not employ any person In violation of the workman's compensation laws of the State of California. I hereby certify that I am properly licensed as a contractor under SQ. FT. the State of CailfArnla Business and Professions Code, Division 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR Chapter 9, and that such licenses are In full force and effect, or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY, am exempt from the provisions of the State of alifornla Business DI 'cion 3, Chapter 9. VALUATION PERMIT FEE $ and Professions Cddg', Signature of PLAN CHECK g �yy�67P 1-1J[ /J// Permittee c[ 5�(J'4'' TAX $ 71 Authorized Agent Date ' TOTAL PAID $172 1 COSTA MESA BUILDING -SAFETY DEPARTMENT P.O. BOX 1200 COSTA MESA, CALIFORNIA 921126 For Applicant to FRI in Complete — Use Ink Only ADBUILDING DRFSSOWNER TENANT ORde (ode MAILING ADORF-SS APPLICATION, FORIST RUC/TURA1: PERMIT0B7 0 0Q 7L RECEIVE PERMIT „x,70 Ll A.P. NO. V 1 LJ Z) IUJ ADDRESS 3333 SPAACEN O. Q� �(J TR h0 8LK TEL. CITY v •� C— �,j Lc� NO. LOT NEW ADD ALTER,REPAIR MOVING DEMOLISH CONSTRUCTION LEND9R / BRANCH � � OWNER (j G dr blah C ADDRFSS VA VE ARCHITECT TEL. USE $ OR EN INFER ADDRESS /] ZONE 6-1 TYPE GROUP � %�. APPROVED CONTRACTOR f �i*ZLD�• BY DATE ADDRIrSS TEL q-5V-%-�� CITY NO. STATE �+/J CITY j �T LIC. NO. APPROVED SETBACK LIC, NO • Ll SIZE NO.OF SLOGS. (PROM C/L STREET OF I -O -r NOW ON LOT FRONT USE OF EXISTING BLDG. Separate permits are required for L. SIDE electric, plumbing and heating work. REAR FT. USE OF BUILDING AND WORK TO BE PERFORMED PLANNING ACTION rl 4 c� DATE APPROVED / r APPROVED S Xa v I hereby acknowledge that I have read this application and state that the above Information is correct and agree to comply with all laws regulating building construction, and I shall not employ any person In violation of the workman's compensation laws of the State of California. hereby certify that I am properly licensed as a contractor under SQ. FT. the State of California Business and Professions Code, Division 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR Chapter S, and that such licenses are In full force and effect, or 1 THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: am exernpt from the rovialons of the State of Ilfornia Business VALUATION PERMIT FEE S and Professions Co ivis 3, Chapter 4. ,. Slpnature of PLAN CHECK y !!!///�jly/, Permittee ` $ TAX S or V Authorized AgentDate TOTAL PAID a CITY OF COSTA MESA DE VE LOPMENT SERVICESIBUl L.DtNG SAFETY RECORD PACKAGE FOR- MY a STREET ADDRESS 0--- ,� WO DONE .� Building Permit ❑ Certificate of Occupancy ❑ Electrical Release Form ❑ Gas Release Form Sanitation Fixture Form LJumbing Permit # Mechanical Permi4Z �O Electrical Permit 445jra ❑ Reinspection Permit # ❑ Health Department Approval ❑ Roofing Certification ❑ Insulation Certification ❑ Dry Chemical System Certification ❑ Flame Spread Certification ❑ Fire Sprinkler Certification Soils Certification ❑ Special Inspection Certification ❑ Other: All Required Documents Include � Clark O.K. to Approve C.O. Inspector O.K. to Release C.O. Building Official CMF 1046-30 City of Costa Mesa Development Services Department Building Safety Division CERTIFICATE OF OCCUPANCY No. P. O. Box 1200 Costa Mesa, California The Building located at 3333 Bristol SC:'eqat. Space 2606 has been inspected and found to Comply with the provisions of all City of Cosia Mesa Ordinances applicable thereto for a Group B2 Occupancy. Use of Building Art. Gallery Legal Description 412-501-02 Mee reverse side for Metes and Bounds) Building Permit No B 54&-A Electrical Permit No. P: 548-07 r Plumbing Permit No, Mechanical Permit No. M 55081 • U2548538 Number of apartments and/or guest roams ISSUED TO: C.J. _S`-�ge>;stroql & Sons 3333 Bristol St., # 2606 Costa msa. CA 92626 Building Official Tonv (!'Da Baca by Date r)PC-An*-Aar` 7. 1CA1 This Certificate of Occupancy SHALL BE posted in a conspicuous place an the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. CMF 1015-46 rev. 1/63 white - Owner; Canary . Numerical File; Pink . $tdg. Permit File e p •- City of Costa Mesa it Building Safety Department I • ' CER�TI�FICATE DF O.CCU.PANCY �'',)T�-R , 3212 P.O. Box 1200 Costa Mesa. California y The Building located at 3333. Bkis-Ed St'r'eet. Stak'aace '277. ha"s been inspected and found to comply",with the provision "'of all City of Costa Mesa Ordinances applicable thereto t for a Group n-7 I Occupancy:. i Use of Building �'ixrnr}maal .Rc�i a s 7', Tni`rir Alff �e'nrtM Legal Description �.P_�!l[€ni�,�-2(1:•� { j ISee reverse side for Metes and Bounds► .. ' Building Permit Na. HIP/F--910 Electrical Permit NoLIP/R-9I,Plumbing Permit NoJ�L/V/ `--gfn r, Number of apartments —f3 and/or `guest rooms —D— r -ISSUED TO: 'Building:Official 11by NTFrK-ryANnTc TW. F PF'WP?TgR Victor C. Nerd-Director Building DiviSia AIDA-GRAY i Date NOVW'>2..--r 5, 1981 This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT.BE removed except by the Building Official of the City_ of Costa Mesa under Sec. 306 (e)'U,B.C� Form SU 34 Rev. 11/7 Iry IN 1r 1.11- 1-VV/V TO 21946 CA (1-83) (Corporation) J TICQR TITLE INSURANCE STATE OF CALIFORNIA COUNTY OF Los Angeles SS' On July 7, 1983 before me, the undersigned, a Notary Public in and for said State, personally appeared -----------------------------------.---------- personally known to me or proved to me on the basis of satisfactory evidence to be the person who executed the within instrument as the ------------- President, and Clairese Payeler_ r�sw��o��••+..�weov��e+��+y personally known to me or ; OFFICIAL. SEAL ! proved to me on the basis of satisfactory evidence to be ! S. ADRIANCE the person who executed the within instrument as the a NOTARY PUBLIC - CALIFORNIA Secretary of the Corporation PRINCIPAL OFFICE IN , that executed the within instrument and acknowledged LOS ANGELES COUNrY to me that such corporation executed the within instru- L My C0M'IZfO° FKP• Aug. 24, 1483 ! ��da��oo���roa��r+•�� mens pursuant to ttsby-I ws or a resolution of its board of directors. r aaa+�� WITNESS my hand ands i'ciaLseal. CA Signature (This area for official notarial scall = CI`. t OF COSTA MEA � Development Services, Division of Building and Safety CERTIFICATE OF OCCUPANCY This certificate is issued pursuant to the requirements of the 2007 California Building Code, Section 110 adopted by the City of Costa Mesa certifies that at the time of its issuance the buildingstructure herein below described was inspected and approved for occupancy as follows: Building Address 3331 stol St . - 2418+' - - Bldg. Permit NumberSC1 1-00353 Use Tenant,.6vement 3 , Group _ M _ Type of Construction 2-A Fire Zone Use Zone Owner of Building -South Coast Plaza T Tenant David "Yurman Address 3315 Fairview Rd., Costa' Mesa, California By'., !� BUILDING OFFICIAL -Keith Clarke, C &O. Date ',12-15-2012 REQUIRED TO BE POSTED IN A CONSPICUOUS PLACE =Iin ' - CITY OF COSTA MESA DEVELOPMENT SERVICES/BUILDING SAFETY R77ECO RD PA AGE FOR: I/M - Cpl- Uo7 ST R ADD SS ,X W RK DONE Building Permit # 032Ado ❑ Certificate of Occupancy rl Electrical Release Form ,--j Gas Release Form ❑ Sanitation Fixture Form 0Plumbing Permit # e Mechanical Permit 10r Electrical Permit #s��-� ❑ Reinspection Permit # ❑ Health Department Approval Cl Roofing Certification ❑ Insulation Certification ❑ Dry Chemical System Certification C Flame Spread Certification ❑ Fire Sprinkler Certification ❑ Soils Certification ❑ Special Inspection Certification Other: /C A All Required Documents Included Clerk O.K. to Approve C.O Inspector O.K. to Release C.O. Building Official CMF 1046-30 C. _'Y OF, COSTA M "SA Development Services, Division of Building and Safety CERTIFICATE OFy OCCUPANCY This certificate is issued pursuant to the requirements of the 2007 California Building Code, Section 110 adopted by the City of Costa Mesa certifies that at the time of its issuance the build*mgstruct.ure herein below described was inspected and approved for occupancy as f6llows: Building Address 3333 Bristol Ztt '- #2`91 2, Bldg:. Permit NumberBC11-00333 Use Jewelry_Retail w Group I'I Type of Construction 1 —'i re Ione Use Zone PDC Owner of Building South 'Coast `I?laza Tenant -Cartier, Address 331 5' Fairview Rd. Costa Mesa By BUILDING OFFICIAL -Keith Clarke, C.B.O. Date CA. 926 2-29-2012 REQUIRED TO BE POSTED IN A CONSPICUOUS PLACE • '�:i�x4•."�;;�._a,.;"C�L.r�"�� "` .. __ _,.,. ,4��,..—�. `,.--�. �"�4�1}_:P' .���.,..-. � `t.�s ""` .. ,..r, yf,,.,;. •u• Y.`�,���..1jrw�L• �L• CT�'Y OP COSTA MT .)A Development Services, Division of Building and Safety CERTIFICATE OF :OCCUPANCY This certificate is issued pursuant to the requirements of the Uniform Building Code, Section 308 adopted by the City of Costa Mesa certifies thatat the time of its issuance the building structure herein below described was inspected and approved for occupancy as follows: 3333 Bristol St,. Ste 24,12. B06-01130 Building Address Bldg: Permit Number Use Jewelry Retail (2,725 s £} ✓ a . Group M Type of Construction - F R ` .' :ire:soe 3 Use Zone South, Coast Plaza - ; CARTIER Owner of Building <_ Tenant Address 3315 Fairview -Rd. , Costa Mesii, `CA .926,26' BUILDING OFFICIAL-Khanh Q.�Nguyen;-C^B.O:.- By, : Lr, 02/21/,% REQUIRED TO BE POSTED 'I'IN A CONSPICOUS PLACE POC 30 DAY "TEMPORARY CERTIFICATE . dF OCCUPANCY" CT -Y OF COSTA W. -ISA Developm6nt Services, Division of Building and Safety CERTIFICATE OF OCCUPANCY This certificate is issued pursuant to the !e4pi'rements,of the Uniform Building Code, Section 308 adopted by the City of Costa Mesa certifies that at the time of its issu'ance.the-building'structure herein below described was inspected and approved foroccupancy as follows-//,/ < 'x Building Address 3333 Bris'Eol- Str. Suite -2412. Bldg. -Permit Number B03-01560 X Use Retail Group M Owner of Building Address 3315 Type of Con, structi6 Te-7.Zone Use Zone South'Coast, Plaza ,�'-T&n;ant "CARTIER" Fairview Fairview Road.,,'\ Costa Mesa, Cx_ 92626" atrosecCentier or: BUILDING OFFICIAL -Rick X, Broi4n,, C.B.O. __.Datej, 07204 1q/,y/,�REQUIRED TO BE POSTED IN A`:C`ONSPICOUS PLACE City of Costa Mesa Development Services Department Building Safety Division P. O. Box 1200 Costa Mesa, California CERTIFICATE OF OCCUPANCY No. The Building located at 3333 Br'islrol Ste. #2412 has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group B2 Occupancy. Use of Building Retail Store Legal Description -112-501-02 lSee reverse side for Metes and Bounds) Building Permit No 852004 Electrical Permit No. E52199 Plumbing Permit No. Mechanical Permit No ISSUED TO: C.J. Secierstroms 3333 Bristol St. Ste&2412 Costa Mesa. Ca 92626 Number of apartments and/or guest rooms Building Official Tonv C r De Baca by - DateY � �•.1 I- lie.., .+i -r L Date Aucrust 14. 1991 This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. CMF 1015-46 rev. 1/83 White - Owner; Canary - Numerical Fite; Pink - Bldg. Permit File r • 44540 COSTA MESA BUILDING -SAFETY DEPARTMENT P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626 For Applicant to Fill in Completely fiyyI l1 BUILDING 33 : ,7— ADDRESS I OWNERPmAn. r U) A MAIL r� R1STo ADDRESS � N CITY r1� /j TEL. CONSTRUCTION LENDER BRANCH ADDRESS ARCHITECT FRC L LI TEL. M312- OR ENGINEER `I r ADDRESS A v 4 Q Y CONTRACTOR Lil { FT, ADDRESS � CITY Q C, 57 NOL� RR QS STATECITY LIC. NO, q �-7 LIC. NO. SIZE NO. OF BLDGS OF LOT NOW ON LOT USE OF EXISTING BLDG. / Separate permits are required for electric, plumbing and heating work. USE OF BUILDING AND WORK TO BE PERFORMED -c -r .4N7 I hereby acknowledge that I have read this application and state that the above Information is correct and agree to comply with all laws regulating building construction, and I shall not employ any person In violation of the workmen's componsation laws of the State of California. I hereby certify that I am properly licensed as a contractor under the State of California Business and Professions Code, Division 3, Chapter 9, and that such licenses are to full force and affect, or I am exempt from the provisions of the State of California Business and Professions Code, Division 3, Chapter 9. Signature of Permittee Authorized Agent PAID AUG 2t1-77PAID002006* 11 L FOR STRUMP44L PERMIT DATE RECEIVED TEL I SVIJ ED PERMIT NO. A.P. NO. / 'y(I BUILDING 3J-33 . ADDRESS TRACT LOT OWNER r 0- SCI V14 9 .27 VALUE S -� FIRE ZONE TT VE GyR/�OUP PROVED BYA [y p DA�EJ r2 ZO E NO, OF USE OF NEW �S PLANS BUILDING Jr YARDS APPROVED YARDS APPROVED MAIN BUILDING ACCESSORY BUILDING (FROM C/L STREET) R FT, FT, S. SIDE F�c•+�� �^''+ 1 DISTANCE BET. BET. MAIN 81 MAIN BLDGS. ACCESS. BLD VAR.* DATE C.U.P. APPROVED SO. FT.co w THE AMOUNT SHOWN UNDER VALUATION IS FOR m THE PURPOSE OF ESTABLISHING A PERMIT FEE ON VALUATION PERMIT FEE S v m PLAN CHECK $ d1 //rryxJ]'�`CC`JJiJ� (T V o (/VV - LL TAX s u f TOTAL PAID S / rQ 71 I sr tj COSTA MESA BUILDING -SAFETY DEPARTMENT P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626 For Applicant to Fill in Completely — Use Ink Only BUILDING 3333 3a�srac. ADDRESS OWNER MAIL ADDRESS TEL CITY NO. CONSTRUCTION BRANCH ADDRESS ARCHITECT j\(J , .J1 TEL. n FNCINFFR "P. -l/ Ar T� NO_ ADDRESS c- a coo4oGF+!"r_ /az_- CONTRACTOR (,000Cv'17 o F4E fier. IMG ADDRESS/463 E• i4c. XY RL -o TEL.3' CITY �ptp/�l� I 61q"114 NO. U*- W. STATE CITY LIC. NO. 3iR9� l."�tv LIC. No. 7,04 I SIZE NO. OF SLOW. OF LOT NOW ON LOT USE OF EXISTING BLDG. Separate permits are required for electric, plumbing and heating work. USE OF BUILDING AND WORK TO BE PERFORMED r+.� Irit'L'+2.lat? GO/t'� IpZ L�770.�-� Z••� I hereby acknowledge that t have read this application and state that the above Information is correct and agree to comply with all laws regulating building construction, and I shall not employ any person in violation of the workman's compensation laws of the State of California. I hereby certify that I am property licensed as a contractor under the State of California Business and Professions Code, Division 3, Chapter 9, and that such licenses are In full force and effect, or I am exempt from the provisions of the State of California Business and Professions Code, Division 3�Cha r 9. Signature Permittee Authorized Agant4gmr X. 41-1, SEP 19-77PAID * its * " „ Cwsa40 861 Z�.60 APPLICATION FOR STRUCTURAL PERMIT RECEIVED BY I DATE RECEIVED MITP isctrcr M. I W 0 mraMEWx,01 r ■ r ��VFTZEW/jw FIRE ZONE TYPE IL GRO��UPPPy // BY ' ATE 47—Af'11 ZO NO.OF USE OF NE • PLANS BUILDING YARDS APPROVED Y S PROV D MAIN BUILDING ACCESSO Y BUILDING REAR I FT. OISTANC BET. BET, MAIN 8+ MAIN BL ACCESS. BLD VAR. + DATE C.U.P. 06 APPROVED APPROVED m'a Y m SQ. FT, a THE AMOUNT SHOWN UNDER VALUATION IS FOR m THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: VALUATION PERMIT FEE S 1.320 PLAN CHECK $ /D 2 $ TAX $ 4 Q e1 U TOTAL PAID S 44,586 COSTA MESA BUILDING -SAFETY DEPARTMENT P.O. BOX 1200 COSTA MESA. CALIFORNIA 92626 For Applicant to Fill in Completely — Use Ink Only BUILDING 3 33 s ADDRESS ADD Pt .4 OWNER MAI L ADDRESS CITY cost& NOL$`�G'OIID CONSTRUCTION LENDER BRANCH ADDRESS R GP' bO Q � NE L, I1{ fr OARCHITECR ENGINE MQUINQ ADDRESS {{Sl �uST CONTRACTOR CO �+CLRtier ADDRESS S L43 M TEL. CITY [,.. NO. STATE CITY LIG. NO. 3 `$ $r O,{` LIC. NO. SIZE =NOW O. OF BLDGS, OF LOT ON LOT USE OF EXISTING BLDG. Separate permits are required for electric, plumbing and heating work. APPROVED BY USE OF BUILDING AND WORK TO BE PERFORMED 1 hereby acknowledge that I have read this application and state that the above information is correct and agree to comply with all laws regulating building construction, and I shall not employ any person In violation of the workman's compensation laws of the State of California. I hereby certify that i am properly licensed as a contractor under the State of California Business and Professions Code, Division 3, Chapter 9, and that such licenses are In full force and effect, or I am exempt from the provisions of the State of California Business and Professions Code, DJvJsJon 3, Chapter 9. Signature of r �•_ 1G Permittee f�.�^'' ~'�� •—? Authorized Agent PA 1:0 ** SEP-1-77FmS,g00 043 196.59 PIjC,9TION FOR STRUCTURAL PERMIT RE Y DATE RECEIVED D TE SS A.P, NO. 0— C/ �Q RMIT NO. BUILDING ADDRESS r1V�! 5 TRACT LOT BLOCK W ADD ALTER REPAIR MQUINQ QED40LISU PERMIT FEE $IV OWNER�7 _F00 PLAN CHECK 3 V USE I r7��OI VALUg /)�y FIRE ZONE TYPE � _ GROUP APPROVED BY DATE ZONE NO. OF77 USE OF NEW PLANS v BUILDING YARDS APPROVED YARDS APPROVED MAIN BUILDING ACCESSORY BUILDING (FROM CILSTREET) h T DISTANCE BET MAIN BLDGS. VAR. 46 C.U.P. * FT. BET. MAIN & ACCESS. BLOGS. DATE APPROVED r. m a m SQ. FT, N THE AMOUNT SHOWN UNDER VALUATION IS FOR THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: VALUATION PERMIT FEE $IV PLAN CHECK 3 V { o � ♦ TAX y !' /7, 1 J TOTAL PAID S "OV 16-7 �; I 00 6357 5 37%555 COSTA MESA BUILDING -SAFETY DEPARTMENT P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626 APPLICATION FOR BUILDING PERMIT For Applicant to Fill i717 REGI V D BY DATE RECEI DATE: ISSUED LDING r�`OWNER ADIDRESS `—C%o%�pf`GJ PER T Q°� r�GE d3AA -P. NO. MAIL BUILDING ADDRESS 3 Z ADDRESS LU LU CL U TEL. CITY NO. TRACT LOT BLOCK Z Z Q CONSTRUCTION W ADDREPAIR 0 LENDER O m J BRANCH I _10 OWNER M -3 ADDRESS V UE M J Q ARCHITECT TEL. 5 $ I U (A OR ENGINEER N ZQ ZONE TYPE Dry GROUP LLl Ir ADDRESS IZ Ly APPROVED LU Z CONTRACTOR RN �� �� G[�j BY DATE7-7 mZ J ADDRESS 'Z'xOd %tejAq LU TELZO NO, OF USE OF N11 ZCITY �( /1AQ� PLANS BUlLDlNG 0 STATE CITY YARDS APPROVED YARDS APPR D U.1 In= L1 C. N0./006,0 LIC. NO.-ZQj'f MAIN BUILDING ACCESSORY BUILDING DO SIZE NO. OF BLDGS. M C/L STREET) OF LOT NOW ON LOT EROFT. FT. USE OF EXISTING BLDG. FT. FT, SIZE OF NO. OF Z NEWBLDG. '-ROOMS STORIES L. SIDE FT. FT, VEXTERIOR WALL ROOF I _ COVERING COVERING REAR FT. FT. J USE OF BUILDING AND WORK TO BE PERFORMED DISTANCE BFT. BET. MAIN & CLCL MAIN BLDGS. ESS; BLDG$. Q VAR. DA O �C-oC«T oi�r 4= �-- C.U.P. APPRRVEO APPROVED fn 3rt N �4�DAT Z O VI hereby, acknowledge that I have read this application and state ATE that the above information is correct and agree to comply with all laws regulating building construction, and I shall not employ r b any person in violation of the workman's compensation laws of C0 the State of California. m Z I hereby certify that I am properly licensed as a contractor under SQ. FT, TAX o the State of California Business and Professions Code, Division 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR Chapter 9, and that such licenses are in full force and effect, or 1 THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY. m am exempt from the provisions of the State of California Business VALUATION IY and Professions Code, Divislon 3, Chapter 9. • �� to PERMIT FEE $ Signature of ��}} •.�(y '� Permittee $ S�C� PLAN CHECK $ �� E 0 Authorized Agent - TOTAL FE u.� r� � A X7473 L qrT 29-73Pc13AI�.��� 13Q� � ' 'COSTA MESA BUILDING -SAFETY DEPARTMENT P.O, BOX 1200 COSTA MESA, CALIFORNIA 92626 PP I ATION FOR BUILDING PERMIT al� For Applicant to Fill in Completely Com/ BUILDIG RE EI ED YDATER EIVED yDATE ISSUED ADDRESS `oU✓7'ir COR9r y P 1 N OWNERR.P. NO rr�� � ADDRESS !3 1 S� Fi�Z tlg� T_Vj BUILDING ' ADDRESS "ML W W LL U TEL. CITYNO. TRACT LOT BLOCK Z Q CONSTRUCTION WALTER REPAIR MOVING _QF&4nt_IRH O �; LENDER b am J Z) BRANCH 1 -j Un) OWNER <W m ADDRESS A LUS ' �f�tJ Q ARCHITECT { TEL. J 4 LnW USE U OR ENGENEER N FIRE ZONE IPE ' GROUf W IM ADDRESS fl IL APPROVE / / 4, 2t4 - LU CONTRACTOR C CG BY �/ DATE r J 0 �,�0 mZ •JCC ` ADDRESS�ta^>ti.�or� W W e \� NEOL y13 Z NE NO. USE OF N£ V �s PLANS BUILDING Z CITY Lam+ G 0 W I STATE CITY YARDS APPROVED YARDS APPROVED LIC_ NO. 'Z V LC. NO. MAIN BUILDING ACCESSORY BUILDING O SIZE NO. OF BLDGS. (FROM CIL STREET) OF LOT NOW ON LOT FRONT FT, T. USE OF EXISTING BLDG. T SIZE OF NO. OF Z NEW BLDG. ROOMS STORIES L St FT FT, VEXTERIOR WALL ROOF _ COVERING COVERING REAR F FT. J USE OF BUILDING AND WORK TO BE PERFORMED DISTANCE OCT. BET. MAIN & CL CL MAIN BLDGS. ACCESS. SLOGS. Q VAR. DATE Q &77L C.U.P. APPROVED r APPROVE / tl 1A -2 f+DATF Z Q STATE VI hereby acknowledge that I have road this application and state that the above information Is correct and agree to comply with all laws regulating building construction, and I shall not employ f any person in Violation of the workman's compensation laws of � the State of California. OD 9 ZI hereby certify that I am properly licensed as a contractor under SO. FT. o the State of California Business and Professions Coda, Division 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR Chapter 9, and that such licenses are in full force and effect, or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: m am exempt from Use provisions of the State of California Business VALUATION and Professions Cnde, Division 3, Chapter 9. PERMIT FEE $ �� ap t' Signature of C 16 m Permittee • Ir'�11�-i/«3 �^_ $©DD PLAN CHECK $ o Authorized Agent �. 4 5 TOTAL FEE $ CITY OF COSTA MESA DEVELOPMENT SE R VICESIBUI LDI NG SAFETY RECORD PACKAGE FOR: STREET ADDRESS WORK DONE 'Building Permit #�%-�ls-KA LAX/Certificate of Occupancy ❑ Electrical Release Form ❑ Gas Release Form F-1 Sanitation Fixture Form Plumbing Permit # ❑Me hanical Permit # Electrical Permit # E -51 -Al ❑ Reinspection Permit # ❑ Health Department Approval ❑ Roofing Certification ❑ Insulation Certification ❑ Dry Chemical System Certification ❑ Flame Spread Certification ❑ Fire Sprinkler Certification Soils Certification ❑ Special Inspection Certification ❑ Other: All Required Documents Included Clerk O.K. to Approve C.O. Inspector O.K. to Release C.O. Building Official CMF 1046-30 .. .v-.- .'i :rti ., ..t .. ".11�.-r.r.('_�-. .'-�. ' iur 1 - • - ''r =s :-0.J�'t"4y, CIri l OF COSTA MEr"AL Development Services, Division of Building and Safety CERTIFICATE OF OCCUPANCY This certificate is issued pursuant to the requirements of the Uniform Building Code, Section 308 adopted by the City of Costa Mesa certifies that at the time of its issuance the building structure herein below described was inspected and approved for occupancy as follows: Buiidin Add 3333 Bristol St. 2423 g ress Use Display/Sale Merchandise Group Type of Construction Owner of Building South Coast Plaza Address 3315 Fairview Rd., Costa Mesa, CA 9262 .:By: . BUILDING OFFICIAL-Khanh Q. Nguyen, C. B.O. 09/26/06 Date (1266 sf)' Tenant Bldg. Permit Number B06-00719 Use Zone PDC PUCCI REQUIRED TO BE POSTED IN A CONSPICOUS PLACE - -•�.•. r,.. - •.rr.-. w.,.+.-.sp,rn.spt.r.V � c ;r�,�-t• �...:u... v.-,T ., :vs, CFY OF COSTA MF-A 17. Development Services, Division of Building and Safety 1*44 k i CERTIFICAT�E;DF OCCUPANCY This certificate is issued pursuant to thetrequirements of the Uniform Building Code, Section 308 adopted by the City of Costa Mesa certifies that at the time of its issuance the building structure herein below described was inspected and approved for occupancy as follows: Building Address 3133•..Bristol St •S p,--2501 f:: °Bldg. Permit Number B06-01119 Use Sales/MerGi andiy-Se (1,115 s€)' r• i; .; k�.,�... � PDC Group M Type of Construction'''?'R'H' 'o`�n` :<>3' Use Zone South Coast \'P7axa%=,"'+ 'BACCfiRAT Owner of Building Tenant Address 3315 Fair' did Costa Mesa',' CA M. •,:��:'By, BUILDING OFFICIAL-Khanh Q. .' Date 10/27 06 REQUIRED TO BE POSTED IN A CONSPICOUS PLACE !=I M ■ C "ty of Costa 2%,a Development Services, Division of Building and Safety CERTIFICATE OF OCCUPANCY This certificate is issued, pursuant adopted by the City of Costa Mesa c below described was inspected andel Building Address 3333 MSTOLATREET #2501 Use RPrai1 Group'' - M Type, of,Construction SpRF�— Fire,Zo Owner of Building C J S6keriiiom &: sons Tenant Address 331 5 Fa l r.ri nt+. Rnnl- ca; Mneme I`A ��� f,27 Building Code, Section 308 the building structure herein J pp1 w M Permit No. B 79349 Use Zone ris g" BUILDING OFFICIAL -Cori -V CSN lkca � ' � By �.�' �, �.� v;�_ ..~ -:? Fb 199 Date ��., erp 11, REQUIRED TO BE POSTEDDIN CONSPICOUS PLACE C City of Costa Mesa i r Development Services Department CERTIFICATE OF OCCUPANCY No. 'Lo C Building Safety Division U �3 -2 P. O. Box 1200 Costa Mesa, California The Building located at^ 'aq'AZ Rriahrnl S esa Anara 9501 has been inspected and found to comply with the provisions of all Citycq o-sta Mesa Ordinances applicable thereto } for a Grou S2 p Occupancy. fill Use of Building TeiI=ralry "Christmas" Store " Legal Description 412-501-02 (See reverse side for Metes and Bounds) Building Permit No— BE 49800 Electrical Permit No.BE 498Q0 Plumbing Permit No. Mechanical Permit No. Number of apartments and/or guest rooms r ISSUED TO: Building Official Tony Me Baca t C.J. Segerstrom & Sons j �r r 3315 Fairview Road by J 1 Costa Mesa, CA 92626 J Date December 37 1990 This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the •;` Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. CMF 1015-46 rev. 1/83 White - Owner; Canary - Numerical File; Pink - Bldg. Permit File City of Costa Mesa Development Services Department Building Safety Division CERTIFICATE OF OCC, UPANCY No. P. O. Box 7200 Costa Mesa, California The Building located at 3333 Bristol St. Sp. #2501 has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group B2 Occupancy. Use of Building Clothing and Luggage Legal Description 412-501-02 (See reverse side for Metes and Bounds) Building Permit No, B54607 Electrical Permit No. E54756 Plumbing Permit No. Mechanical Permit No. M54694 Number of apartments 1 and/or guest rooms ISSUED TO: Building Official Tonv C' De Baca C.J. Seaerstrom & Sons P�^, 3315 Fairview Rte. by j -4 ---71 = r x 3 Costa Mesa, CA 92626 Date January 6. 1992 This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. CMF 1015-46 rev. 1/83 White - Owner; Canary - Numerical File; Pink - Bldg. Permit File G;Yy�- Yl � CI OFC STA MESA DEVELOPMENT SERVICESIBUILDING SAFETY RECORD PACKAGE FOR: t STREET DRESS / WORK D Er ��C tai�t8ing Permit #� ' icate of Occupancy Electrical Release Form ❑ Gas Release Form iF Sanitation Fixture Form rmumbing Permit # echanical Permit + Electrical Permit ❑ Reinspection Permit =#- M ❑ Health Department Approval ❑ Roofing Certification ❑ Insulation Certification ❑ Dry Chemical System Certification ❑ Flame Spread Certification ❑ Fire Sprinkler Certification Soils Certification ❑ Spe spection Certification ther: ��� All Required Documents Include -_ ' 77�A Cierk O.K. to Approve C.O. Inspector O.K. to Release C.O. Building Official CMF 1045-30 r . CITY OF COSTA MESA BUILDING SAFETY DIVISION GAS OR ELECTRICAL UTILITY RELEASE FORM TRACT LOT ADDRESS GAS ELEC. NO. UNITS NO. METER OUTLETS NO. METERS RELEASED -3 l r THESE,INSPECTIONS AREA RESULT OF: (CHECK ONE) Q'NEW CONSTRUCTION ❑ REWIRING f; '❑ OTHER (EXPLAIN) _ �� 1 / 7 151--7-- - r a� Y � Date Released ' f Signed CMF 0771-46 t Z + CAT. NO. NNO0627 TO 1944 CA (9-84) (Individual) 1 TICOR TITLE INSURANCE STATE OF CALIFORNI sI�_ COUNTY OF ss, rte, SS. On I U1�11T.,Vl�/, 7 1 69 �!!'�flJ _hduz said State, personally appeared personally known to me or proved to me on the basis of satisfactory evidence to be the person_ whose name /S�- subsc[ to the within instrument and acknowledged that exe- cuted the same. WITNESS my hand and official 1. Signature , a Notary Public in and for —6606 0 0 ago ..+�r.rti�a+♦ L OF OFFICIAL SEAL LORI L. WHITE Notary Public -California Y d Y Principal Office In Orange County .�' My Comm. Exp. Mar. 17, 19$9 a -*aa (This area for official notarial seal) �j CAT. NO, NNO0627 TO 1944 CA (9-84) (Individual) STATE OF CALIF± IA COUNTY OkF On = U said State, personally appeared J TICOR TITLE INSURANCE }a , personally known to me or proved to me on the basis of satisfactory evidence to be the person_ whose name / —� subs crj bed. to the within instrument and acknowledged that exe- cuted the same. WITNESS my hand and official seal_ Signatu F the pndersigncd, a Notary Public in and for OFFICIAL Sj:AI ai�rtF:� l% ��. iad't C-,U;C; y My CoaFFsis;3,a Exp, 5.r Z, 198E (This area for official notarial seal) CAT, NO, NNO0627 TO 1944 CA 47-821 f,ndividual) Md' TITLE tHSUPtANCE AND MUST .,KW STATE OF CALIFORNIA COUNTY 01; G i GnaQ I SS. On rk Q VeIM 6 t ?6 before me, the undersigned, a Notary Public in and for said State, personally appeared a V i , personally known to me or proved to me on the basis of satisfactory evidence to be the persons whose name t , 2 subscribed to the within instrument and acknowledged that exe- cuted the same. WITNESS my hand and official seat. Signature OFFICIAL SUL- SALLY E. POULSEN vfi NOTAPY PUBLIC • CALIFORNIA ORANGE COUNW o, ► My Comm. E"pf'" Fsh6 4' II000 GAT, NO. NNO0627 TO 19" CA (9-84) _I Ondividual) 5 Ind TICOR TITLE INSURANCE STATE OF CALIFORNIA COUNTY OF Q s C3.r!2� 4-7-� SS' WN % .- 4-1., On I I U said State, personally appeared before me, the undersigned, a Notary public in and for personally known to me or proved to me on the basis of satisfactory evidence to be the person-)C—whose name __ t S subscribed to the within instrument and acknowledged that exe- cuted the same. WITNESS my hand and official seal. i Ste'+ Signature r G"7FiC1AL SE L SALLY E. POULSEN y� y (tiOTARY PiJi3LIC •CALIFORNIA QRANGE COUNTY My Comm. Expires Fab. 9, 1990 (This area for official notarial seal) } STATE OF CALIFORNIA COUNTY OF ff / OnT✓_�_�7.,E1nn�._��� G/v� before me, the undersigned, a Notary Public in and for said State, personally appeared�C m • +R 1.t1! ti1C7 / tin? a+d personally known to me (or proved to me on the c basis of satisfactory evidence) to be the persons who executed the within instrument as r= �/ C' .President arr4 Seewow +, on behalf of s� Ca�aeuGna�_�mPa��' the corporation therein named, and acknowledged to me that ' ; o, OFFiCiAL SEAL. c}_� such corporation executed the within instrument pursuant toits P.E. ALLEN l ° _ ' NOTARY PUBLIC - CALIFORNIA by-laws or a resolution of its board of directors. o PRINCIPAL GFF[CE IN ORANGE COUNTY WITNESS my hand and official seal. `; a� Mt CarnmissiOn EXP- Ave, 21, 1987 Si9 nature Q___ (This area for official notarial seat) CITY OF COSTA MESA •DEVELOPMENT SERV ICESIBUI LDING SAFETY RECORD P CKAGE FO elok--..j �RE�DE]RESS Y � �f WORK DONE L Building Permit # 1* 1 Certificate of Occupancy Electrical Release Form ❑ as Release Form ❑ Sanitation Fixture Form Plumbing Permit # Mechanical Permit # Electrical Permit # Reinspection Permit # ❑ Health Department Approval ❑ Roofing Certification ❑ Insulation Certification ❑ Dry Chemical System Certification ❑ Flame Spread Certification ' Fire Sprinkler Certification ❑ Soils Certification Special IInnsp'fectioon Certification �Other: �` / / � All Required Documents Include Cie 7I.K. to Approve C.O. n5pector O.K. to Release C.O. Building Official CMF 1046.30 L ` CITY OF COSTA MESA DEVELOPMENT SERVICEWBUILDING SAFETY �yFIECOR'D.PACKAGE FOR: r � -c STREET ADDRESS WORKOONE ® Building Permit # 15 7 -GR Certificate of Occupancy 1� Electrical Release Form ❑ Gas Release Form Sanitation Fixture Farm Plumbing Permit #sy-15070 Mechanical Permit # r�11_Lt i Electrical Permit # zC ❑ Reinspection Permit # ❑ Health Oepartment Approval ❑ Roofing Certification ❑ Insulation Certification ❑ Dry Chemical System Certification ❑ Flame Spread Certification ❑ Fire Sprinkler Certification L Soils Certification ❑ Special Inspection Certification Other: Alt Required Documents Includedclerk -U?A- ,g O.K. to Approve C.Q. Inspector O.K. to Release C.O. Bulld4ng Offlcla! CMF 1046-30 City of Costa Mesa Development Services Department Building Safety Division CERTIFICATE OF OCCUPANCY No. L P. O. Box 1200 Costa Mesa, California The Building located at 1111 BriRt01 Stroat has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group R? Occupancy. Use of Building_ rrlt}rS Rnrro-l_ Legal Description 412501— (See reverse side for Metes and Bounds) Building Permit No T47AgAl Electrical Permit No.P7,;n7S Plumbing Permit No.p25070 Mechanical Permit No. M24761 Number of apartments and/or guest rooms / ISSUED TO: Building Official C. J. Segerstrom �- 3315 Fairview Road by Costa Mesa, CA 92626 Date This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. CMF 1015.46 rev. 1/83 White - Owner; Canary - Numerical File; Pink - Bldg. Permit File CITY OF COSTA MESA BUILDING SAFETY DIVISION GAS OR ELECTRICAL UTILITY RELEASE FORM TRACT LOT ADDRESS GAS ELEC. NO. UNITS NO. METER OUTLETS NO. METERS RELEASED THESE INSPECTIONS AREA RESULT OF: {CHECK ONE) .r} LSNEW CONSTRUCTION ❑REWIRING ❑OTHER (EXPLAIN) ��r///L r� Zm= Date Released Signed CMF 0771-36 z4v az-F6 = 041 I.��o - a�Y 31.85 COSTA MESA BUILDING-SAFETY DEPARTMENT P.O. BOX 7200 COSTA MESA, CALIFORNIA 92626 /AP91LICATION FOR BUILDING PERMIT For Applicant to Fill in Completely � E ED Y TERECEI D �t�O~ ��/ST7iG ��'.'' _' ZE)3U� ADILDING DRESS 333 ff OWNER H IAf )JIX T !J'''e4- i A.P. NO. O -0 PE MAi LBUILOING�3� ADDRESS t'^^ ADDRE Z CLLLJ 0.0 U CITY NO. TEL' TRACT LOT BLOCK HZ Z Q CONSTRUCTION O LENDER t�j 0. m J =) J N BRANCH .! //''',� A < J ADDRESS OWNER ( 3 ALOE lb J Q ARCHITECT TEL. S $ — OR ENGINEER N Q Z < FIRE tr ADDRESS ZONE TYPE7. GROUP 0. li! Ls! Z `-� CONTRACTOR &6,10c+J d7rTIs bac ecTeGw APPROVED BY w DATE Jp T OC ADDRESS E. YA4L45" A./O ' LJJO w TEL 1. `%1 �JL.�1� 2 E NO.OF Ie USE OF N&= "' PLANS (I BUILDING Z CITY L.,/r6/1 NO. 33G-S+36 O STATE CITY 2q 3 7f14�1 YARDS APPROVED YA O APPROVED W x Llc. No. 317 Li C. NO. MAIN BUILDING ACCESSORY BUILDING SIZ£ NO. OF BLOCS. (FROM C/L STREET) OF LOT NOW ON LOT RO FT. FT. USE OF EXISTING BLDG. SIZE OF NO. OF ZZ NEW BLDG. ROOMS STORIES L. SI FT. FT. U EXTERIOR WALL ROOF _ COVERING COVERING REAR J USE OF BUILDING AND WORK TO BE PERFORMED DISTANCE BET. BET. MAIN & 0. MA IN SLOGS. ACCESS. BLDGS. lF15mu_ irle " to1",AeLCr_s 1%J C.U.P. # APPROVED O I^APPROVED 'fie f'QATF (Al. Nc_w InA Z O VI hereby acknowledge that I have read this application and state that the above inforrrlation is correct and agree to comply with all laws regulating building construction, and I shall not employ any person In vlolati0n of the workmen's compensation laws of j1X the State of California. 2 Qoo m Z I hereby certify that I am property licensed as a contractor under , SO. FT. the State of California Business and Professions Code, Division 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR Chapter 9, and that such licenses are In full force and effect, or I am exempt from the provisions of the State of California Business THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY• VALUATION and Profesalons Code, Division 3, Chapter 9. m tv Signature of PERMIT FEE $ qA� 7 m Permittee $ �� jV� PLAN CHECK $ E fff jj 3S n LL Authorized Agent TOTAL FEE $ r— i A MESA BUILDING -SAFETY DEPARTMENT BOX 1200 COSTA MESA, CALIFORNIA 92626 For Applicant to Fill in Completely BUILDING �) ADDRE 7 — P MAIL � ADDRESS W W TEL. U CITY�j¢ NO. CONSTRUCTION O (r LENDER (L M J BRANCH J < LU J ADDRESS m ARCHITECT TEL. _j < OR ENGINEER S V NO. U Q W rr ADDRESS IL W Lt1 Z CONTRACTOR r JO. M Z J CC ADDRESS W LU TEL. Z = CITY NO. Z i - U) STATEQ �Q� C1TY V) tX LIC. NO. 8 LrC. No..�9�� Z) 0 SIZE NO. OF BLDGS. OF LOT '� NOW ON LOT -� USE OF 0—C)EXISTING BLDG, F SIZE OF NO. OF Z NEW BLDG. Zo ROOMS STORIES VEXTERIOR WALL ROOF _ COVERING COVERING J USE ggF BUILDING AND WORK TO BE PERFORMED d Yds FnArT tl•117)i-rin.lr- CL Q 0 z 0 U In Z ,i, 8-75 CHS' 01785 APPLICATION FOR BUILDING PERMIT RE(I D BY D 7� CEI DATE ISSV f M r OWNS FIRE ZONE TYPf GROUP APPROVED BY DATE 1 ZO E NO. OF USE OF N I L PLANS BUILDI YARDS APPROVED YARDS APPROVED MAIN BUILDING ACCESSORY BUILPP {FROM C/L STREET) 11 7 ;/-./ DISTANCE BET. V MAIN BLOGS. BET. MAIN ACCESS.' VAR.# DATE C, U.P, + APPROVED 0,%, .%lJ nnTc-/ —�/� v7 I hereby acknowledge that I have read this application and state 17 11 N that the above Information is correct and agree to comply with all taws regulating building construction, and I shall not employ any person In violation of the workman's compensation laws of SO. FT. m TAX o the State of California. I hereby certify that I am properly licensed as a contractor under THE AMOUNT SHOWN UNDER VALUATION IS FOR i THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY., Q the State of California Busin4ss and Professions Code, Division 3, Chapter 9, and that such licenses are In full force and effect, or I am exempt from the provisions of the State of California Business and Professions Code, Divisloh 3, Chapter . _ ,4 by 4S'S! C0 nature of VALUATION -PLAN /, PERMIT FEE $ • Q'r�/ N CHECK $ m •U. or - /.- I9R &t& TOTAL I v 442' 0 COSTA MESA BUILDING -SAFETY DEPARTMENT P.O. BOx 7200 COSTA MESA, CALIFORNIA 92626 For AppGc n o in Co pletel — Use Ink BUILDING ADDRESS CVC J OWNER MAIL ADDRESS TE L. CITY NO. CONSTRUCTION LENDER BRANCH ADDRESS ARCHITECT TE OR ENGINEER N 0. ADDRESS CONTRACTOR ADDRESS TEL CITY NO t_ STATECTY LIC. NO "��� �j LIC. NO. SIZE NO. OF BLDGS. OF LOT NOW ON LOT USE OF EXISTING BLDG. Separate permits are required for electric, plumbing and heating work. USE OF BUILDING AND WORK TO BE PERFORMED W/.'A—P'/� NA ,(J1—6-77r+t<Iu'uPOO 53S ....'- ' e. . it APPLICATION FOR STRUCTURAL PERMIT RECEIVED BY I DATE RECEIVED p67E ISSUEC IIIIIIII A.P. NO. v BUILDING ADDRESS TRACT 1 LOT BL C NEW 181212 ALTER EPAIR OWNER VALUE S $ FIRE ZONE A TYP GROUP APPROVED:k BY DATE ZONE NO. OF USE OF NEW PLANS BUILDING YARDS APPROVED YARDS APPROVED MAIN BUILDING CC ES ORY BUILDING (FROM CA STREE / REAR I / DISTANCE BET MAIN SLOGS. VAR. + G.U.P. + / FT. BET. MAIN ai ACCESS. SLOGS. DATE -V I hereby acknpwiedge that I have read this application and state r� that the above Information is correct and agree to comply with m all laws regulating building construction, and I shall not employ i any person in violation of the workman's compensation laws of �+ the State of California. .: I hereby certify that I am property licensed as a contractor under SQ. FT. w the State of California Business and Professions Code, Division 3,THE AMOUNT SHOWN UNDER VALUATION IS FOR M Chapter 9, and that such licenses are In full force and effect, or I THE PURPOSE OF ESTABLISHING A PERMST FEE ONLY: e am exempt from the provisions of the State of California Business VALUATION PERMIT FEE $V aProfessio 4 Code, Division 3, Chapter 9. . m Signature of Permittee `�' 1440, $ 1Y v PLAN CHECK $22, m 4.nd O u TAX $ f Authorized Agent TOTAL PAID $ OWNER BRENTANO'S INC. DATE 9_20_73 1J0B ADDRESS 3333 Bristol Avenue BUILDING PERMIT N0. 371()2 AnGENERAL CONTRACTOR Orvin_E.,,pineerinQ Corp. DESCRIPTION of WORK Fire Sarinkiprc AP's+. LOT TRACT FIRE ZONE VALUE N'; CTJONS Signature Date GROUP TYPE QSOIL. GA5 SUBCONTRACTOR WATER Plumbin ROUGH PLUMBING PROP. SWR. LINE HOUSE CON. [] SPRINKLING SYSTEM MISCELLANEOUS ROUGH HEATING AND AIR CONDITIONING TEMPORARY SERVICE OR POLE UNDERGROUND POWER ROUGH WIRING Heating and Vent. TRENCHES Lj FORMS STEEL REINF. FLOOR SYSTEM BOND BEAM STEEL REINFORCE SHEATHING FRAME AND FLASHING LATHING — IN F1 OUT PLASTER, BROWN COAT ST- -URAL, FINAL glecItic HE S. VENT., REFRIG. AND A.C., FINAL PLUMBING, FINAL AND GAS TEST ELECTRIC. FINAL OWNER BRENTANO'S DATE .9-14-73 JOB ADDRESS 3333 Bristol BUILDING PERMIT NO. 37280 GENERAL CONTRACTOR INTERSTATE NEON CORP. DESCRIPTION of WORK Advertising Sign_ �t- No. 140 -052 -08&0q -OT TRACT FIRE ZONE VALUE $ 700.00 1. ECTIONS Signature I Dare 11GROUP TYPE ZONE C15 GAS SUBCONTRACTOR WATER Plumbin ROUGH PLUMBING PROP. SWR. LINE Q HOUSE CON. [, SPRINKLING SYSTEM MISCELLANEOUS ROUGH HEATING AND AIR CONDITIONING TEMPORARY SERVICE OR POLE UNDERGROUND ❑ POWER ❑ ROUGH WIRING Heating and Vent. TRENCHES FORMS M STEEL REINF. FLOOR SYSTEM BOND BEAM STEEL REINFORCE SHEATHING FRAME AND FLASHING LATHING — IN OUT PLASTER, BROWN COAT ':TURAL, FINAL K_._. LNG, VENT., REFRIG. AND R.C., FINAL t_ % PLUMBING, FINAL AND GAS TEST n BUILDING, FINAL IZA-2-� I'L•,7-i' CIS OF COSTA MF- A Development Services, Division of Building and Safety CERTIFICA. -TW OF OCCUPANCY !1r/ter This certificate is issued pursuant to the,requirements of, the .2010-California�Building Code, Section 111 adopted by the City of Costa Mesa certifies that.at the,time=of its issuance the building structure herein below described was inspected and approved for occupancy as follows: Building Address 3333 Hr,isto'lr5_t, #229.0 ,!.. �B1dg Permit NumberBC12-00567 Use J CREW - ff � � }( "Jjc� v u u Group M Type of Constructs`an �p-8P Erfni Ffre^Zone I 0 Use Zone � %JACR-1EJ00Ownerof Building SDu Co��t Pl� a�'a— � Tenant _ Address IN-WOM BUILDING OFFICIAL-K1anti REQUIRED TO BE Lb 7 atev A2 /A±�--" V [N A CONSPICUOUS PLACE 37302 COSTA MESA BUILDING -SAFETY DEPARTMENT P.O. BOX 1200 COSTA MESA, CALIFORNIA 92625 For Applicant to Fill in Completely ILDING DRESSNER 3333 Bristol Avenue Brentano's Inc. DRESS 609 Fifth Ave. 6th Floor Y I New York, N. Yo NO'NSTRUCTION NDER None ANCH ROOF DRESS COVERING ARCHITECT TEL. ADDRESS CONTRACTOR Orvin Engineering Corp. ADDRESS P. 0. BOX 338 f IL Zir tttYlYl:�i.��' sEP 20 77CPAHAN �1.. APPLICATION FOR BUILDING PERMIT Rr:iV)D BY gQ7E RECEIrV�ED DATE ISSUED U -0/1 / /moi %i n n A.P. NO. BUILDING ADDRESS TRACT LOT OWNER FIRE ZONE TYP APPROVED X VALUE DATE �ff �mA LaHabra, Ca. 90631 1-404NO. 0 ZONE OF PLANS USE OF BUILDING NEW ` CITY ROOMS STORIES NOL$? ROOF COVERING COVERING STATE t 50?5� C— 6 CITY 213p YARDS APPROVED YARDS APPROVED LIC. NO. LIC. NO. MAIN BUILDING ACCESSORY BUILDING (FROM C/L STREETi SIZE f NO. OF BLOCS. OF LOT NOW ON LOT FRONT FT. FT. USE OF - FT. EXISTING BLDG. BET. MAIN & ACCESS. BLDGS, SIZE OF NO. OF NEW BLDG. ROOMS STORIES EXTERIOR WALL ROOF COVERING COVERING USE OF BUILDING AND WORK TO BE PERFORMED Fire Sprinklers I hereby acknowledge that I have read this application and state that the above Information is correct and agree to comply with all laws regulating building construction, and I shall not employ any person in violation of the workman's compensation laws of the State of California. I hereby certify that I am properiY licensed as a contractor under the State of California Business and Professions Code, Division 3, Chapter 9, and that such licenses are in full force and effect, or I am exempt from the provisions of the State of California Business and Professions Code, Division 3, Chapter 9. Signature of ORVIN GINE ' iNG ORP. Permittee C/V Authorized Agent REAS FT. FT. DISTANCE BET. MAIN BLDGS. BET. MAIN & ACCESS. BLDGS, VAR.* C.U.P. DATE APPROVED APPROVEQ to SO. FT. o THE AMOUNT SHOWN UNDER VALUATION IS FOR THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: m VALUATION m PERMIT FEE $ +00 j m $r f 61 5.00 LAN CHECK $ • E 4 `o TOTAL FEE $ C/( Z . a [w]` '^ Z Za oU) a m J J C!3 Qw M J m J Q U � Z Q W CC CL W wZ J Q T Z J Ir LU W Z l— W0 70 ... :.... . , 369.48 ! li_ 10-73%per°00 996* *** .. ��.:� 328.19 COSTA MESA BUILDING -SAFETY DEPARTMENT P.G. BOX 1200 COSTA MESA, CALIFORNIA 92626 For Applicant to Fill in Completely BUILDING AD0RESSS• �'^�^�^'•il OWNER ,rr- MAIL 58 to `+tl >—' T SSV it ADDRESS I"' TEL. CITY /VC7.,j YtA2./t /Va • NO. CONSTRUCTION BRANCH ADDRESS ARCHITECT OR ENGINEER R64 ' E OL t+ �Z2dZ A.P. NO. L V� A weS7WCV0 2N Lilfi ADDRESS T BLOCK Ili -00 a CONTRACTOR X AQ — Q ADDRESS i_„�S'J aILLEE 0=U116 S* CITY APPROVED BY DATE TEL, NO. —qb'j STATE LIC. NO. Bl z+� CITY LIC. NO. `+ SIZE �y �Q[J NO. OF BLDGS. OF LOT F NOW ON LOT USE OF L. SIDE T. EXISTING BLDG, vz FT. DISTANCE BET. MAIN BLDGS. SIZE OF NO. OF DATE APPROVED NEW BLDG. ROOMS STORIES EXTERIOR WALL ROOF COVERING COVERING THE AMOUNT SHOWN UNDER VALUA N IS FOR THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: USE OF BUILOING AND WORK TO BE PERFORMED %tlf F,01d2- W69 21C I hereby acknowledge that I have read this application and state -- 'hot the above information is correct and agree to comply with all laws regulating building construction, and I shall not employ' any person in violation of the workman's compensation laws of the State of California: I hereby certify that I am properly licenseQ,,ivisicn r under the State Afr 'ess and Prvfes 3Chapter 9nses are in fuct, or Iam exemns of the Statusine and Profen Chapter 9 Signature Permittee Authorized Agent APPLICATION FOR BUILDING PERMIT RECEIVAY VS o E 137! E D PATE I UED A.P. NO. L V� A PER ITN BUILDING pDRESS .J At TRA T BLOCK w DALTER k REP MOVING __T_ OWNER ZnF,C17WA Q.3 / tT, us S�Ef,� to2 L VALUE L 00 d L FIRE ZONE TY P GROUP APPROVED BY DATE ZONE=NLO.F USEOF NEW BUILDING YARDS APPROVED MAIN BUILDING YARDS APP r VE ACCESSORY BUILDf (FROM C/L STREET) FRONT FT. F FT. L. SIDE T. REAR FT. vz FT. DISTANCE BET. MAIN BLDGS. BET. MAIN & ACCESS. BLDGS. VAR. + C.U.P. * DATE APPROVED / APPROVED / 0.1 DATE 7Arfi SQ. FT. 7AX THE AMOUNT SHOWN UNDER VALUA N IS FOR THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: VALUATION $ Z/j 67OQ J O PERMIT FEE $ / z PLAN CHECK $ o TOTAL FEE $� a) m a i Ir m _D M 0 LL CITY OF COST,a MESA I DEVELOPMENT SERVICESIBUILDING SAFETY RECORD PACKAGE FOR: .�� � Q �� /►,, STREET ADDRESS V=42!Lw WORK DN Building Permit #'6 &e ❑ Certificate of Occupancy ❑ Electrical Release Form ❑ Gas Release Form -] Sanitation Fixture Form ❑ Plumbing Permit # Mechanical Permit #r�7�`7 ❑ Electrical Permit # ❑ Reinspection Permit # ❑ Health Department Approval ❑ Roofing Certification ❑ Insulation Certification ❑ Dry Chemical System Certification ❑ Flame Spread Certification ❑ Fire Sprinkler Certification Soils Certification ❑ Special Ir2jpection Certification Other: All Required Documents Includ rk O.K. to Approve C.O. Inspector O.K. to Release C.O. Building Official CMF 1046.30 � ..� City of costa 2M.5a � Development Services, Division of Building and Safety CERTIFICATE OF OCCUPANCY 1-0 This certiflcake is issued pursuant to�the�reguirements of; the�Uniform Building Code, Section' 308 adopted by the•City of Costa Mesa certifies. that. avthe time of its issuance the building structure herein below described was inspected a/nd{approved fo;7C& ipancy-as;follows: Building Address 3333 BRISI�OL ,SiEHET 02240 Bldg. Permit No. B 766683 Use RETAIL I !c /.�'. _ ,� �2� i�11;t✓� `y� Group M Type of;Go struction IFR SP ^FirEZoneUse Zone _ C1-5 Owner of Building C. J. .gdgerbtrom -` /)Tenant "Jtr/CEJ"' Address 3315 Fairview }oast' !,Costa Mesa` Ca '' 2 -- s'1 C ? 1{ !� �V �, ;•.., �� if By BUILDING OFFicL4,L-tong t'Ibe Baca Date�March 21, 1996 REQUIRED TO BE POSTED IN-' CONSPICOUS PLACE .. z. ..,F.. , .. •sof ... s..r,A— '0' 7.. t :J'_;f-'..r.: ..... ... .. .... `+i ;r...�.+�: i4l'; CITY OF COSTA M�5�%� DEVELO?MENT SERVICESIBUILDING SAFETY RECCiRD PACK GE FOR: STREET ADDRESS WORK DONE Building Permit �1� ❑ Certificate of Occupancy ❑ Electrical Release Form ❑ G elease Form station Fixture Form PI ing Permit Mechanical Permit'4"AIV,3 Electrical Permit #C-45 ❑ Reinspection Permit # ❑ Health Department Approval ❑ Roofing Certification ❑ Insulation Certification ❑ Dry Chemical System Certification ❑ Flame Spread Certification Fire Sprinkler Certification L, Soils Certification CJ Special Inspection Certification R�,Other: All Required Documents Include 'Clerk O.K. to Approve C.O. O.K. to Release C.O CMF 1046.30 Inspector Building official _ City of Costa Mesa Development Services Department CERTIFICATE OF OCCUPANCY No. 0© 219 Building Safety Division `; 1 5 P. 0. Box 1200 Costa Mesa, California The Building located at 3333 Bristol Street, Space _2240 has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group 82 Occupancy. Use of Building Retail Legal Description 41.2-501-02 (See reverse side for Metes and Bounds) Building Permit No. B 40390 Electricai Permit No. F 44548 Plumbing Permit No. p AnA17 Mechanical Permit No. 1*1 40393 Number of apartments and/or guest rooms gir:e Prevention parmit No. F 40424 ISSUED TO: Building Official C--eav"m LAm4at-e% C.J. Seaerstrom & Sons 3315 Fairview Road by % !,. -r- Costa Mesa, CA 92625 Date March 1, 1990 This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. CMF 1015-46 rev. 1/83 White - Owner; Canary - Numerical File; Pink - Bldg. Permit File PC#2848-93 A CITY OF COSTA MESA ='1 DEVELOPMENT SERVI CESIBUI LDING SAFETY R`t'- D PACKAGE FOR: 33 3 BRISTOL STREET SPACE #2261 PARr.m. #140--052-06 B-2 STREET ADDRESS RETAIL STORE "MOSSIMO" WO R K DONE )ff Building Permit # B64224 IM Certificate of Occupancy ❑ Electrical Release Form ❑ Gas Release Form C' Sanitation Fixture Form [_I Plumbing Permit # Mechanical Permit +-M6429.8.___ Electrical Permit # E64734 ❑ Reinspection Permit # ❑ Health Department Approval ❑ Roofing Certification ❑ Insulation Certification ❑ Dry Chemical System Certification ❑ Flame Spread Certification ❑ Fire Sprinkler Certification C Soils Certification ❑ Special Inspection Certification Other. F64726 All Required Documents fnclu ed Clerk O.K.to Approve C.O. nsp ctor O.K. to Release C.O. Building Official CMF 2046-30 . I Cid of C0.5ta maa Development Services, Division of Building and Safety CERTIFICATE OF OCCUPANCY This certificate is issued pursuant tq,,,therequireinents of.�th`niform Building Code, Section 308 adopted by the City of Costa Mesa certiff&,that'at-th'e time of its.issuance the building structure herein below described was inspected acids pr`o' 6'hr•occuparlcytias follows: 3333 B1�ISTOL''&RM UNIT 2Z6I C B64224 Building Address Bldg. Permit fVo. Use RETAIL STORE �.., '�� ?; ' i Group B-2 Type of Coristruction 11 FR _SP Fire Z`one ti Use Zone CIS Owner of Building C.J•' SEGERSTROK- -�T rant f1 m6sn o - �..{,�5rri�ti'_'-X _�r Address 331MR9IEU ROAD, COSTA HE 'CA 92626' .UI BUILDING OFFICIAL-Itonp6 J7C[Ga`—R_ REQUIRED TO BE J AC -OUS PLACE r �� a I=I City of Costa Mesa *Development Services Department CERTIFICATE O F OCCUPANCY No. Building Safety Division " P. O. Box 1200 Costa Mesa. California The Building located at 3333 BRISTOL STREET #2261 has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group B-2 Occupancy. Use of Building RETAIL STORE "HOSSIMOV Legal Description 140-052-06 (See reverse side for Metes and Bounds) Building Permit NoUNA-&-i Electrical Permit No. E64734 Plumbing Permit No, Mechanical Permit No.M642Wt Number of apartments and/or guest rooms Fire Prevention Permit No. F64726 ISSUED TO: ; Building Official /"TONY C'DE BACA C.J. SEGERSTROM & SONS 3315 FURVIEW ROAD by r Gam' COSTA MESA CA 92626 Date This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. CMF 1015-46 rev. 1/83 White - Owner; Canary - Numerical File; Pink - Bldg. Permit File ' � I T� COSTA v?�3yMESA �- DEVELOPMENT SERVICESIBUiLDING SAFETY RECORDPACKA FOR STREET ADDRESS WORK DON Ef E& tfuilding Permit # ❑ Certificate of Occupancy ❑ Electrical Release Form ❑ Gas Release Form r Sanitation Fixture Form ❑ Plumbing Permit =#- E� " M anical Permit �1L9 Electrical Permit #� ❑ Reinspection Permit # ❑ Health Department Approval ❑ Roofing Certification ❑ Insulation Certification ❑ Dry Chemical System Certification ❑ Flame Spread Certification r Fire Sprinkler Certification IJ Soils Certification ❑ Special Inspection Certification ltd' Other:' 1 All Required Documents Includedg 1�rm Clerk'�'� O.K. to Approve C.O. Inspector O.K. to Release C.O. Building official CMF 1046-30 City of Costa Mesa DeveBui ding Safety Dnt Services ivision Department CERTIFICATE OF OCCUPANCY No. 0 3 CI U 0 P. O. Box 1200 Costa Mesa, California The Building located at 3333 Bristol Street, Space 2261 has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group BZ Occupancy. Use of Building Retail Legal Description 412-50.1-02 (See reverse side for Metes and Bounds) Building Permit No B 45757 Electrical Permit No. E 46011 Plumbing Permit No, Mechanical Permit No. M AsgpQ Number of apartments and/or guest rooms Fir'.,�revention Permit No. F 45940 �ony Me Baca ISSUED TO: Building Official C. J. Seaerstrom & Sons } f 3315 Fairview Road by— Costa Mesa, CA 92626 Date March 14, 1990 This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. CMF 1015-46 rev. 1/83 White - Owner; Canary - Numerical File; Pink - Bldg. Permit File ■ 4n602 COSTA MESA BUILDING -SAFETY DEPARTMENT P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626 rain 13E7_ 1 53 .5_ 5 APPLICATION FOR BUILDING PERMIT For Applicant to F!1! in Completely RECEIV DATE RECEIVED p TE ISSU •� 333 ��S si. n1N1'ns�y, Y§ �DYrN'' MiZ�3 p"QLr,, A. P, NO ^-Q T p r 333 B2ls 5T. BUILDI G AODRE553'��j a, A aL .01 TEL.�j /Y ��-�FNO. TRACT - BLOCK N W A / 1 BRANCH OWNER 6140WOL-' ^ i' 17-e ADDRESS _ / -- D O+l-6 VALUE q- [O� G QGG ARCHITECT Jf���� TEL i jj� C OR ENGINEERWkLs".1 J1r 4JS TJ�C. TN S $I-'2 ADDRESS 3j/yo twoS{. OWtA40 FIRE ZONE I TY E GROUP CONTRACTOR I,.I CQ,�S RuG �,)•� �. APPROVED BY DATE AdDRESS ��� 6AILr %4161 TEL O E NO. OF USE OF N CITY yj�l rid! , NO. PLANS BUILDI G STATE �n CITY LIC. NO- S-� LIC. NO. YARDS APPROVED YARDS APPROV D MAIN BUILDING ACCESSO Y Stj!NG SIZE NO. OF BLDGS. (FROM C/L STREET) �^ OF LOT NOW ON LOT FRQNT FT. T USE OFw AA EXISTING BLDG, F SIZE OF NO. OF NEW BLDG. ROOMS STORIES r- 1j'V L. FT, EXTERIOR WALL ROOF bel COVERING COVERING S '.4 REAR FT. SE OF BUILDING ANO WORK TO BE PERFORMED DISTANCE BET. BET. MAIN iii MAIN BLDGS. ACCESS, BLDGS. ' _ 1�'T iO/L ern !f-a�1u04�45 VAR. il'`- DATE C.U.P.+1 APPROVED APPROVE O� TATE 1 hereby acknowledge that I have read this application and state that the above information is correct and agree to comply with all laws regulating building construction, and I shall not employ any person in violation of the workman's compensation laws of re the State of California. I hereby certify that I am properly licensed as a contractor under SO. FT. THE AMOUNT SHOWN UNDER VALUATION IS FOR the State of California Business and Professions Code, Divlsicn 3, Chapter 9, and that s licenses areplfull farcean effect, or i THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: from p visionsofoaSifnia Business Profession 3,ov, VALUATION —71 Ih 1749 and od rvision . PERMIT FEE $ Signature D Permittee $ 1 PLAN CHECK $ Authorized Agent w TOTAL FEE It J HJT 4ii l 7.0 COSTA MESA BUILDING -SAFETY DEPARTMENT P.O. BOX 1200 COSTA MESA, CALIFORNIA 92826 PQ;J 10T 27-75r.1i;_. 1062* ***-46.70 r k APPLICATION FOR STRUCTURAL PERMIT For Applicant to Fill in Completely — Use Iltk Only REc I D BY OAT E ECE1VEp �G ~ A.P. NO. Ilk -4062-907 DATE ISS D /O p� P I d ADOFIESs 3 3 IZ1S St • _ OWN9R .514OLOOE14 /AIZL MAIL p ST �f BUILDING I& AODRESS VA AOORESS rJYlfs'fb V • TEL(� C►T Y *a ���, NO TRACT LOT BLOCK CONSTRUCTION LENDER BRANCH OWNE ADDRESS VALUE PC US A S ARCHITECT TEL. OR ENGINEER FIRE ADDRESS ZONE TYPE -/ GROUPCj— CONTRACTOR Ien" FIVLE Kl�lCt_C'4 APPROVED ��((�� //��'III/ BY /T DATE ) ADDRESS '� ai //^�� p, TEL Z y�r' PLOANS N I A �.r7 CITY 5"�b �tyy Cp�--• NO.S�(p� 44 a BUILDIF STATE//�� �j CITY YARDS APPROVED YARD APPROVED LIC. NO.'L 028 LIC. NO. MAIN BUILDING ACCESSORY BUILDING SIZE NO. OF BI DOS IF ROM C/L STREET) OF LOT NOW ON LOT FRONT FT. FT. USE OF EXISTING BLDG. fr F Separate permits are required for L S112L FT. FT, electric, plumbing and heating work. REAR FT. FT. USE OF BUILDING AND WORK TO BE PERFORMED DISTANCE BET. BET. MAIN & MAIN BLOGS. ACCESS. BLDGS. L % VAR. DATE C.U.P. 0 APPROVED APPROVED QATF 1 herapY acknowledge that I Rave read this application and state that the above Information Is correct and agree to comply with if laws regulating building construction, and I shall not employ any person In violation of the workman's compensation laws of the Stets of California. I heresy certify that I am properly licensed as a contractor under SO. FT. THE AMOUNT SHOWN UNDER VALUATION IS FOR the Stote of California Business and Professions Coda, Divlslon 3, Chapter 9, and thet such licenses are In full force and effect, or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: am exompt from the provi o s of the State of C�fornia Business VALUATION PERMIT FEE $ and Professions C , Divi o 3, Chapter 9. PLAN CHECK $ Signature TAX $ S Q Permfttes a ` TOTAL PAI D $ 4 Q Auth fsad bent r k CITY OF COSTA MESA DEVELOPMENT SERVICESI$UILDING SAFETY RECORD PACKAGE FOR. 233.3 STREET ADDRESS WORK DONE Building Permit #95h;r ❑ Certificate of Occupancy ❑ Electrical Release Form ❑ Gas Release Form Sanitation Fixture Form ❑� /Plumbing Permit # � 1��' Mechanical Permit% CP Electrical Permit+& to Reinspection Permit # ❑ Health Department Approval ❑ Roofing Certification ❑ Insulation Certification ❑ Dry Chemical System Certification ❑ Flame Spread Certification ❑ Fire Sprinkler Certification L Soils Certification ❑ Special Inspections Certification ,. Other:�L�/ All Required Documents Included Clerk O.K. to Approve C.O. Inspector O.K. to Release G.O. Building Offlow CMF 1046-30 City of Costa Mesa Development Services Department-1CERTIFICATE OF OCCUPANCY No. 0 �+` �++ Building5afety0ivision C�'-J, P. O. Box 1240 Costa Mesa, California The Building located at 3333 Bristol Street, Space 2259 has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group R�) Occupancy. Use of Building Qf4tai 1 Legal Description 412-510-02 (See reverse side for Metes and Bounds) Building Permit No, B 46394 Electrical Permit NjW528,E45921 Plumbing Permit No, Fire I2rotection Permit No. F 46550 Mechanical Permit No ISSUED TO: Number of apartments and/or guest rooms Building Official Tony C'Da Baca (If T. fipaPral-rnm & Sona 3315 Fairview Road by f nghA r1AgA. CA 42626 T - - Date_ May 2, 199 This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. CMF 1015-46 rev. 1/83 White - Owner; Canary - Numerical File; Pink - Bldg. Permit File t CIr--'Y OF COSTA MF CA Development Services, Division of Building and Safety CERTIFICATE OF OCCUPANCY This certificate is issued pursuant to ttie'requireinents of the Uniform Building Code, Section 308 adopted by the City of Costa Mesa certifies that at the time of its issuance the building structure herein below described was inspected and approved for occupancy as follows.-.,,, 3333 Bris6ol St. ; -,,St2.2.55 B07-00053 Building Address Bldg. Permit Number Use Clothing Retai,1 (2,325 s.f.) TM" M \ s i—PP r XXXXXXX PDC Group Type of Construction Fire Zone Use Zone South .Coast Plaza BALLY ' Owner of Building Tenant 3315 Fairview "Rd., Costa Mesa, CA 9262 Address BUILDING OFFICIAL-Khanh Q. Nguyen, CA'0.1 Date 08/30/07 REQUIRED TO BE POSTED IN A CONSPICUOUS PLACE I City of Costa Mesa Development Services Department Building Safety Qivisi Ori CERTIFICATE OF OCCUPANCY No. 002644 P. O. Box 1200 Costa Mesa, California The Building located at 3333 R. Sri.tnl_Strt-ets_ gnacp _7_255 has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group t=h Occupancy. Use of Building Retail Legal Description 412--501-02 (See reverse side for Metes and Bounds) Building Permit No R 22F'+M Electrical Permit No._P 7A71.Fe Plumbing Permit No. P 30797 Mechanical Permit No. _ M 29973 Number of apartments ISSUED TO: C. J. Seaerstrom & Sons 3315 Fairview Road Costa Mesa, CA 92626 Building Official and/or guest rooms William T. Howard by Date September 23, 1988 This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. CMF 2015-46 rev. 1/83 White - Owner; Canary - Numerical File; Pink - Bldg. Permit Fite COSTA MESA BUILDING -SAFETY DEPARTMENT P.O. BOX '1200 COSTA MESA, CALIFORNIA 92626 For Applicant to Fill in Completely -- Use Ink Only BUILDING .fyy a ADDRESS r ///�J OWNER OR / � TENANT L/I 7?Q /7G 1,7 MAILING APPLICATION FDiU�YI'RHeZVM PERMI'e42e 25 RECEIVO BY PERMIT A.P. NO. BUILDING n r'S Q s QCeZy6� RDD KESS .7 UNIT OR SPACE NO. ri V V rt c..a.a TEL. T NO. LOT BLK. CITY NO. NEW ADD ALTER REPAIR MOVING DEMOLISH CONSTRUCTION LENDER BRANCH Le,,,f&rz,' S OWNER G ADDRESSV f Iw!// - A 4. UE ARCHITECT TEL, USE s75 csoo. OR ENGINEER NO. ADDRESS ZONE TYPE GROUP T n CONTRACTOR / 1'' �U APPROVED BY DATE/—Z ADDRESS TEL. CITY G AJ? rI IATDLl NO.Vq STATE CITY AP OVED S TRACKS LIC. NO. LIC. NO. SIZE NO. OF BLDGS. (FROM C/LSTR OF LOT NOW ON LOT FBONT USE OF 'f EXISTING BLDG, II Separate permits are required for L. SIDE electric, plumbing and heating work.. REAR Top— USE OF UI N D WOR BE PERFORMED PLANNING ACTION DATE L ' APPROVED APPROVED RY I hereby acknowledge that I have read this application and state that the above Information is correct and agree to comply with all laws regulating building construction, and I shall not employ any person in violation of the work Tan's compensation laws of the State of California. �FTE C' 0 I hereby certify that I am properly licensed as a contractor under SQ. the State of California Business and Professions Code, Division 3, THE AMOUNT "OWN'U ER VALUATION IS FOR Chapter 9, and that such licenses are in full force and effect, or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: am exempt from the ovisipns of the State of California Business Professions Cod 3, Chapter 9. VALUATION PERMIT FEE S 23 and , Division PLAN CHECK S r— Signature of lye Permittee,p t _— s7S,dva•—~ TAX $ or Q �c-,2� .7 Authorized Agent Date �� �J [�7 TOTAL PAID $ z f heC,k Pa;d 'Ise TL' I All— /CX.) l—/CX.) 9 842 8�27iso ao,.�o COSTA MESA BUILDING SAFETY DEPARTMENT APPLICATION FORSTRUCTURAL PERMIT P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626 RECEI E Y PERMIT r.r For Applicant to Fill in Completely — Use Ink Only.BUILDING O'1``/�1 41t15 A.P. NO. 140-052-20 ADDRESS OWNER OR -T� C TENANT / BUILDING ADDRESS 3333 Bristol, > #246B UNIT OR MAILING SPACE NO. ADDRESS TR.NO. LOT BLK. TE L. CITY INO. CONSTA UCT10N NEW ADO ALTER IREPAIR IMOVING DEMOLISH LENDER X ti BRANCi -I I OWNER�j'L r �C- ADDRESS ARCHITECT TEL. USE /�� JUE$ a715. OR ENGINEER NO 0 ADDRESS ZONE TYPE GROUP APPROVED CONTRACTOR+� %. BY DATE ADDRESS S,Zz O / wTEL - 0146/ CITY NO. 3 7S% STATE '�J CITY LIC. NO. LIC. NO. APPROVED SETBACKS SIZE NO. OF BLDGS. (FROM C/L STREET) OF LOT NOW ON LOT FRONT FT. USE OF EXISTING BLDG. FT. Separate permits are required for L. SIDE FT. electric, plumbing and heating work: REAR FT, USE OF BUILDING AND WORK TO BE PERFORMED PLANNING ACTION DATE APPROVED APPROVED I hereby acknowledge that I have read this application and state that the above information is correct and agree to comply with all laws regulating building construction, and I shall not employ any person in violation of the workman's compensation laws of the State of California. I hereby certify that I am properiy licensed as a contractor under SQ. FT. the State of California Business and Professions Code, Division 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR Chapter 9, and that such licenses are in full force and effect, or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY, am exempt from the pr isions of th tate of California Business and Professions Co vision 3, ter 9. VALUATION PERMIT FEE $ T V PLAN CHECK $ f /j Signature f , K+`� Permittee or $/]r TAX $ dC Q Authorized Agent Date TOTAL PAID c CITY OF COSTA MESA DEVELOPMENT SERVICESIBUIWING SAFETY RECORD PACKAGE FORL. STREET ADDRESS WORK DONE L� BB ilding Permit #��4a lPJ Certificate of Occupancy ❑ Electrical Release Form r, Gas Release Form i I Sanitation Fixture Form/�C�!}' �-�fi tubing Permit #�or..�7�V 4��—Mechanical Permit Electrical Permit # 9 % ❑ Reinspection Permit :#— F-1 ❑ Health Department Approval ❑ Roofing Certification ❑ Insulation Certification F—I Dry Chemical System Certification ❑ Flame Spread Certification Fire Sprinkler Certification ❑ Soils Certification �❑�Special Inspection Certification L`S Other: )eon=Y tY All Required Documents Include Clerk O.K. to Approve C.O InSpeCtor O.K. to Release C.O. Building Official CMF 1045-30 CIT`' OF COSTA MES.' ; Development Services, Division of Building and Safety CERTIFICAT4E=OF"0CCUPANCY ��`�1� N 1,x!7 This certificate is issued pursuant to,the,r qrem ient&of,the - 22010 alifo ia,8tTding Code, Section 111 adopted by the City of Costa Mesa certifies that at the -gine of -its issuance the.buildi�njz;strructure herein below described was inspected and approved for occupancy as follows: 3333 Bristol t #2249Is Building Address N-- f\ i= Use RETAIL Group Mk _ Ty> N R i`p � Owner of Building South Co, __-. _. Address BUILDING OFFICIAL-Khanh BC13-00313 ��Bl'dg�Pernut Number Fi. a:Zone Use Zone Tenant Bir: t�i' Paris LLC 92626 Y o REQUIRED TO BE POSTED IN A CONSPICUOUS PLACE Y i .fir :rx.-. "•gM1°+" Kum.:f--w.-Awa,.�.r�r.rrrMr'.r5,i�n...:A,:�yry ,:.r+'6�d"-^�r*'7�.��•.�r.�.f''.M�•_,,;l,i.�i2s�+,k. ...,.,,,r,•,.. T,M.-.r � r - ,_ , ME CITY OF COSTA MESA Development Services, Division of Building and Safety CERTIFICATE -FrOCCUPANCY This certificate is issued pursuant to the require ements ofithe 2010-Califorrua,$uilding Code, Section 111 adopted by the City of Costa Mesa certifies th to ai the-time of its issuance he buiIai\n j structure herein below described was inspected and approved for occupant as follows: 3333 Cristo st #2249; . Bldggn BC13-00313 Building Address : Permit Number Use RETAIL r" J.�r ti«.»..�.....�"�'�* � Group Type of Construc onT �- p` T}f� -4p' Group Use Zone Owner of Building South .Coast P1 2� _ , rant A rl� Paris LLC Address 3315 Fairy .90,W ,RC ,p CoS�tra-?— 'es' CA 92626, jam, BUILDING OFFICIAL-t1rihNguy C:B 0�'AlxrrDat�3 foo �� r REQUIRED TO BE POSTED IN A CONSSPICUOUS PLACE U T?o EGA BUILDIN BOX 7260 COSTA L PERMIT" • , . IM --U PERMIT'�'�'e F1 For Applicant to Fill in Completely - Us lnk Only BUILDING�rC ADDRESS --d A.P. NO. �U 42 BUILDING OWNER OR Ft.. 5p � .� N TENAT t } -}z ADDRESS J p 3333 MAILINGa / ADDRESS UNIT OR SPACE NO. Z (� /' TEL. JZ TR.NO. LOT BLK. CITY C H -fes NO. 32 -7- CONSTRUCTION NEW I ADD ALTER REPAIR MOVING DEMOLISH LENDER BRANCH S OWNER s clM'F S O C ADDRESS VALUE USE prs lA ARCHITECT t TEL. r 4/.4% OR ENGINEER -Lor N /J GTYP ~1 — gyp.. ADDRESS ZONE GROUP CONTRACTOR, = E � APDATE S — I6- 80 / ADDRESS3IDO L Q¢ TEL CITYCot�a NO. STATE CITY LIC. NO. 3g , Z LC. NO.0 0 APPROVED SETBACKS SIZE NO. OFBLDGS. (FROM ILSTREE ) OF LOT NOW ON LOT FRONT USE OF EXISTING BLDG. Separate permits are required for E F AP I electric, plumbing and heating work: REAR USE OF BUILIDING AND WORK TO BE PERFORMED PLANNING ACTION DATE APPROVED APPROV I hereby acknPwledge that I have read this application and state that the above information is correct and agree to comply with all laws regulating building construction, and I shall not employ any person in violation of the workman's compensation laws of the State of California. SO. FT. 00 0. I hereby certify that I am properly licensed as a contractor under the Stateof California Business and Professions Code, Division 3, THE AMOUNT SH WN UNDER VALUATION IS FOR Chapter 9, and that such licenses are in full force and effect, or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: am exempt from the provisions of the State of California Business VALUATION PERMIT FEE $ and Professions Co e, ivision 3, Chap 9. ,�- •' Signature of Permittee PLAN CHECK $ . 6v $�+� TAX $ or Authorized Agent Date TOTAL PAID $ Q 0 Z . W W aU Z Z_ H Ocn am J =) J U) Q W co J m J Q U � �a W = CL W WZ J Q :i cc J [_ W W OZ ZH WO (n CC Z)O :3895;) COSTA MESA BUILDING -SAFETY DEPARTMENT P.O. BOX 1200 COSTA MESA CALIFORNIA 92626 :F—6-7P$taa 308s�-�x5.5� cr PP I TION FOR BUILDING PERMIT For Applicant to Fill in Completely RE EI Y I DATE RECEIVED TE ISSUED BUILDING��� ADDRESS OWNER ,5 �FL D S �l'' A.P. NO. SZ-�—� P RMIT NO. MAIL 7 %/i} — � BUILDING ADDRESS 333 ST�2-to ADDRESS W / � ;I G L i_ va EL. CITY �S NO. ,1Q� ' TRACT LOT BLOCK CONSTRUCTION ADD LENDER BRANCH OWNER Sti �►M� ADDRESS ,r' 1 VALUE C90 ARCHITECT TEL_. h OR ENGINEER FIRE i ADDRESS ZONE TYPE ROUP r },. CONTRACTOR (� �� !. APPROV!M ' BY DATE ADDRESS S TEL. ZO E NO. OF PLANS USE OF NEW It_),Z, CITY NO, BUILDING STATE CITY YARDS APPROVED YAROS APPROVED LIC. NO. LIC. NO. MAIN BUILDING ACCESSORY BUILDING SIZE NO. OF BLOGS IF ROM C/LSTIR EET) OF LOT NOW ON LOT FRONT FT. FT. USE OF EXISTENG BLL 61JO9!✓- DG. Gam_ FT S1ZE OF NO. OF NEW BLDG. ROOMS STORIES L SIDE T. FT, EXTERIOR WALL ROOF COVERING COVERING REAR FT. FT, USE OF BUILOIN�G/°NO WORK OBE PE FORMED OISTANCE BET. BET. MAIN & FA IT N O F C MAIN BLOCS. ACCESS. BLOW. r -r VAR,# DATE Q G C.U.P. + APPROVED, r T � APPROVEDw r7 o � /sTATE I hereby acknowledge that I have read this application and state that the above information Is correct and agree to comply with all laws regulating building construction, and I shall not employ any person In violation of the workman's compensation laws of a- the State of California, I hereby certify that I am properly ficensed as a contractor under df / FT. THE AMOUNT SHOWN UNDER VALUATION IS FOR the Stateof California Business and Professlons Code, Division 3, Chapter 9, and that such licenses are In full force and effect, or I am exempt from the provisions of the State of California Business THE PURPOSE OF ESTABLLSHING'A PERMIT FEE ONLY: R VALUATION and Professlons Ion 3 ier 9. C=j:Z PERMIT FEE $ a Signature of / Permittee $�% PLAN CHECK $ E Authorized Agent TOTAL FEE $ r • 37525 COSTA MESA BUILDING -SAFETY DEPARTMENT P.Q. BOX 1200 COSTA MESA, CALIFORNIA 92626 . For Applicant to Fill in Completely BUILDING , !� ADDRESS !�j33✓ _L3Ris%O C_ ,L,�i OWNER %-LprZ5HCi1� of-�dS MAIL _._.._ ADDRESS TEL. CITY NO, CONSTRUCTION LENDER BRANCH ADDRESS ARCHITECT TEL. ADDRESS CONTRACTOR ADDRESS '7_2d70 \1109 L3 0jZ_r0 ^% TEL. CITY /Z� l+f 4414 C—_fM NO. '7516-183 STATE CITY Lic. NO. 1 E7G 6 t O LIC. NO. ZC>34 SIZE=NOW O. OF SLOGS. OF LOT ON LOT USE OF EXISTING BLDG. SIZE OF NO. OF NEW BLDG, ROOMS STORIES EXTERIOR WALL ROOF COVERING COVERING USE OF BUILDING AND W04K TO BE PERFORMED r r SA7- c. A7 i ep" c r Ff lzrm- S0=>i2 ► i.1, fe,c.r' 0Z5 I hereby acknowledge that I have read this application and state that the above information is correct and agree to comply with all laws regulating building construction, and I shall not employ any person in violation of the workman's compensation laws of the State of California. I hereby certify that I am properly licensed as a contractor under the State of California Business and Professions Code, Division 3, Chapter 9, and that such licenses are in full force and effect, or I am exempt from the provisions of the State of California Business and Professions Code, Division 3, Chapter 9. Signature of Permittee Authorized Agent AI IN-s-73CPfPD;s.00 3�7* **t*W5.50 APPLICATION FOR BUILDING PERMIT REC I BY DATE RECEIVED DAISSUEDPA.P.ND. I O - 4&� c>'BUILDINGADDRESS 6 TRACT LOT OWNER Iicc . .ice/ t� (/►� ALU$ -. FIRE If ZONE / /STYPE L GROUP —62- BYPROVED , Z . /�f DATE ZONp'% I,G NO, OF USE OF NE ��f L! PLANS BUILDING YARDS APPROVED YARDS APPR D MAIN BUILDING ACCESSORY BUILDING (FROM C/L STREET} C-~ L SIDE T. FT. REAR FT, FT. DISTANCE BET. B MAIN & MAIN SLOGS. ACC . BLDGS. VAR. + DATE C. U.P. + APPROVED APPROVED m m TAX SO. FT. o THE AMOUNT SHOWN UNDER VALUATION IS FOR THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY. m VALUATION m PERMIT FEE S jJ'• U N 7 dQ m g PLAN CHECK $ E 'o LL TOTAL FEE $ r 374 � COSTA MESA BUILDING -SAFETY DEPARTMENT P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626 For Applicant to Fill in Completef LDING ADDRESS OWNER MAIL ` Z ADDRESS W LLJ TEL. 0-0 CITY NO, Z Q CONSTRUCTION �j r O LENDER CO t2 L EL to ..J :) BRANCH J Ln M J ADDRESS ARCHITECT TEL. J N OR ENGINEER "tt_ t. C0il7 l4 N �� W CC ADDRESS l �✓� j7 T AYT !cf 0— LLI Z CONTRACTOR rm O J X ADDRESS Z_ JZ__ W CITY Lcj 7 NO. z ! 4�3 LU O STATE Q CITY O LIC. NO. J� !� LIC. NO. SIZE NO. OF BLDGS. OF LOT NOW ON LOT USE OF EXISTING SLOG. 17,V -1-C41 11_ Z I' SIZE OF ��L ej NO. OF Z NEW BLDG. ROOMS STORIES Q EXTERIOR WALL. ROOF V COVERING COVERING J USE OF BUILDING AND WORK TO BE PERFORMED a a O cn Z O H U z QCT 10-73,A;,00 39:)'x`'. P I ATION FOR BUILDING PERMIT DIST CE BET. MAIN BLDGS. RECEIV D TE ISSU/E/�D DATE APPROVED V Ol� ©^�� -- / [FRECW2DATE any person in violation of the workman's compensation laws of RfvT A. P. NO �/�a �' .PE BUILDI G SO. FT* o the State of California Business and Professions Code, Division 3, ADDRESS Chapter 9, and that such licenses are in' full force and effect, or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY. m TRACT' LOT BLOCK OWNER FIRE ZONE APPROVED VALUE OATE Z E NO.OF USE OF NE PLAN' BUILDING YARDS APPROVED YARDS APPROVED MAIN BUILDING ACCESSORY BUILDING (FROM C/L STREETS FRONT FT. - r. FT a REAR FT. FT. DIST CE BET. MAIN BLDGS. BET. MAIN & ACCESS. BLOCS. VAR. + C.U.P. DATE APPROVED APPROVED, ^^Tr /4,� I hereby acknowledge that I have read this application and stateA that the above information is correct and agree to comply with D, all laws regulating building construction, and I shall not employ /f , any person in violation of the workman's compensation laws of !!�� the State of California. l hereby certify that I am property licensed as a contractor under SO. FT* o the State of California Business and Professions Code, Division 3, THE AMOUNT SHOWN UNDER VAL N IS FOR i Chapter 9, and that such licenses are in' full force and effect, or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY. m am exempt from the provisions of the State of California Business VALUATION and Professions Cn Divisi 3,ZChapterf SII PERMIT FEE N Signature of Permittee LYv $G % PLAN CHECK $ �SJ Q Authorized Agent , Cg_FLL 4A I_ FEE CITY OF COSTA MESA C'e VE LOPMENT SER VICESIBUI LD1 NG SAFETY RECOk,) PACKA FOR: STREET ADDRESS WORKDONE Building Permit`�� ❑ Certificate of Occupancy ❑ Electrical Release Form ❑ Gas Release Form Sanitation Fixture Form V Plumbing Permit # Ka ----Mechanical Permit # L?Z-n?fi Electrical Permit # 8- E-1 ❑ Reinspection Permit # ❑ Health Department Approval ❑ Roofing Certification ❑ Insulation Certification ❑ Dry Chemical System Certification ❑ Flame Spread Certification ❑ Fire Sprinkler Certification Soils Certification ❑ Special Inspection Certification Other: All Required Documents Included E—r W Clerk 0. K. to Approve C.0 O. K. to Release C.0 CMF 1046-30 Inspector Building Official CM 1/ F City of Cosa Mesa Development Services Department Building Safety Division CERTIFICATE OF OCCUPANCY No. 902540P. O. Box 1200 Costa Mesa, California The Building located at has been inspected and foun-d�to complyiwith.the pr.ovisions of all City of Costa Mesa Ordinances applicable thereto for a Group Occupancy. Use of Building _ Legal Description s1L"JV-1.'V.. 1See reverse side for Metes and Boundsl Building Permit No _ Electrical Permit No. r nn --co Plumbing Permit No. Mechanical Permit No. Number of apartments and/or guest rooms rP;r- vCnr$ction Permit No. F 29741 tSSU'ED TO: Building Official -I. _•---- :..0 . by 3313 Fairview Road U7 Costa vmScir CA Date Se2tember.14r 198_7, W ��y This Certificate of Occupancy SHALL BE posted in a conspicuous place on the'premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. CMF 1015.46 rev. 1/83 White -Owner; Canary - Numerical File; Pink - Bldg. Permit File C "'tAp o f Costa 21)�,-.-,Ja Development Services Division o Building and Safety p � f 9 CERTIFICATE OF _OCCUPANCY This certificate is issued pursuant tQ,tlier quirement the Uniform Building Code, Section 308 adopted by the City of Costa Mesa cetfies f•.that at-th'e time of,its issuance the building structure herein below described was inspected andEa' ' ' �` "� p pproved°for=o_cCupanry...as�follOws: Building Address 3333 BRISTOL.�STREET UNIT:. ZZ49 Bldg.Permit No. B69817 Use g RETAIL STORE lfr� 1(� _ /�...� I `� _ �: �1� IDA Group B -Z Type.af,Construction I -FR Use Zone Owner of Building C. J,. -,SEOERSTROM- & -SON S- - jTenant ; i%LILLIE RUBIN Address 3315 FAIRVIEW AVENUE; -COSTA ,MESA; CA 925.26 s,Y/ �' = ." By / BUILDING OFFICIAL-�OTIp6��QGCi. y r,. f ; - ✓�,\;ti"Date REQUIRED TO BE POSTED -IN A CONSPICOUS PLACE f City of Costa Mesa Building Safety Department • CER T I F I C A T E'' . OF- O.0 C UP A N C.Y :f° 2-M. P.O. Box 1200. 5• . t Costa Mesa, California l V.The Building lo6ated'at 3333 Rri!i of Street - Rizz011iO4e )tic Stare — g0itp 972 has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto. . for a Group A—') Occupancy. Use of Building rr TVr j;;1 Ratait inr� Legal Description' 1a 'P411[1i'i—nro—WI (See reverse side for,Metes and.Bounds) �:: i ••F .- - r [I €moi - - r Building Permit NoA-775- Electrical Permit No'. R--12 7 Plumbing Permit No. R-1917IM-17t, Number of apartments =D— and/or guest rooms —— ISSUED T0: '. Building Official Y sRIZZ'fJT AS B S'InTiE ViCWr .C. �' rt on--DireCtor Building DIVISiot SOUTH -COAST PL .n Date Dec d)er 4, 1981 This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT.BE removed_ except by the �. Buildin Official of the City 'of Costa Mesa under Se inn { } U B C -Worm SU 34 Rev. 11/70' C�, - .� .. .S • it • _S � � `r s CAT of Costa '141"Weresa 0 2pip� I= Development Services; Division of Building and Safety CERTIFICATE OF OCCUPANCY This certificate is.yissued pursuant to nfs o qu reme f�,t�.eyniform Building Code, Section 308 adopted by the'CIW of Costa Mesa certifies below described was inspected a /d 7164 Building Address 3333 BRISTOL, STRMU, UNIT 4287 Use Rntail 11� Iffr� Al - lir ince the building structure herein ,--�`Bldg. Permit No. B 78322 Group M TYpe',of'C6nstkuctidn t- Fire Zone I Owner of Building South �C640r."-Plaza\ AC,Tenant WSOU"E Y.. Address "8911 Fa4x3rj v- -n X!, r -o# -o M�' M, sa Use Zone r I -R P By, BUILDING OFFICIAL-toriv N 6�) - Date '.0,rA.. 2A REQUIRED TO BE POSTED -IN-A CONSPICOUS PLACE toolw CriY OF ttSTA MESA DEVELOPMENT SERVICES/BUILDING SAFETY REC PACKAGE FOR: 6, < STREET ADDRESS WORK DONE Building Permit # Certificate of Occupancy Electrical Release Form yC7, Gas Release Form Sanitation Fixture Form Plumbing Permit # Mechanicai Permit #�_qql_— ❑ Elect i OT t IF Reinspectic�n Permit # ❑ Health Department Approval ❑ Roofing Certification ❑ Insulation Certification ❑ Dry Chemical System Certification ❑ Flame Spread Certification Fire Sprinkler Certification Soils Certification Special Qype Certi •cation Other: � �?, C) k' All Required Documents Incl 1 ' to Approve C.O. ,n K 1n RPIPASP f` n. t CMF 1046-30 Inspector Building Official � CI: Y OF COSTA ML,-.)A' F� J Development Services, Division of Building and Safety CERTIFICATE QF 6tt-UPANCY 3 This certificate is issued pursuant to.the requirements of the 2007 California Building Code, Section 110 adopted by the City of Costa Mesa certifies that at'the'tiine of its issuance the buildin_ g,structure herein below described was inspected and approved for occupancy as follows: £ - Building Address 3333 'Bra sl 01 `Street t 2°49 } Bldg` Permit Number BC11-00266 m.., Use COMMERCIAL <>>. Group P. Type; 'f'Constiuction T A Fire Z z e Use Zone PDC Owner of Building South" oast 1laza Tenant Chopardak° Address 3315 _t -a: irviiew Road, CAta...Mesa t,...,CA 92626 •z t- By � BUILDING OFFICIAL -Keith Clarke, C, D. ,W ke; 10-12-11 REQUIRED TO BE POSTED IN A CONSPICUOUS PLACE i,�••.-:.s.:._+fa.w�'�.- �^' ay,�+;!—.�"u�+x,.;r^v;K1•�':.��+hblt�3"�,=;��tM,.��'"'Cvd.:,.-`"if'�+'.a' ""'�'',;`,'rw �i-a�� a : . , � .}. _ .. ® Ch Y. )F COSTA ME P � Development Services, Division- of Building and Safety CERTIFICATE OFOCCUPANCY This certificate is issued pursuant to, the requir1. ements of the Uniform Buildxng,Code, Section 308 adopted by the City of Costa Mesa certifies that at the time of its'issuance'the building structure hereinbelow described was inspected and approved for occupancy as follows St St l i 3333 Bristol -St. e '24 09 Building Address Bldg. Permit Number a06- 04411 ¢. I Use Display/Sa16, rierchand1se - i. E. 4° c R{= PDC M 1- FGroup Type of Construction 1�F1 Use Zone Owner of Building South Coast PT'aza �` Tenant CII0 :.: R �r 3315 Fairview Costa Mesa, CA 926'26 Address BUILDING OFFICIAi -Khanh Q.. Nguyen;'tC ""`D M, '07/14/06 ~� REQUIRED TO BE POSTED IN A CONSPICOUS PLACE �� IV a4* -Y- IF< - CITY OF COSTA MESA DE VE L,DFMEI'ST'SER VICESIBUI LDING SAFETY RECORD PACKAGE EOR: STREET ADDRESS Y C�C�Y/,/.,I✓�/^ WORK DONE L �4� Bu' 'ng Permit l5' Certificate of Occupancy ❑ Electrical Release Form ❑ Gas Release Form Sanitation Fixture Form LI Plumbing Permit # ❑ Mechan' I Permit # Electrical Permit # �� ❑ Reinspection Permit # ❑ Health Department Approval ❑ Roofing Certification ❑ Insulation Certification ❑ Dry Chemical System Certification ❑ Flame Spread Certification ❑ Fire Sprinkler Certification Soils Certification ❑,," Special Inspection Certification LPOther: E c;;' r4;;;� ..._..._..__.._._ All Required Documents Include—4 z1 Clerk O.K. to Approve C.O. Inspector O.K. to Release C.O. Building officiai CMF 1046-30 City of Costa Mesa Development Services Department Building Safety Division CERTIFICATE OF OCCUPANCY NorJ P. O. Box 1200 Costa Mesa, California The Building located at 3333 Bristol Street, Soaya 9M7 has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group B2 Occupancy. Use of Building Retail Legal Description 412-501-22 (See reverse side for Metes and Bounds) Building Permit No B 23989 Electrical Permit No. E 24158 Plumbing Permit No Mechanical Permit No. Fire Prevention permit No. F 24337 ISSUED TO: C.J. Scieratcom & Sons 3315 Fairview Road Costa It3sa, CA 92626 Number of apartments and/or guest rooms Building Official William T. Howard by Date November 11, 1986 This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. CMF 1015-46 rev. 1/83 White - Qvuner; Canary - Numerical File; Pink - Bldg. Permit File CITY OF COSTA MESA DEVEL.G:'MENT SERVICESIBUILDING SAFETY RECORD PACKA E FOR: I' LIVY --5'--V/—ei— STREET ADDRESS WORK DONE Z-- Building Permit ��o" ❑ Certificate of Occupancy ❑ Electrical Release Form ❑ Gas Release Form Sanitation Fixture Form �;MMechanical lum 'ng Permit Permit #03-64-1� 4� Electrical Permit ❑ Reinspection Permit # ❑ Health Department Approval Roofing Certification Insulation Certification Dry Chemical System Certification Flame Spread Certification Fire Sprinkler Certification Soils Certification Special Inspection Certification Other: All Required Documents Included Clerk O.K. to Approve C.O Inspector O.K. to Release C.0 Building Official GMF 1046-30 City of Costa Mesa Development Services Department Z !. Building Safety Division CERTIFICATE OF OCCUPANCY No. v (} 0 4 P. O. Box 1200 Costa Mesa, California r� The Building located at 3333 Bristol Strut, Sciace 24.07.._ _ has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group F3?. Occupancy. Use of Building Cl.othina Legal Description 412-501-02 (See reverse side for Metes and Bounds) Building Permit No—B 34072 Electrical Permit No. I'. 3410Ra Plumbing Permit No. Mechanical Permit No. M 34259 Number of apartments and/or guest rooms ISSUED TO: _C.J. S--aerstrom & Sores _ 3315 Faicvia-w Road Costa Mnoa, CA 92626 Building Official William T_ 9nw;4rr1 by Date August -23j 1988 - This Certificate of Occupancy SMALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. t CMF 1015-46 rev, 1/83 White - Owner; Canary - Numerical File; Pink - Bldg. Permit File CITY OF COSTA MESA OE.VELOWENTSERVICES/BUILDING SAFETY RECORD PACKAG OR: 32;;�3� STREET ADDRESS ,�. ,,// WORK DONE L7 uilding Permit # CJ Certificate of Occupancy ❑ Electrical Release Form ❑ Gas Release Form r' Sanitation Fixture Form LI Plu Ing Permit # Mecha I Permit #lCLf.CsL Electrical Permit #' ❑ Reinspection Permit # ❑ Health Department Approval Roofing Certification Insulation Certification Dry Chemical System Certification Flame Spread Certification Fire Sprinkler Certification Soils Certification Special Inspection Certification Other: All Required Documents Included Clar c O.K. to Approve C.O. O.K. to Release C.0 CMF 1046-30 Inspector Building Official City of Costa Mursa Development Services Department • Building Safety Division CERTIFICATE OF OCCUPANCY No. P. O. Box 12013 Costa Mesa, California The Building located at -1333 Rri afinl__Strnrat. Rna(-r-+ 2406 has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group A7 Occupancy. Use of Building Rraf-ali 1 Legal Description Al iSee reverse side for Metes and Bounds) Building Permit No , -B 48871 Electrical Permit No. E 49315 Plumbing Permit No. Mechanical Permit No. M 49323 Number of apartments and/or guest rooms ISSUED TO: C.J. Seaerstro-m & Sons 3315 Fairviow�'Road Costa Mesa, Ck, 92626 Building Official _ Tony C' De Baca by Date January 30, 1991 This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. CMF 1415-46 rev. 1/83 White - Owner; Canary - Numerical File; Pink - Bldg- Permit File CITY OF COSTA MESA DEVELOPMENT SERVICES/BUILDING SAFETY RECORD PACKAGE FOR: I0. ye, 5 BEET ADDRESS T. z' WORK DONE ❑ Building Permit # ❑ Certificate of Occupancy ❑ Electrical Release Form ❑ Gas Release Form ❑ Sanitation Fixture Form tt ❑ Plumbing Permit #� ❑ Mechanical Permit * 93�7 ❑ Electrical Permit # IfAd-Iff_ _Iml.4! ❑ Reinspection Permit # ❑ Health Department Approval ❑ Roofing Certification ❑ Insulation Certification ❑ Dry Chemical System Certification ❑ Flame Spread Certification G vire Sprinkler Certification ❑ Soils Certification ❑ Special Inspection Certification ec ❑ Other: III �? All Required Documents Included i k O.K. to Approve G.O. Inspector O.K. to Release C.O. Building Official CMF 1046-30 City of to-sta 21) e5a Development. Services, Division of Building and Safety rt CERTIFICATE OF OCCUPANCY ' This, certificate is issued pursuant to thedrequirements of-the Uniform Building Code, Section 308 adopied by the City of Costa Mesa cer fies-that_`at-the time cif its'zssuance the building structure herein v, , ...below described was inspectedand:approved fo%c(upancy:as follows:\ Building Address 3333 B2406 BR g. Permit No. B 81554 Use t RETAIL .. ,. � ,. , � ��� of sem_-" --_ ��,�1'. Group M Type�Construction I--SP ..,,Zone? "xUse Zone CIS � C.J:= Sergerstro-m' 6-'Sbiis-r:.•30� I I.A1dC" Owner of Building -=7Teriant r, Address 3333';`B4I5TQL STRgET UNIT- 240,'6766STA MESA,( CA.' 626 BUILDING OFFICIAL- t0n*P �!P6 )5,aCIT Date", 20, 1997 REQUIRFD TO BE POS bI_NI ` A CONSPICnUS PLACE 0 CITY OF COSTA MESA DEVELOPMENT SERVICESIBUILDLNG SAFETY RECORD FArK GE FOR: f STREET ADDRESS WORKGONE zLJ Building Permit # Certificate of Occupancy ❑ Electrical Release Form ❑ Gas Release Form 7 Sanitation Fixture Form ❑ ymbing Permit # t�_ ir]4nicai Permit�rJUJO Electrical Permit ��� ❑ Reinspection Permit # ❑ Health Department Approval ❑ Roofing Certification ❑ Insulation Certification ❑ Dry Chemical System Certification ❑ Flame Spread Certification rl Fire Sprinkler Certification I—, Soils Certification ❑ Speciat Inspection Certification ❑ Other: All Required Documents Included Clerk O.K. to Approve C.O. Inspector O.K. to Release C.O. Building Official CMF 1046.30 City of Costa Mesa f Y' Development Services Department Building Safety Division CERTIFICATE O F OCCUPANCY No. P. O. Box 1200 Costa Mesa, California t The Building located at -411'4 Phr;-ur-.,t af-,-��. has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto 1. for a Group R7 Occupancy. [LIN Use of Building_ Rof-ai i Legal Description _41 2—liffl —02 (See reverse side for Metes and Bounds) Building Permit No R rAOPA Electrical Permit No. E: 54992 Plumbing Permit No. Mechanical Permit No. M 54994, M 55059 Number of apartments and/or guest rooms ISSUED TO: C.,7. Schpr.4trnm A cnnc 3333 Bristol St., Space 2401 C'-oStA rA o17F,7F, Building Official Tony CI:aca by Date January 23, 1992 This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. CMF 1015-46 rev. 1/83 White - Owner; Canary - Numerical File; Pink - Bldg. Permit File vCITY dF COSTA MESA DEVELOPMENT SERVICEWBUILDING SAFETY RECORD PACKA FOR: ST EET ADDRESS a WOR O E BU T19' Permit r l Certificate of Occupancy ❑ Electrical Release Form ❑ Gas Release Form Sanitation Fixture Form IJ lumbing Permit #�1� M anical Permit # �� Electrical Permit O ❑ Reinspection Permit # ❑ Wealth Department Approval ❑ Roofing Certification ❑ Insulation Certification ❑ Dry Chemical System Certification ❑ Flame Spread Certification ❑ Fire Sprinkler Certification CJ Soils Certification ❑ Special 7—ZOLILr n Certif,Other: All Required Documents Included65 �< Clerk O.K. to Approve C.0 Inspector O.K. to Release C.0 Building Official CMF 1046.30 City of Costa Mesa Development Services Department Building Safety Division CERTIFICATE OF OCCUPANCY No. P. O. Box 1200 Costa Mesa, California The Building located at, 3333 Bristol Street, Spnen 24tH has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group B2 Occupancy. Use of Building Retail Legal Description 412-501-05 lSee reverse side for Metes and Bounds) Building Permit No B 6012A Electrical Permit No. E 604 R Plumbing Permit No. P 60397 Mechanical Permit No. M 60180 Number of apartments and/or guest rooms FIRE PREVENTION PERMIT NO.F 60491 ISSUED TO: Building Official Tonv CrDe Ha( -a C.J. Selaerfstrom & Sorin 3315 Fairview Road by _ Costa Mena. Ca 920A Date Febrdary 24, 1993 This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. CMF 1015-46 rev. 1/83 White - Owner; Canary - Numerical File; Pink - Bldg. Permit File r 44359 COSTA MESA BUILDING -SAFETY DEPARTMENT P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626 For Applicant to Fill in Completely — Use Ink Only BUILDING For OWNER MA 14 ADDRESS TEL. i0IT YNO. N5TRUCTION .PL16, t -.b- CCp '27oo7666 APPLICATION FOR STRUCTURAL PERMIT REdIj O BV 5f E C`E�I'!yDATE ISSUED PERMIT NO. A.P. NO. /L� BUILDING ADDRESS TRACT I LOT I B BRANCH OWNER ADDRESS • A AL E ARCHITECT TEL.SE $ OR ENGINEER _jy��__ _ _ FIRE ADDRESS r ZONE TYPE GROUP CONTRACTOR V) /A14 )CIAc— Q�/� APPROVED727 7� BY V DATE I- ADDRESS /(J ZONE/} NO.OF USE OF NE TEL. CITYi1PAM[ _ NO ' v `" PLANS BUILDING F STATE CITY YARDS APPROVED YAR PROVED LIC, ND. w LIC. NO.MAIN BUILDING ACCESSORY BUILDING p {� SIZE NO, OF gLpGS, (FROM C/L STREET) a OF LOT NOW ON LOT FRONT, FT. FT, Q USE OF. „(A EXISTING BLDG. / p Separate permits are required for L SILE FT. FT. electric, plumbing and heating work. A REAR FT. FT. IW, USE OF BUILDING AND WORK TO BE PERFORMED DISTANCE BET. BET. MAIN & Q MAIN SLOGS. ACCESS. BL )GS. A L VAR. 0 DATE Q I C.U.P. :0 APPROVED > APPROVED Bx DATE C�. w 0 I hereby acknowledge that I have read this application and state Ln n that the above information Is correct and agree to comply withco GL all laws regulating building constructlon, and I shall not employ Z any person In violation of the workman's compensation laws of .� the State of California. I herby certify that I am properly licensed as a contractor under . m SOFT. o N THE AMOUNT SHOWN UNDER VALUATION IS FOR m the State of California Business and Professions Code, Division 3, Chapter 9, and that such licenses are In full force and effect, or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: am exempt from tha p visions of the State of California B slness VALUATION PERMIT FEE $ 9 n fA and Professlons Cod Ivislon 3, Chapter 9. M PLAN CHECK S o L Signature of �Y�! V �� PermEttee $ '/ TAX $ U TOTAL PAID S Authorized Agent W a Q 14 n -i to 44305 S� COSTA MFESA BUILDING -SAFETY DEPARTMENT j P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626 APPI T N FOR STRUCTURAL PERM] icant to Fill in Completely — Use Ink Only I^ REc I 8 DATE RECEIVED D TE ISSUED FOORESS X333 Ql2t Id Ij i L I N P RMITNO7 A.P. NO.IYa `t7SA' _ BUILDINGfj��� S AMAILDDRESS 3 �� sC,�y C+7-' ADDRESS S L7/j �t N �B �% TRACT CfTY �© 5TA NOTE . LOT O k CONSTRUCTION W AD P LENDER / L1,41 BRANCH yy OWNER G VCS//�J ADDRESS _ lam_ VALUE 314 `�1" /. i .�1 ARCHITECT NEQBE"�oN SOI- NEL��7� OR ENGINEER SE . ADDRESS S ELL AVE M FIRE ZONE TYPEIr. GROU CONTRACTOGiMtpL,] I(]C� APPROV BY DATE tj ADDRESS I lam] SC1��TZr/ +� ZONE NO. OF USE OF NEW _ �� PLANS BUILDING f/L L CITY �� NOLg'js /19 STATE CITY s YARDS APPROVED YARDS APPROVED LIC. NO. LIC. NO.9� MAIN BUILDING ACCESSORY BUILDING SIZE NO. OF SLOGS. (FROM CIL STREET) OF LOT NOW ON LOT -FRONT FT.FT. USE OF EXISTING SLOG. F r� FT. ©, Separate permits are required for L SIDE t electric, plumbing and heating work. REAR FT. USE OF BUILDING AND WORK TO BE PERFORMED DISTANCE BET. BET. MAIN' MAIN BLDGS, ACCFSS. BL ' VAR.0 DATE Az 70e4776 G.U.P. * APPROVED APPROVE _d 3' 22 ihereby acknowledge that I have read this appiication and state that the above Information is correct and agree to comply with all laws regulating building construction, and I shall not employ any person in violation of the workman's compensation laws of the State of California. 1 hereby certify that 1 am properly licensed as a contractor under SO. FT. THE AMOUNT SHOWN UNDER VALUATION IS FOR the State of California Business and Professions Code, Division 3, Chapter 9, and that such licenses are In full force and affect, or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: am exempt from the provisions of the State of California Business VALUATION PERMIT FEE $ and Professions Code, Division 3, Chapter 9. PLAN CHECK a a Signature of h^ . Permittee S ✓ Qa TAX S Authorized Agent TOTAL PAID $ �A72 COSTA MESA BUILDING -SAFETY DEPARTMENT P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626 For Applicant to Fill in Completely — Use Ink Only BUILDING = ADDRESS 3333 ie"iSZ L .5R--L2;-T— OWNER 5R-- 2TOWNER G,FFR`�riCy CJIFL��-.. fiot'ti. MAIL ADDRESS TEL. CITY NO. CONSTRUCTION LENDER BRANCH ADDRESS ARCHITECT TEL. OR ENGINEER N ADDRESS CONTRACTOR &041: ' W P11 L L �i?jL ice' ADDRESS ALixo. TEL CITYG'7 vTE Cf;LiF. NO STATE LIC. O. �� ���3 C- L- L1CYN0. CIT -7C-4'9 SIZE No. OF BLOCS. OF LOT NOW ON LOT USE OF EXISTING BLDG. Separate permits are required for electric, plumbing and heating work, USE OF BUILDING AND WORK TO BE PERFORMED I hereby acknowledge that I have read this application and state that the above information Is correct and agree to comply with ell laws regulating building construction, and 1 shall not employ any person In violation of the workman's compensation laws of the State of California. I hereby certify that I am properly licensed as a contractor under the State of California Bustriess and Professions Code, Division 3, Chapter 9, and that such licenses are in full force and effect, or I am exempt from the provisions of the State of California Business and Professions Code, Division 3, Chapter 9. Signature of Permittee Authorized Agent "CT 15-75P"t4p0 595'.- ****20.30 Cps' APPLICATION FOR STRUCTURAL PERMIT REC IV BY I DATE RECEIVED p E ISSUE❑ !o�/��7- /,,4st A.P. NO. I dfIVrLJti7 V BUILDING a ADDRESS J TRACT LOT I BLOCK OWNER, ` , 11SE�ii/iA �� FIRE ZONE TYPE GROUP APPROVED BY { DATE ZO �t NO.OFANS USE OF NE JJ PLANS BUILDING YARDS APPROVED YARpS PPROVED MAIN BUILDING ACCESS RY T3U1LDiNG (FROM C/L STREET) REAR I FT. FT. DISTAN E BET. BET. MAIN & MAIN BL ACCESS, BLDGS. VAR. C.U.P. q(E APPROVED m m io w APPROVED RY DATEn SQ. FT. THE AMOUNT SHOWN UNDER VALUATION IS FOR THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: a VALUATION PERMIT FEE a J cr`Q LO M PLAN CHECK $ O $ !'L�L� TAX S u TOTAL PAID $ 3 • Y .'.'• ,.—f^41J'~ ) 41ir CPS'UU i�J^ 1f 5.fK 159.R( COSTA MESA BUILDING-SAFETY DEPARTMENT P.0. BOX 1200 COSTA MESA, CALIFORNIA 92626 PL AT N FOR BUILDING PERMIT For Applicant to Fill in CompletelyTqFREAV BY DATE RECEIVED TE SSU BUILDING ADDRESS ! S 1+ X33 OWNER CAPr—Z/ d A.P. NO. / • � O5 � �d / RM T MAILBUILMISIG Fi4 f-0 C> %k J/1 Vol /'� S ADDRESS E ADDRESS :J r�3/ f_ CL Uj U TE- CITY LC 6r,4 /—y &tCA NOL 6;qP�Qi!�C� TRACT LOT BLOCK ZZ Q CONSTRUCTION A LENDER O am ry J BRANCH �.. OWNER ADDRESS VALLI J < �fARCHITECT Qn 7�� OR EN INA19XS6 F5 Nr0, �4 �tl _ Cg7c S L U 0 INEER _ w Cr ADDRESS �f ! v r-A/ - �CA�vu,s ZONE TYPE GROUP LLI 00467 ED OAT JPR CONTRACTOR BY _ OAfeePe a ADDRESS //I/ t57 W W CITY !'- K NOL,3H9-lJ6l ZOSV NO. OF USE OF NEW PLANse�z_ BUILDING S`ir.A W O STATE �p CITY LIC. NO. �r�� LIC. NO.� YARDS APPROVED YARDS APPROVED MAIN BUILDING ACCESSORY BUILDING (J SIZE NO. OF BLDGS. It-HUM C/L STREET) OF LOT NOW ON LOT FRONT F FT. USE OF EXISTING BLDG. R. 5 TIV& FT It SIZE OF NO. OF NEW BLDG, ROOMS STORIES L. SINK FT, EXTERIOR WALL ROOF COVERING COVERING REAR F FT. USE OF BUILDING AND WORK TO BE PERFORMED DISTANCE BET. BET. MAIN & MAIN BLDGS. ACCESS. SLOGS. VAR.# DATE C.0 P 10 APPROVED Li�7j('ST !�Ad APPROVED NBy _QATF a I hereby acknowledge that I have read this application and state that the above information is correct and agree to comply with all laws regulating building construction, and I shall not employ any person in violation of the workmen's compensation laws of V] the State of California. I hereby certify that I am properly licensed as a contractor under SQ. FT. O the State of California Business and Professions Code, Division 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR Chapter 9, end that such licenses are In full force and effect, or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY; am exempt from the provisions of the State of California Business VALUATION and Profassions ode Divys�on 3, Chapter 9. rte' C—C"'�/��' PERMIT FEE $ r Signature ofos Permittee N i _� $ 2 ` PLAN CHECK $ � Authorized Agent J TOTAL FEE CITY OF COSTA MESA DEVGLDPMENT SERVICESIBUILDING SAFETY RECORD PACKAGE FOR: 3333 P�r�_sfo1 -Spac-e-zz. co eZ'Io 5 6-(--5+e, STREET ADDRESS WORK DONE Building Permit =# 16 Z Certificate of Occupancy ❑ Electrical Release Form ❑ Gas Release Form L Sanitation Fixture Form ❑ Plumbing Permit # ❑ Mechanical Permit # ® Electrical Permit # EZ(,00 ❑ Reinspection Permit # ❑ Health Department Approval ❑ Roofing Certification ❑ Insulation Certification ❑ Dry Chemical System Certification ❑ Flame Spread Certification ❑ Fire Sprinkler Certification CJ Soils Certification ❑ Special Inspection Certification ❑ Other: All Required Documents Included lark O. K. to Approve C. 0. Ins pec or Q.K. to Release C.O. Building Official CMF 1046-30 City of Costa Mesa Development Services Department Building Safety Division CERTIFICATE OF OCCUPANCY No. O (''� Q� q 111Q J1 P. O. Box 1200 Costa Mesa, California The Building located at ._ 13.33 Rrri-ctol Sna(%_Q 2212 _ has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group R2 Occupancy. Use of Building Canezio Shoe Store Legal Description 412.-501-02 ISee reverse side for Metes and Bounds) Building Permit No. 4V21977 Electrical Permit No.E24760 Plumbing Permit No, Mechanical Permit No ISSUED TO: C_ J_ cs>nAraf-rnm Number of apartments and/or guest rooms Building Official 331.5 Fairview Road by C'naf•st rMwgar rA giF2F % �.. Date / This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. CMF 1015-46 rev. 1/83 White - Owner; Canary - Numerical File; Pink - Bldg. Permit File 7C7-'7- - i� -�.�� CITY OF COSTA MESA DEVELOPMENT SERVICES/ErVILDING SAFETY RECORD PACKA E FOR: TREET ADDRESS WORK NE Ilding Permit # Certificate of Occupancy ❑ Electrical Release Form ❑ Gas Release Form itation Fixture F umbing Permit ## a—/ ,Z 1.2-- chanical Permit #If 11,1742 ' Electrical Permit # ry;o ❑ Reinspection Permit # ❑ Health Department Approval ❑ Roofing Certification ❑ Insulation Certification ❑ Dry Chemical System Certification ❑ Flame Spread Certification Fire Sprinkler Certification CI Soils Certification ❑ ectal In;pecttion Certification ot Other: All Required Documents Included Clerk O.K. to Approve C.O. Inspector O.K. to Release C.O. Building Official CMF 1046-30 City of Costa Mesa Development Services Department Building Safety Division CERTIFICATE OF OCCUPANCY No. P. O. Box 1200 Costa Mesa, California The Building located at 3333 RriRtnt Srrppr, Snnep_7?h _ has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto . r for a Group R? Occupancy. Use of Building RArn11 T Legal Description 417-5(11- ns iSee reverse side for Metes and Bounds) Building Permit No u AIC10;1 Electrical Permit No. R 61795 Plumbing Permit No. 2051 119 Mechanical Permit No. M 6110A Number of apartments and/or guest rooms Fire Prevention Permit No. F 61284 ISSUED TO: C.J. Segerstrom & Sons 3315 Faieview Road Costa Mesa, Ca 92626 Building Official Ronv C'De Bnna by . 4 - ' Date March 7. 1993 This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. CMF 1415-46 rev. 1/83 White - Owner; Canary - Numerical File; Pink - Bldg. Permit File :ITY OF COSTA'-'I'IESA Development Services, Division of Building and Safety CERTIFICATE OF OCCUPANCY z This certificate is issued pursuant to the requireinents•af the 2007 California Building Code, Section 110 adopted by the City of Costa Mesa certifies that at the time of its issuance the building structure herein below described was inspected and approved for occupancy as follows: Building Address 3333 Bristol Street '##2224 Bldg. Permit NumberB-Cl 1--D.040 - Use Tenant 'Use- Sony -Store Group M Type of Construction 'V -A fire Zone Use Zone Owner of Building South Coast Plaza Tenant _ _Sony Address3315 Fairview "Rd., Costa Mesa, California' 13y BUILDING OFFICIAL -Keith Clarke, CA.0. " ' Dat( December 7, 2011 REQUIRED TO BE POSTED IN A CONSPICUOUS PLACE i I w C3 71 COSTA MESA BUILDING -SAFETY DEPARTMENT P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626*-' For Applicant to Fill in Completely — Use Ink Only BUILDING, ADDRESS South Coast Plaza OWNER OR Pronto Ristorante TENANT MAILING ac�F,i I /8l 520.65 APPLICATION FOR -STRUCTURAL PERMIT " REC D Y PERMIT A. P. NO. tl-C �%� ^ L�,' BUILDING !Z ADDRESS 'y rI F UNIT I �Q SPACE NO. 00 N D ro Ln m m 0 LL Z. U IL i O. LOT BLK. 7 CITY Costa 1�lESar NO`.540-80$3 CONSTRUCTION N/A NEW I ADD ALTE REPAIR MOVING DEMOLISH LENDER BRANCH OWNER ADDRESS A VALUE USE /� yT` L� $ ARCHITI=CT Drafting NE OR ENGINEER Service `499-4478 ADDRESS 18468 Ward Street, Fountain V1y ZONE S TYPE GROUP CONTRACTOR TOPM CONSTRUCTION CO.rINC. BYPROVED DATE ADDRESS 1101 Dove St.rPO Box 7830 CITY Newport Beach NEL' 752-1730 STATE 304361 CITY 21938 LIC. NO. LIC. NO. APPROVED SE BAC SIZENO. OF BLDGS. (FROM C/L STR ET} OF LOT NOW ON LOT RONT T. USE OF EXISTING BLDG.SIDE FT. Separate permits are required for L. SIDE FT. electric, plumbing and heating work. REAR FT. USE OF OUILDING AND WORK TO BE PERFORMED PLANNING ACTION t g� DATE !v GJ APPROVED APPROVE !Z i Cil ! I hereby acknowledge that I have read this application and state that the above information is correct and agree to comply with all laws regulating building construction, and I shall not employ any person in violation of the workman's compensation laws of the State of California. I hereby certify that I am properly licensed as a contractor under SQ.FT. the State of California Business and Professions Code, Division,3, THE AMOUNT SHOWN UNDER VALUATION IS FOR Chapter 9, and that such licenses are in full force and effect, or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: am exempt from the provisions of the State of ornia Business VALUATION PERMIT FEE $ ter and Professions C , Division 3, Chap9. Signature o PLAN CHECK $ 1 20 .� Perml4ee $ TAX $ `© or Authorized Agent Date TOTAL PAID $ 00 N D ro Ln m m 0 LL Z. U IL i Ah (Pronto Restaurant) 0682 6/10/79 COSTA MESA .BUILDING•SAFETY DEPARTMENT APPLICATION FOR STRUCTURAL PERMIT P.O. )3OX 1200 ,COSTA MESA, CALIFORNIA 92626 RECEIVED BYRMIT For Applicant to Fill in Completely — Use Ink Only 48595 L BUILD IN s3333 ADDRESBristol - Costa Mesa A.P. NO. BUILDING OWNER OR South Coast Plaza TENANT ADDRESS NIT OR MAILING ADDRESS 3315 Fairview Rd., Costa SPACE NO. TR.NO. LOT BLK. TEL. mesa CITY NO. NEW ADD ALTER REPAIR MOVING DEMOLISH CONSTRUCTION LENDER BRANCH OWNER ADDRESS VALUEs400,00 USE r 4OO OD ARCHITECT TEL OR ENGINEER NO, 937-42 ADDRESS 6330 San Vicente Blvd.-L.A. ZON JI;7/(..DATE E GROUP CONTRACTOR Illi, Construction Co. APPROVED BY r ADDRESS 1401 Dnvp TEL. CITY Newport Beach NO 7_5_2 - 2 STATE TY APPROVED SETBACKS LIC. O. 125852 , Cat. B LiC. NO. 000883 SIZE NO. OF BLDGS. (FROM C/L STREET) OF LOT NOW ON LOT gONT USE OF EXISTING BLDG. per 'ts it Seect L. SIDE FT. c ect c, p mb' g " 1 rk: zelVat REA FT. USE OF BUILDING AND WORK TO BE PERFORMED PLANNING ACTIO �- DATE HVAC . P APPROVED APP O I hereby acknowledge that I have read this application and state that the above Information is correct and agree to comply with all laws regulating building construction, and I shall not employ > any person in violation of the workman's compensation laws of m the State of California. I hereby certify that I am properly licensed as a contractor under CD SO. FT, a the State of California Business and Professions Code, Division 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR m Chapter 9, and that such licenses are in full force and effect, or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: �; am exempt from the provisions of the State of California Business VALUATION PERMIT FEE $ q and Professions ode, Division 3, Chapter 9. '^ ra PLAN CHECK $ 479.05 o Signature of Permittee LL s 400 , OOO TAX a 28 DO 2 . Authorized Agent Datp TL jejdfa TOTAL PAID $1,244.05 r/ COSTA MESA BUILDING SAFETY DEPARTMENT" APPLICATION FORNTRUQTURAL PERMIT 660 44 TA P.0..BOX 1200 -COSTA MESA, CALIFORNIA 92626 ��+=- - -• __—L mom RECEIVED BY PERMIT NO 4 8 5-9_ 6 For Applicant to Fill in Completely — Use Ink Only BUILDING A.P. No. /y C3— O�� —ao ADDRESS 3333 Bristol. St .-COstaMes OWNER OR BUi LDI NG ADDRESS TENANT South Coast Plaza MAILING UNIT N ��� NO. ADDRESSPACE 3315 FairviewFalrVleW Rd . TR.NO. LOT BLK. TEL CITY Costa Mesa NO.546-011 CONSTRUCTION NEW I ADD ALTER REPAIR MOVING DEMOLISH LENDER BRANCH OWNER ADDRESS V LUE USE USE ARCHITECT TEL OR ENGINEER Gruen Assoc. N GG I �". /�� $ .77 ADORE SSZO E Y GROUP SOL 12E VIED _ CONTRACTOR BY DATE /71 ADDRESS TEL. CITY Ne ort Beach ND• 752 -920 STATE CITY APPROVED SETBACKS p LIC. NO, 125852, Cat B LIC. NO. 000883 SIZE NO. OF SLOGS. (FROM C/L STREET) OF LOT NOW ON LOT FRONT FT. USE OF EXISTING BLDG. R. SIDET Separate permits are required for L. SIDE FT. electric, plumbing and heating work: REAR FT. USE OF BUILDING AND WORK TO BE PERFORMED PLANNING ACTION ( DATE ( APPROVED APPROVED gy DATE I hereby acknowledge that I have read this application and state that the above information is correct and agree to comply with all taws regulating building construction, and I shall not employ any person in violation of the workman's compensation laws of the State of California. I hereby certify that I am properly licensed as a contractor under SQ. FT, the State of California Business and Professions Code, Division 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR Chapter 9, and that such licenses are in full force and effect, or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: am exempt from the provisions of the State of California Business VALUATION PERMIT FEE $ and Professions Code, Division ,Chapter 9. PLAN CHECK $ Signature of � `� Permittee $ QO TAX $ or Authorized Agent Date / TOTAL PAID $ __—L mom (21 City of Costa Mesa Development Services Department CERTIFICATE OF OCCUPANCY No. @GU362 Building Safety Division P. O. Box 1200 Costa Mesa, California The Building located at 3333 �10L SPACE #2224 has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto ti for a Group_ Ii -2 Occupancy. Use of Building RESTAURANT Legal Description 140-452-20 iSee reverse side for Mates and Bounds) Building Permit No r',-11.722 Electrical Permit No. G-11.722 Plumbing Permit No. G-11722 Mechanical Permit No. Number of apartments and/or guest rooms ISSUED TO: Building Official /j, ATS S'TnRANFI`F: byL�.- 3333 _SRI.6TQL 42224. COSTA MESA, CA. Date This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. CMF 2015-46 rev. 1183 White - Owner; Canary - Numerical File; Pink . Bldg. Permit File b City o4f Costa Mesa Development Services Department n Building Safety Divisipn CERTIFICATE OF OCCUPANCY No.fl P. O. Box 1200 Costa Mesa, California —' The Building located at 3333 Rristol Rt-reay. rre, 229A has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto t � for a Group 92,Occupancy. a ?' Use of Building Restattranl* , `Legal Description 412-501-02 (See reverse side for Metes and Bounds) r f Building Permit No- BP 38509 Electrical Permit No I . E 38860 Plumbing Permit No. B' 38509 Mechanical Permit No. Number of apartments and/or guest rooms •F s. ISSUED TO: Building Official George Edmiston -.,0. J. Segerstrom & Sons ' ' z 3315 Fairview Road by� • _ C_ ,fl —90sta - Mesa, CA 92626 rt ; Date November ' 20, 1989 ',"This Certificate of Occupancy SHALL BE posied'iri a conspicuous place on the premises and SHALL NOT BE.removed except by the Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. o CMF 1015-46 rev. 1/83 White -Owner; Canary - Numerical File; Pink - Bldg. Permit File i + City of Costa Mesa Development Services Department C E R T I F I C A T E OF O C C U P A N C Y No. Building Safety Division P. O. Box 1200 Costa Mesa, California The Building located at 3333 BRISTOL STREET UNIT. 2244 has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group B-2 Occupancy. Use of Building RETAIL STORE `MANN TAYLOR" Legal Description 412-501-05 (See reverse side for Metes and Bounds) Building Permit No. B62674 Electrical Permit No. E62833 Plumbing Permit No. P62980 Mechanical Permit No. MA3028 Number of apartments and/or guest rooms Fire Prevention Permit NO.F62849 ISSUED TO: Building Official XONY /CODE BACA C..7 SEGERSTROM & SONS 3315 FAILRVIEW ROAD by COSTA.MESA. CA 92626 Date This Certificate of Occupancy SHALL BE posted in a conspicuous place on the,remkes and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. CMF 1015-46 rev. 1/83 White - Owner; Canary - Numerical File; Pink - Bldg. Permit File 11 V 10, City of to'5ta 2Y) e5a joPbevel6pment Services, Division of Building and Safety CERTIFICATE OF _OCCUPANCY This certificate is issued pursuant to the regqu_ ntf the Uniform Building Code, Section 308 r adopted by the City of Costa Mesa certi&s• that_at-the time s.fssuance the building structure herein below described was inspected andpprroved}for-occupancy.as AAIr fllVl � Building Address 3333 BRISTOLaSTRM QNIT�i2213 �, Bldg. Permit No. B 81733 Use RETAIL I/r' ^ _.»^,..f�A�. Group M Typepf,_Construction I -FR Fire Zone'-' e Use Zone C1 -B Owner of Building C; Ji._�5 y rstra i So� s T pant # II ` 3333'BRISTOL, BRISTOL• \STREB�f uk _-:2 C4STA� MESA, iCA Z r� 6 Address _ - �k�tk4"K7 � ��` Bpi%� BUILDING OFFICIAL- On'y �6 2 Cacao" w..:a rsa 20 1997 REQUIRED TO BE POSTEDIN A CONSPICOUS PLACE 0 CONSTRUCTION AND PLANNING APPROVALS Permit # Date Inspector - POOL & SPA _ APPROVALS Permit # Date Inspector 1. Temporary Electrical Service or Pole 43. Pool & Equipment Location - Soil Pipe-Undrgrn 447 Steel Reinforcement 3. Electrical Conduit Utility- ndrgrn - 45. Forms 4. Electrical Conduit-Undrgrn 46. Electrical Bonding 5. Steel ein orce 47. Rough Plumbing & Pressure Test ' 6. Electrical UFER Grn 48. APPROVALTO COVER-GUNITE ' 7. Footings 49. Electrical Conduit-Undr rn B. Foundation50.. Gas Pipe, urJ Undr rn;•Test 9. Water Pipe-Undrgrn 51. Backwash Lines P-Tra`",❑ Undrqrn 10. Structural Floor System 52. APPROVALTO DECK 11. Property Sewer Line & House Connection 53. Backwash & Receptor -Final 12. Street Sewer Connection _ 54. Heater & Vent -Final 13. Rough Plumbing 55, Pluoiib6na S%Fstprn _ Final 14. Rough Electric -Conduit - 56. Electrical -Final 15. Rough Electric -Wiring - 57. Solar System -Final 16. Rough Heating & Air Conditioning - - Fencing & Access Approval 17. Ducts, in Structure _ - APPROVED FOR PLASTERING 18. Ducts, Ventilating 60. POOL/SPA SYSTEMS FINAL 19. Gas Pipe -Rough & Test 20. Roof Framing 21. Roof Sheathing NOTES: 22. Frame and Flashing 23. Insulation 24. Lathing & Siding 25. Drywall Nailing s 26. Plaster Brown Coat 27. Electrical Power Meter -Final 28. Final Electric 29. -Final Heating & Air Conditioning 30. Final Gas Pipe -Test 31. Final Plumbing 32. Water Service -Final ' 33. Gas Service -Final 34. Solar Domestic -Final _ 35. Landsca e Sprinkling System 36. Sound Attenuation 37. Handicap Regulations 38. FINAL STRUCTURE & BUILDING 39. Special Requirements Completed 40. Electric Release to Edison 41. Gas Release to Southern California Gas Co. 42. CERTIFICATE OF OCCUPANCY No - Date CITY OF COSTA MESA DEVELOPMENT SER:JICES/BUILDIINNfG SAFETY RECORD PACKAG FOR: �? -2 ��ST EET ADDRESS C-16` f WORK DONE L_�.,' Bui ing Permit # 6zX,� �f Certificate of Occupancy ❑ Electrical Release Form ❑ Gas Release Form Sanitation Fixture Form �❑ Plumbing Permit # E& Mechanical Permit L�- Electrical Permit # ❑ Reinspection Permit # ❑ Health Department Approval ❑ Roofing Certification ❑ Insulation Certification ❑ Dry Chemical System Certification ❑ Flame Spread Certification F-1 Fire Sprinkler Certification . Soils Certification El Special Inspection Certification LSA Other: All Required Documents Included.&t-- y; Clerk Q.K. to Approve C.Q. Inspector O.K. to Release C.Q. Building Official CMF 1046-30 City of Costa Mesa ` Development Services Department Building Safety Division CERTIFICATE OF OCCUPANCY No. �} P. 0. Box 1200 Costa Mesa, California The Building located at 3333 Bristol Street, Space 2237 has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group RP Occupancy. Use of Building etail Legal Description 412-501-02 ISee reverse side for Metes and Bounds) Building Permit No B 34336 E lectrical Perm it N o. 4 . -?:V-4L.-72--Plumbing Permit No. Mechanical Permit No. M 34419 Fire Prevention permit No. F 34583 ISSUED TO: rr.7,. Begragtnm & Sonli 3315 Fairview Road ."nQt-= MQca ra 92626 Number of apartments and/or guest rooms Building Official William T. Howard b Y Date August 14 1988 This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the `Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. CMF 1015-46 rev, 1/83 White - Owner; Canary - Numerical File; Pink - Bldg. Permit File .' y P02585-94 A CITY OF COSTA MESA DEVELOPMENT SERVICES/BUILDING SAFETY RECORD PACKAGE FOR: 3333 BRISTOL STREET UNIT 2237 PA C'EL #2585-94 A B-2 STREET ADDRESS RETAIL STORE "CACHE" WOMENS STORE WORKDONE Building Permit #$68900 �X Certificate of Occupancy ❑ Electrical Release Form ❑ Gas Release Form r Sanitation Fixture Form N ] Plumbing Permit # '1269021 XM Mechanical Permit +BL9-661 M Electrical Permit # E68984_ ❑ Reinspection Permit # ❑ Health Department Approval ❑ Roofing Certification ❑ Insulation Certification ❑ Dry Chemical System Certification ❑ Flame Spread Certification r] Fire Sprinkler Certification Soils Certification ❑ Special inspection Certification NE Other: F69465 — All Required Documents included c O.K. to Approve C.O. Insp@ for O.K. to Release C.O. Bulldlnq Official CMF 1046-30 fit of Costa Nesa Development Services, Division of Building and Safety CERTIFICATE OF OCCUPANCY This certificate is issued pursuant to,_thj equirements of --the ,,, Uniform Building Code, Section 308 i adopted by the City of Costa Mesa certifies`.that.at-the time of,its.issuance the building structure herein below described was inspected an&approved for occupaiicyaas 169ows: Buil Address 3333 BRISTOL STREET UNIT 2237 B68900 Building � � Bldg. Permit No. Use RETAIL STORE rig VOL - Group B -Z Type of:Coristructi6nr 1 FR SP 1y Fire Zone 1 Use Zone ! Owner of Building C.J. SEGERSTROM &j0NS Tenant CACAE�' Address 3315 FAIRVIEW ROAD COSTA" MESA , CV92626.0 t.<3 \,, Bye BUILDING OFMCIAL-tOnp VN Sata Date,,,>�� �� y ter...,--„�-r°�{_'��,. REQUIRED TO BE POSTE&IN A CONSPICOUS PLACE Cf Y OF COSTA Mh 3A Development Services, Division of Building and Safety CERTIFICATE OFOCCUPANCY This certificate is issued pursuant to the requirements of the Uniform Building Code, Section 308 adopted by the City of Costa Mesa certifies thatat the time of its issuance the building structure herein below described was Inspected and approved for occupancy as follows: Building Address 3333 Bkistol''St Ste 2231 Bidg.,PermitNumber BC08-00240 Use Retail Clothing _(2,240 s.f.) Group M Type of Construction 1—A Fire Zone ,xxxx Use zone PDC Owner of Building South" Coast Plaza Tenant BALENCIAGA Address 3315 Fiarview Rd., Costa Mesa,' CA _ ByWOu BUILDING OFFICIAL-Khanh Q. Nguyen, C.B.O. 11/17/08 Date REQUIRED TO BE POSTED IN A CONSPICUOUS PLACE INa Z . CLU I— Z Z_ �H O CL CO J D J C7 Qw M J � m a ZQ UJ a (L Ly J Z O _mz J fr LLI W Z� LUO D I'D 39749 COSTA MESA BUILDING -SAFETY DEPARTMENT P.O. BOX 1200 COSTA MESA, CALIFORNIA 92626 F A 1' t C.11; C f f - R �b-75LA-1 -00 835'` *�'* ?31. C.I. �Pdcel!ON FOR BUILDING PERMIT Or pp !Cant O ! !!? amp ate y AECDATE RECEIVED DATE ISSUED UILDI NI MF rADDEl RESSSD:..1C11� ] r �I� ON A)S101 JZ Al� A.P. N� PEWNER MAI L /� OOMP4e BUILDING ADDRESS ADDRESS g a�� .i TEL. CITY /I jj *! c+0 NO. TRACT LOT BLOCK CONSTRUCTION r LENDER s BRANCH OWNER ADDRESS VALUE ARCHITECT TEL'y� S $ OR ENGINEE 4 At 1" ADDRESS l d/A r ] SJ�Cy FIRE ZONE TY E GROUP APPROVED DATE r CONTRACTOR �j BY ADDRESS �IJ1 TEL NO..Jy�w1��» Z NO.OF PLANS USE OF N USE ON CITY ��� �� STATE C17Y LIC. NO. LIC, NO. Z., YARDS APPROVED MAIN BUILDING YARDS APPROVED ACCESSORY BUILDING SIZE NO. OF BLOCS, (FROM C/L STREET) OlVdv OF LOT NOW ON LOT E50NT F FT. USE OF i/vFT EXISTING BLDG. SIZE OF NO. OF NEW BLDG. ROOMS STORIES L. SI T FT. EXTERIOR WALL ROOF COVERING COVERING REAR FT. USE OF BUILDING AND WORK TO BE PERFORMED DISTANCE BET. BET. MAIN & /+i MAIN BLDGS. ACCESS. BLOCS. VAR. * DATE C.:) C.U.P, 46 APPROVED �+ APPROVED ^� I hereby acknowledge that I have read this application and state that the above Information 1s correct and agree to comply with all laws regulating building construction, and I shall not employ f` any person in violation of tTha workmen's compensation laws of the State of California, b I herebycertify that I am y properly licensed as a contractor under SO. FT. TAX the State of California Business and Professions Code, DivIzIrn 3, THE AMOUNTSHOWN UNDER VAL TION IS FOR Chapter 9, and that such licenses are in full force and effect, or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONI-Y: am exempt from the provisions of the State of California Business VALUATION and Prof esslons Code, Divis on 3 er 9. PERMIT FEE $ Signature of / Permittee / ' / $ 3 �t�0 '' PLAN CHECK $ s Authorized Agent TOTAL FEE $ m 0 i m N D In E `o LL 39869 COSTA MESA BUILDING -SAFETY DEPARTMENT P.Q. BOX 1200 COSTA MESA, CALIFORNIA 92626 For Applicant to Fill in Completely -511PA ?5 BUILDING ADDRESS 3333 8e,:�7101- OWNER 14SAD" C0,6pjQ/+C-1( MAIL ADDRESS tl.l IL TEL. d- U CITY NO. Z Q CONSTRUCTION 11- (n LENDER M D BRANCH Ln Q Lu ADDRESS CID -j M ARCHiT£CT TEL. Q OR ENGINEER N 0. C� (n a Ul o.LU Z -iO S3 -J Cr a= Z>- �O STATE CITY 0. U) cc �O H Z Q U_ IL 0 a Q 1— C/) Z _0 U H Z ADDRESS BET. MAIN & ACCESS. BLDGS CONTRAGTOR�pD�-DL`S �iF f71916 ADDRESS ���� 67- Vi4� ��✓p CITY TEL. NO, •' .54, �3L�L`%*'�i SIZE OF LOT NO. OF SLOGS. LOW ON LOT - USE OF EXISTING BLDG. SIZE OF NEW SLOG. !r/��' �/� NO. OF ROOMS STORIES EXTERIOR WALL COVERING ROOF COVERING USE OF BUILDING AND WORK TO BE PERFORMED u4c — Rr-rA I4 57VALC /Ire -IV91 1 hereby acknowledge the-, l have read this application and state that the above information is correct and agree to comply with all laws regulating building construction, and I shall not employ any person In violation of the workmen's compensation laws of �R 1 5-75PA-"U0 551+-" ****2-4-160 C,Ic- APP I TION FOR BUILDING PERMIT R EI D Y DA E/RECEIVED D�9ED�O �OPA.P. NO. BUILDING Q �` tr ADDRESS�J �'aTRACT LOT BL OWNER FIRE ZONE TYPE 771rGROUP APPROVED BV DATE � ~' Z NO.OF 07 USE OF N PLANS ON, SUILDIN YARDS APPROVED YA D APPROVED MAIN BUILDING ACCESSORY BUILDIN (FROM C/L STREET) DISTANCE SET. MAIN BLOGS. BET. MAIN & ACCESS. BLDGS VAR. =h'- DATE C.U.P. * APPROVED APPROVED THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: I the State of California. ice( I hereby Certify that I am properly licensed as a Contractor under Q 1SO. FT. O the State of California Business and Professions Code, Division 3, THE AMOUNT SHOWN UNDER VALUATION IS FOR Chapter 9, and that such licenses are In lull force and effect, or I am exempt from the provisions of the State of California BusinessVALUATION THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY: and Professions Code, Division 3, Chapter 9. m n PERMIT FEE $ SI nature of P�e�►� �"^ m Parm[ttee s �/�� PLASM CHECK $ E Authorized Agent �OGlIG'�1 �J7}i7E / 4 !/ o LL TOTAL FEE $ r" 4j,445,PA Ili p r� ..4AR 22`76 .001086 'r�'rittr'XO.�I� COSTA MESA BUILDING -SAFETY DEPARTMENT P,O. BOX 7200 COSTA MESA, CALIFORNIA 92626 APPLICATION FOR STRUCTURAL PERMIT For Applicant to Fill in Completely — Use Ink Only RECEIVE Y DATE RECEIVE D E SSU D BUILDING. iSrOL tri' ADDRESS + �L ~ _ wig 01 PERMIT NO. rADORESS C��{l�) �,eyS Ih/� A.P. NO. MAIL BUILDING 330 K(i Lr ADDRESS TEt.%ia►u NO. TRACTN � y�` �r 4../x..1 N� BRANCH ADDRESS ARCHITECT TEL. ADDRESS [' CONTRACTOR f ,s ADDRESS/J' i 4N TEL CITY NO. R STATEyC_ CITY LIC. NO. 3'1� �" jLIC. NO. 2 W SIZE NO. OF 81 DOS r3. OF LOT NOW ON LOT Q USE OF 52 EXISTING BLDG S Separate permits are required for G electric, plumbing and heating work. W USE OF BUILDING AND WORK TO BE PERFORMED F Q KkF Q d Ct; W G1 hereby acknowledge that I have read this application and state C9 that the above information is correct and agree to comply with G. all laws reguletfrsg building construction, end I shall not employ Z any person in violation of the workman's compensation laws of the State of California. 3 I hereby certify that I am properly licensed as a con tr or under the State of California Business d Professions Cod vision 3, Chapter 9, and that such licen re In full force a act, or I llf rnI Business am exempt from the rovislon of he Stat of Ce and Professi ns Code Ivislon apter Signature of Permittee Authorize Age t OWNER FIRE ZONE T APPRO ED BY Q , I NO. OF PLANS YARD 5APPROVED MAIN BUILDING (FROM CIL STREET) DISTANCE BET MAIN BLDGS. VAR, * C.U.P..0 APPROVED USE OF NS*V _+sf/11I .► YA BET. MAIN ACCESS. St DATE APPROVED APPROVED RY BUILDIN SG. FT. THE AMOUNT SHOWN UNDER VALUATION IS FOR THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY; VALUATION PERMIT FEE $CAD . Q �% PLAN CHECK $ r $ / 46 TAX $ s TOTAL PAID i YA �• ORO l� r+ - USE OF NS*V _+sf/11I .► YA BET. MAIN ACCESS. St DATE APPROVED APPROVED RY BUILDIN SG. FT. THE AMOUNT SHOWN UNDER VALUATION IS FOR THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY; VALUATION PERMIT FEE $CAD . Q �% PLAN CHECK $ r $ / 46 TAX $ s TOTAL PAID i YA 4.136 ; -2-761"00 � 1 zx 4, *** 133.1° COSTA MESA BUILDING -SAFETY DEPARTMENT P.O. 13OX 1200 COSTA MESA, CALIFORNIA 92626 APPLICATION FOR STRUCTURAL PERMIT For Applicant to Fill in Completely —Use Ink REC EJ VrRO BY AT AE D D E ISSV aooRss �3 3 ` 2 1341 STOL.t//���'tt /27 A.P. NO. �VJ/� P OWNER S �/VJ MAIL BUILDING ADORES I ADDRESS s _5,n/�� TEL CITY NQ. Q— TRACT LOT BLOCK CONSTRt1CnON NEW 1, ADD ALTCR REPAIR `/ J', LENDER BRANCH OWNER s Un�s ADDRESS VA UE S S FIRE ARCHITECT j TEL.7 OR ENGIN ER f/ /LG N ADDRESS I3 0 i9NL b ZONE TYPE GROUP CONTRACTOR 1T14_447W-&_V0A1C9AfI ip BYPROVED DATE r ADDRESS 37 TEL.07 Z NO. OF USE OF NEW e CITY.Jpf,1/i/ LG NO. � C, PLANS BUILDING STATE CITY YARDS APPROVED YARDS APPROVED LIC. NO. LIC. NO. MAIN BUILDING ACCESSORY BUILDING SIZE NO. OFBLDGS. (FROM /L STREET) OF LOT NOW ON LOT i FT. FT. USE OF 1 EXISTING BLDG. E,2 F Separate permits are required for L SI FT. F electric, plumbing and heating work. REAR FT. USE OF BUILDING AND WORK TO BE PERFORMED DISTANCE BET. BET. MAIN & MAIN BLDGS. ACCESS, BLDGS. C L �L O L VAR. -0 C. U.P. 46 DATE APPROVED APPA I hereby acknowledge that I have read this application and state that the apove Information Is correct and agree to comply with ell laws regulating building construction, and I shall not employ any person in violation of the workman's compensation laws of the State of California. I hereby certify that I am properly licensed as a contractor under SQ. FT. THE AMOUNT SHOWN UNDER VALUATION IS FOR the State of California Business and Professions Code, Division 3, Chapter 9, and that such licenses are in full force and effect, or I THE PURPOSE OF ESTABLISHING A PERMIT FEE ONLY am exempt from the provisions of the State of California Business VALUATION PERMIT FEE $ and Profesdions Code, Division 3, Chapter 9. PLAN CHECK $ /7 Slgnaturaaf�/ w'O _/ TAX $ 1-14 Permittee . &/ i� �- s l Authorized Agent TOTAL PAID S2T I CITY OF COSTA MESA DEVELOPMENT SERVICES/BUILDING SAFETY RECORD PACKAGE FOR: 3 3 3.3 (yua Zz 3 STREET ADD ESS WORK DONE Building Permit # QZ 2-17 ® Certificate of Occupancy ❑ Electrical Release Form ❑ Gas Release Form F Sanitation Fixture Form ❑ Plumbing Permit # [� Mechanical Permit #J23 -2--q-2-07. Electrical Permit # Z 55 _--- ❑ Reinspection Permit # ❑ Health Department Approval ❑ Roofing Certification ❑ Insulation Certification ❑ Dry Chemical System Certification ❑ Flame Spread Certification ❑ Fire Sprinkler Certification F Soils Certification ❑. Special Inspection Certification 59 Other: Z 7 O 5 9 All Required Documents Included P,4 adza, rk O.K. to Approve C.Q. Inspe for O.K. to Release C.Q. / Building Official CMF 1046-30 Ck /?7,5 City of Costa Mesa Development Services Department CERTIFICATE O F OCCUPANCY No. 0 010 7 3 Building safety Division P. O. Box 1200 Costa Mesa, California The Building located at 3333 Bristol. Snaca 2231 has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group R7. Occupancy. Use of Building Fas1h4 nn Coram racv Legal Description 412_,;oi_n71 iSee reverse side for Metes and Bounds) Building Permit No B24127 Electrical Permit No. F24551 Plumbing Permit No. Mechanical Permit No. M247 D7 Number of apartments and/or guest rooms Fire Permit No. P24859 `� ISSUED TO: Building Official L i,c,r°Y Edison Brothers 501 N. Broadway by �1? St. Louis. MO Date %� This Certificate of Occupancy SHALL- BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. CMF 1015-46 rev. 1/83 White - Owner; Canary - Numerical File; Pink - Bldg. Permit File . ..r+a9...-, ., r 5 _ rr•y .rfw i- .i✓r,.-., yw,�w sa .. r .. ^r'N'-„^N:w.✓+•.M..y.,e.... »�,�{ r,F-.. er .r s .+a..o. � -+n �•.-r.. w .�-m.�.. Y _ _� ..,t CIT' OF COSTA MEc- Development Services, Division of Building and Safety CERTIFICATE OF OCCUPANCY This certificate is issued pursuant to the requirements of the 2007 California Building Code, Section 110 adopted by the City of Costa Mesa certifies that at the time of its issuance the building structure herein below described was inspected and approved for occupancy asfollows: Building Address 3333 1849 Bristol St. Bldg. Permit Number BC09-00262 Use Clothing Retail, (2;X60 sf ) Group M Type of Construction ` 1 -A Fire Zone XXXXX Use Zone PDC Owner of Building South Coast Plaza" Tenant;�HENRI---v-BENDEL Address 3315 Fairview `Rd., Costa Mesa, CA , BUILDING OFFICIAL-Khanh Q:,,Nguyeri;:C:B.O. Date 11 - o 9 REQUIRED TO BE POSTED IN A CONSPICUOUS PLACE � - CI, Y OF COSTA MijA - I=I Development Services, Division of Building and Safety ,CERTIFICATE OF OCCUPANCY This Certificate is issued pursuant to the requirements of the Uniform Building Code, Section 308 adopted by the City of Costa Mesa certifies that at the time of its issuance the building structure herein below described was inspected and approved for occupancy as follows: 3333 Br,i`stol. St. , 25°04>.,. Building Address Bldg, Permit Number B C0 8- 0 0 0 4 2 Use Mercantile (859:; s. f.. ) Group M Owner of Building Address 3 315 Type of Construction 1-FR'Fire Zone XXXXX... Use Zone PDC J , South Coast Plaza Tenant PZAGET Fairview- Avey.'J, Costa Mesa; BUILDING OFFICIAL-Kh h Q NenC B O an guy, -.4 Date 06/04/08 ! REQUIRED TO BE POSTED IN A CONSPICUOUPLACE 4 I ' ...':.•��.^r-.:�r� fir. 5 1 4, �4y • 1 �r Iii 'e" - - - , ••(� �ti•5,;�5 ii • • � � � j�'� • a 'T �'�GF _ � 'sr S� t •wM1-•�ln± 4 �+' ' . {. J •• 1-tµ [r}��", kC ;' •,^�ti t���r,. '-batt �-:.j �:. M CITY OF COSTA MESA DEVELOPMENT SERVICESIBUIWING SAFETY RECORD PACKA FOR.,, STREET ADDRESS WORK D NE Building Permit #s� ' Certificate of Occupancy lam' Electrical Release Form ❑ Gas Release Form �an�on Fixture Form li l�umbing Permit #� yam'/Mechanical Permit#!!.►�-������r Electrical Permit 07 ❑ Reinspection Permit # ❑ Wealth Department Approval Roofing Certification Insulation Certification Dry Chemical System Certification Flame Spread Certification Gire Sprinkler Certification Soils Certification Special Inspection Certification Other: All Required Documents Included O. K. to Approve C, 0. 0. K. to Release C.0 CMF 1046-30 Clerk Inspector Building Official City of Costa Mesa Development Services Department Building Safety Division CERTIFICATE OF OCCUPANCY No. ®G 2 7, 4 P. O. Box 1200 Costa Mesa, California The Building located at 3333 19nA has been inspected and found to comply with the provisions of all City of Costa Mesa Ordinances applicable thereto for a Group r12 Occupancy. Use of Building Rostatlranf- Legal Description_ 412—S01-02 (See reverse side for Metes and Sounds) Building Permit No. _n 2Sn5? Electrical Permit No.P2S57o,t;—)ti„KA Plumbing Permit No. p neerr% Mechanical Permit No. M 17r%gI > Number of apartments and/or guest rooms ISSUED TO: C. J. _ Se-baRrgt ream t Snna 3315 Fairview Road Costa V-?3An. CA -q;1699 Building Official .•*�� __ _ ------- by Date November (60W 1986 This Certificate of Occupancy SHALL BE posted in a conspicuous place on the premises and SHALL NOT BE removed except by the Building Official of the City of Costa Mesa under Sec. 307 (e) U.B.C. CMF 1015-46 rev. 1/63 White • Owner; Canary - Numerical File; Pink - Bldg, Permit File 3L r ! e -CITY OF COSTA MESA BUILDING SAFETY DIVISION GAS OR ELECTRICAL UTILITY RELEASE FORM Al. W TRACT LOT ADDRESS GAS ELEC. NO. NO. METER OUTLETS NO. METERSUNITS RELEASED THESE INSPECTIONS AREA RESULT OF: (CHECK ONE( ED NEW CONSTRUCTION ❑ REWIRING EP'OTHER (EXPLAIN( wFilrYNl.d���f� N ////:a A% Uate Released CMF 0771.46 Signed t W oc r :L n i CAT. NO. NNO0627 TO 1844 CA I9 -84j � TICOR TITLE INSURANCE (Individual) STATE OF CALIFOR� .., ) COUNTY OF j} On_! V QT&KL-�L _ before me, the undersigned, a Notary Public in and for said State, personally appeared , personally known to me or proved to me on the basis of satisfactory evidence to be the person_ whose name IS subscr� d to the within instrument and acknowledged that exe- cuted the same. WITNESS my y and and offici seal. Signature ' (This area for official notarial seal) State of `► - On this the a -L day of ct_ro6/0_ 19 &6, before me, SS. f9� County of CQAAj�L� _ /4!� t'�p��l�JJ the undersigned Notary Public, personally appeared e C _&w^ 4- 64_4,-jE Wi L tArk s OFFICIAL. SEAT, ❑ personally known tome SAM PROODIAN • NOTARY PUBLIC -CAUFORNIA t�proved to me on the basis of satisfactory evidence ORANGECOUNiY to be theerson subscribed to the My Comm.Expireslon.2A,1990 p (s) whose name( s) within instrument, and acknowledged that executed it. WITNESS my hand and)pfficial sea Notary's Signatuie SAM .ROOD �-/lllt ✓.C✓.r✓-,/1.l!JJ.llll./✓✓.111J✓-/✓✓✓.r1t✓✓.Y.lJllff-/.rff✓.C.�.�1.�11✓.11JY.YJ.1111./J1-lJ✓./1.1.1111J✓.111Jlll✓.11/l� t W K V CAT. NO. NNO0627 To 1944 CA (9-84) (Individual) STATE OF CALIFORN COUNTY OF On lr/.t /� Z:0— said State, personally appeared f TICOR TITLE INSURANCE SS. before _-,the undersigned, a Notary Public in and for , personally known to me or proved to me on the basis of satisfactory evidence to be the person_ whose name1 � _ subscribed to the within instrument and acknowledged that exe- cuted the same. WITNESS my hand and officialpeal. Signature µ+ ♦M M o OFFICIAL SEAL LORI L. WHITE Notary Public -California Principal Office In Orange County ,,,..,► My Comm. Exp. Mar. 17, 1989 •.. (This area for official notarial seal) Aof C0.5ta Me a T Development Services, Division of Building and Safety CERTIFICATE OF OCCUPANCY This certificate is issued pursuant th t/er-requirements of rthe,niform Building Code, Section 308 adopted by the City of Costa Mesa celiies-.that.`at the time of,its'issuance the building structure herein below described was inspected and ap0myee for occupancy�as follows:, Building Address 3333 BRISTOL46IRM � UNIT 1831 V NBldi Use "CQZRAEDELLI CHO4 OI:ATE�CQidANY'.' Group B-2 Type of Coristructiony-N Fire'Zone�' Owner of Building C. J.? SBGBRSTBM-S--SONS- Tenant "C$IRARDE ,' �I.i .� Permit No. B68882 Use Zone !PDC 1-9vnrnt sqvV fYTVPAMVU' AddressISTA 3 31 FA 121 BUILDING OFFICIAL -cony tv]D-e 2�'aca.. f REQUIRED TO BE POSTED'IN_ rr-A CONSPICOUS PLACE CITY OF COSTA MESA c Development Services, Division of Building and Safety CERTIFICATE OF-DCCUPANCY This certificate is issued pursuant to the requirements of the Uniforni'BuiIding Code, Section 308 adopted by the City of Costa Mesa certifies that at the time of approved for occupancy as follows:�r�� Building Address 3333 Bristol . Use Retail I (— p;1) Grou M et 411824 )w described was inspected and Permit Number B02-00329 \t Use Zone Owner of Building South I Caast',;Plaza '¢.r,^�-14Teriant }CCB MONACO" 3315 Fairview Road \Costa"Mesa, CA 926'2b Address d<Fetrus, Chief of it BUILDING OFFICIAL -Rick A�, Srown C.B.0. "Date'% . tf% REQUIRED TO BE POSTED"INA CONSPICOUS PLACE =I CITY OF COSTA MESA c Development Services, Division of Building and Safety CERTIFICATE OF F OCCUPANCY This certificate is issued pursuant to the requirements of the Unifofrm'Btiild hgCode, Section 308 adopted by the City of Costa Mesa certifies that at the time of its issuance,t}e.building structure herein below described was inspected and approved for occupancy as follows:4� Building Address 3333 Br`:istol/St. Ste 1837 Bldg:P&imitNumber 8 4'01086 Use Retail Group M Type of Construction ,hFR-S P ac Fire:Zone �� 't: Use Zone P DC Owner of Building Address 3315 Fairvie LA , Ti?nant " 1r ­fl ,R.d% i> Costa Mesa, &A�— 9262 �' A ABy L BUILDING OFFICIAL -Rick A': BrOw3l.C.B.O.�� P e t e"T aria c / '-1 mbination Inspector REQUIRED TO BE POSTED-IN- CONSPICOUS PLACE C TY OF -COSTA 1� _'ESA ft Development Services, Division of Building and Safety kt,7+ CERTIFICATE30F _OCCUPANCY This certificate is issued pursuant to the requirement of the Uniform Building Code, Section 308 adopted by the City is ,. , of Costa Mesa certifies that at the time of its issuance the�building structure herein below described was inspected and approved for occupancy as followfs:����� Building Address 3333 BRISTOL: 1821 Bldg: Permit Number BOO --00864 J�•� � � ,�� � - •_� ,�,4✓i- ,.tet`^ I __, _ • ;<, Use RETAIL 7,350 SF T:'I­FORfBOTTERY- BARN AIDS- Group M Type of Construction'.'1 FRt; Jsx Fire'Z.rte r Use Zone SOUTH COAST `PLAZA C/0 ,CJ, SEGERSTROM .' �.` BA$N RIDS Owner of Building ` "'Y'^` =//: Tenant Addres 53333 FAIRVIEW ROAM,^COSTA MESA 92626 ;By BUILDING OFFICIAL -Rick A:,Brown.C.B.O. %�`' _ <.. ',��09,/08/2000 Dates✓i REQUIRED TO BE POSTED IN A CONSPICOUS PLACE CITY OF COSTA MESA zi -'0P Development Services, Division of Building and Safety CERTIFICATE_DF-OC_ CUPANCY This certificate is issued pursuant to the requirements of the Uniform Building Code, Section 30$ adopted by the City of Costa Mesa certifies that at the time 0'f its issuance',the building structure Herein below described was inspected and approved for occupancy as follows:�rSir 3333 Bristolt Suite 1811 Bl -,BO1-00694 Building Address`r r- - 81dg, PErmit Number Use Retail Group M Type of Cdnstruction Z>� M7 TffirP,Fire'Z6ne �' �' Use Zone FDG { South Coast�Flaza 1 ���_'^, Ainericaxt Eagle Outfitters" Owner of Bui�din� = Te`nant c//o egers lroa ons 3315 Fairview' Rd's Costa' Mesa CA 492626 Address 1,, ' BUILDING OFFICIAL -Rick A.,BroWIL;X B.O. ' e Datej REQUIRED TO BE POSTED IN A CONSPICOUS PLACE _--- -- ---- „__ E 1 . -. -. �"'-, - =?��. ✓' .f 4�1�-L+ � ` . ���"J �n'F.c=�...1'_:�:.1 4-. Tf�Y� ,r. .. .�,-��. �.,-+---- �-�...c.wr � � ..-�.�^+:--�.„.� �-^"-•��...,. ,.. .. ^-- Y., v.rP... -v CITY OF COSTA MESA Development Services, Division of Building and Safety CERTIFICATE OF OCCUPANCY This certificate is issued pursuant to the requirements of the 2007 California Building Code, Section 110 adopted by the City of Costa Mesa certifies that at the time of its issuance the building structure herein below described was inspected and approved foroccupancy as follows: Building Address 3333 1621 Bristol. St. 'Bldg. Permit Number BC10-00 157 Use Retail (1,021 S.f.) Group M Type of Construction ZEA Fire Zone xX:kxx Use Zone PDC Owner of Building South Coast Plaza'Ieriarit"��Fp :. NERVE LEGER Address 3315 Fairview Rd. ,, ' Costa Mesa, CA BUILDING OFFICIAL-Khanh Q. Nguyen; C B.O , F 0 7 / 2`1 / Date �� REQUIRED TO BE POSTED IN A CONSPICUOUS PLACE Aff CIr Y OF COSTA Mr -A ,oPDevelopment Services, Division of Building and Safety CERT , IFICATE OF OCCUPANCY This certificate is issued pursuant to the'r6quirements.of the Uniform Building Code, Section 308 adopted by the City of Costa Mesa certifies that at the time of its issuance the building structure herein below described was inspected and approved for occupancy as follows: Building Address 3333 Bristo"l St. Ste 1620. Bldg. Permit Number B06-01704 Use Restaurant t3,, 3.92 9 f Group A-3 Type of Construction 'Fire --_may x XX.XXX.XX Use Zone PDC Owner of Building South Coast Plaza Tenant VIF Dr.. FRANr-r. Address3315 Fairview Rd.';.; Costa mesa; CA 92626 BUILDING OFFICIAL-Khanh,Q,",Nguyen, C.B.O. By Dke. - 06/27/ REQUIRED TO BE POSTED IN A CONSPICOUS PLACE 1=1 Cl -Y OF COSTA M,T--)A 7 ............ 1,0111000P Development Services, Division of Building and Safety ` CERTIFICATE OF OCCUPANCY This certificate is issued pursuant to ttierrequiremerits`of the Uriiform°Btiilding Code, Section 308 adopted by the City of Costa Mesa certifies that at the time of its issuance the building structure herein below described was inspected and approved for occupancy as follows: Building Address 3333 ]ar.isto1 st. 5tei 1624- Bide..Pernit.Number 1306-00)5L_ Merchandise Sales(1,094 s.f ) Use M ;. :�FFt XXXXX Group Type of Construction Fire Zone Use Zone POC SoutK Coast Plaza WOLFpRb` Owner of Building Tenant 3315 Fairview". Rd'. Costa .Mesa., CA 926.26'., Address Y BUIL,DINGOFFICIAL-Khanh Q. Nguyen,.C.B:O:' 02/01/08 - Date REQUIRED TO BE POSTED IN A CONSPICUOUS PLACE